Guide to Implementation

A Guide to the Implementation of the WHO

Multimodal Hand Hygiene Improvement Strategy
GUIDE TO IMPLEMENTATION

CONTENTS
DEFINITION OF TERMS 4
KEY TO SYMBOLS 5

PART I
I.1. OVERVIEW 6

I.2. ABOUT HAND HYGIENE IN HEALTH CARE 6

I.2.1. Rationale for a Guide to Implementation
I.2.2. The problem of health care-associated infections and the importance of hand hygiene
I.2.3. A global response to the problem

I.3. ABOUT THE GUIDE TO IMPLEMENTATION 7

I.3.1. Purpose of the Guide to Implementation

I.4. WHO MULTIMODAL HAND HYGIENE IMPROVEMENT STRATEGY 8

I.4.1. The strategy components
I.4.2. The implementation toolkit
I.4.3. The step-wise approach

PART II
II.1. SYSTEM CHANGE 11
II.1.1. System change – definitions and overview
II.1.2. Tools for system change – tool descriptions
II.1.3. Using the tools for system change –
examples of possible situations at the health-care setting level

II.2. TRAINING AND EDUCATION 16

II.2.1. Training and education – definitions and overview
II.2.2. Tools for training and education – tool descriptions
II.2.3. Using the tools for training and education –
examples of possible situations at the health-care setting level

WHO/IER/PSP/2009.02

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2
 GUIDE TO IMPLEMENTATION

II.3. EVALUATION AND FEEDBACK 22

II.3.1. Evaluation and feedback – definitions and overview
II.3.2. Tools for evaluation and feedback – tool descriptions
II.3.3. Using the tools for evaluation and feedback –
examples of possible situations at the health-care setting level

II.4. REMINDERS IN THE WORKPLACE 27

II.4.1. Reminders in the workplace – definitions and overview
II.4.2. Tools for reminders in the workplace – tool descriptions
II.4.3. Using the tools for reminders in the workplace –
examples of possible situations at the health-care setting level

II.5. INSTITUTIONAL SAFETY CLIMATE 29

II.5.1. Institutional safety climate – definitions and overview
II.5.2. Tools for institutional safety climate – tool descriptions
II.5.3. Using the tools for institutional safety climate –
examples of possible situations at the health-care setting level

PART III
III.1. PREPARING AN ACTION PLAN 33

III.2. IMPLEMENTING THE STEP-WISE APPROACH 39

III.2.1. Step 1: facility preparedness – readiness for action
III.2.2. Step 2: baseline evaluation – establishing knowledge of the current situation
III.2.3. Step 3: implementation – introducing the improvement activities
III.2.4. Step 4: follow-up evaluation – evaluating the implementation impact
III.2.5. Step 5: ongoing planning and review cycle – developing a plan for the next 5 years

APPENDIX
USEFUL WEBSITES 47
DISCLAIMER 47
HUG ACKNOWLEDGEMENT 47

3
GUIDE TO IMPLEMENTATION

DEFINITION OF TERMS

Action plan A detailed, carefully-prepared scheme of activities to be

initiated or continued in order to improve hand hygiene
at a given health-care facility.

Alcohol-based handrub An alcohol-containing preparation (liquid, gel or foam)

designed for application to the hands to reduce the
growth of microorganisms. Such preparations may
contain one or more types of alcohol with excipients,
other active ingredients and humectants.

Efficacy / efficacious The (possible) effect of the application of a hand hygiene

formulation when tested in laboratory or in vivo situations.

Effectiveness / effective The clinical conditions under which a hand hygiene

product has been tested for its potential to reduce
the spread of pathogens, e.g. field trials.

Hand cleansing Actions to prevent skin irritation.

Hand hygiene A general term referring to any action of hand cleansing.

Hand hygiene The person at a facility assigned to coordinate the

co-ordinator preparation and implementation of the hand hygiene
improvement programme.

Handrubbing Applying an antiseptic handrub to reduce or inhibit

the growth of microorganisms without the need for an
exogenous source of water and requiring no rinsing
or drying with towels or other devices.

Handwashing Washing hands with plain or antimicrobial soap and water.

Health care-associated An infection occurring in a patient during the process

infection (HCAI) of care in a hospital or other health-care facility which
was not present or incubating at the time of admission.
This includes infections acquired in the hospital but
appearing after discharge, and also occupational
infections among staff of the facility.

4
 GUIDE TO IMPLEMENTATION

KEY TO SYMBOLS

The following symbols are used throughout the Guide to Implementation as a quick
reference for users. The symbols highlight specific actions, key concepts and
also reference the tools and resources available as part of the suite of materials
available to aid implementation.

Key Concept
Alerts the reader to an issue of importance for success.

Tools
Indicates a section of the Guide to Implementation
where explanations on the tools included in the
implementation toolkit are included.

Key Action
Indicates a section of the Guide to Implementation where
key actions for the implementation of the WHO multimodal
hand hygiene improvement strategy are pointed out.

5
PART I

OVERVIEW ABOUT HAND

Health care-associated infection (HCAI) places a serious disease HYGIENE IN HEALTH
burden and has a significant economic impact on patients and
health-care systems throughout the world. Yet good hand hygiene,
CARE
the simple task of cleaning hands at the right times and in the right
way, can save lives. Rationale for a Guide to Implementation
World Health Organization (WHO) has developed evidence-based The WHO Guidelines on Hand Hygiene in Health Care present the
WHO Guidelines on Hand Hygiene in Health Care to support evidence base for focusing on hand hygiene improvement as part of
health-care facilities to improve hand hygiene and thus reduce HCAI. an integrated approach to the reduction of HCAI. Implementation is
of utmost importance to achieving an impact on patient safety and
This Guide to Implementation has been developed to assist
therefore this guide aims actively to support the use of the guidelines.
health-care facilities to implement improvements in hand hygiene in
accordance with the WHO Guidelines on Hand Hygiene in Health Care.
The problem of HCAI and the importance of
The strategy described in this Guide to Implementation has been
hand hygiene
designed to be used by any health-care facility, irrespective of the
level of resources or whether the facility has already implemented HCAI affects hundreds of millions of people worldwide and is a major
any hand hygiene initiatives. The approach focuses primarily on global issue for patient safety. At both the level of the country and of
improving hand hygiene compliance by health-care workers who the health-care facility, the burden of HCAI is significant, although it
work with patients. Through the actions proposed by the strategy, may be difficult to quantify at this stage.
improvement of infrastructures for hand hygiene along with
In general, and by their very nature, infections have a multifaceted
enhancement of knowledge and perception about hand hygiene
causation related to systems and processes of health-care provision
and HCAI and of the patient safety climate is also meant to be
as well as to political and economic constraints on health systems and
achieved. The ultimate goal is to reduce both the spread of
countries. They also reflect human behaviour conditioned by numerous
infection and multi-resistant germs as well as the numbers of
factors, including education. However, acquisition of infection, and in
patients acquiring a preventable HCAI, and thus to prevent
particular cross-infection from one patient to another, is in many cases
waste of resources and save lives.
preventable by adhering to simple practices.
Details of all of the tools supplied to support successful
Hand hygiene is considered to be the primary measure necessary
implementation of a hand hygiene improvement strategy
for reducing HCAI. Although the action of hand hygiene is simple,
at any health-care facility are provided in this guide.
the lack of compliance among health-care workers continues to
be a problem throughout the world.

Yet hand hygiene improvement is not a new concept within health

care. Many health-care facilities around the world already have
well-established policies and guidelines and undertake regular training
programmes in this area. Increasingly, actions are being undertaken
to introduce alcohol-based handrubs at the point of care. However,
long-lasting improvements remain difficult to sustain, and many
facilities worldwide have not yet begun to address hand hygiene
improvement in a systematic way. This is due to numerous constraints,
particularly those relating to the very infrastructures and resources
required to enable attention to turn to hand hygiene improvement.

6
 GUIDE TO IMPLEMENTATION PART I

A global response to the problem ABOUT THE GUIDE TO

In 2005, WHO Patient Safety launched the First Global Patient Safety
Challenge, Clean Care is Safer Care, to galvanise international focus
IMPLEMENTATION
and action on the critical patient safety issue of HCAI and on the central
This Guide to Implementation and the related implementation toolkit
role that hand hygiene compliance by health-care workers plays in
will assist in the development of local action plans to address hand
reducing such infections. In 2009, WHO Patient Safety launched an
hygiene improvement and sustainability, starting now.
extension to this programme; SAVE LIVES: Clean Your Hands, an
initiative that aims to ensure an ongoing global, regional, national and
local focus on hand hygiene in health care. In particular, SAVE LIVES: Purpose of the Guide to Implementation
Clean Your Hands reinforces the “My 5 Moments for Hand Hygiene”
The Guide to Implementation:
approach as key to protect the patient, the health-care worker and the
• is a manual to be used to facilitate local implementation and
health-care environment against the spread of pathogens and thus
evaluation of a strategy to improve hand hygiene and thus
reduce HCAI.
reduce HCAI at individual health-care facilities;
This approach encourages health-care workers to clean • assists health-care facilities in preparing a comprehensive action
their hands (1) before touching a patient, (2) before clean/aseptic plan to improve hand hygiene irrespective of their starting point;
procedures, (3) after body fluid exposure/risk, (4) after touching
• supports the components of the WHO multimodal hand hygiene
a patient and (5) after touching patient surroundings.
improvement strategy, as presented in the WHO Guidelines on
Hand Hygiene in Health Care, which is described in the next section.

My 5 Moments The guide will inform you how to:

• prepare an Action Plan for hand hygiene improvement;
• evaluate the elements that exist in the health-care facility
for Hand Hygiene for ensuring effective hand hygiene;
• identify what system changes are needed at a health-care system
or health-care facility level to support implementation of the
WHO Guidelines on Hand Hygiene in Health Care;
• select and access alcohol-based handrubs and other
products used for hand hygiene;
• provide appropriate and effective education and reminders
4
AFTER

1
BEFORE
TOUCHING TOUCHING
A PATIENT A PATIENT to health-care workers irrespective of their starting point;
• develop approaches to ensuring an institutional safety climate;
• undertake evaluation and feedback (e.g. observation of hand
hygiene compliance); and
• maintain momentum and motivation for continued hand hygiene
at facilities that have already achieved excellent standards.
5
AFTER
TOUCHING PATIENT
SURROUNDINGS
The primary target audience for this Guide to Implementation is:
• professionals in charge of implementing a strategy to improve
hand hygiene within a health-care facility.

As part of their ongoing commitment to reduce HCAI, WHO Patient The Guide to Implementation may also be of value to the following:
Safety has developed this revised Guide to Implementation and a series • WHO country office staff;
of tools to support health-care workers in establishing and sustaining • Ministry of Health leads for patient safety / infection control;
good hand hygiene practices by health-care workers and reducing
• infection prevention and control practitioners;
HCAI at health-care facilities worldwide. This is part of the long-term
SAVE LIVES: Clean Your Hands initiative. • senior managers/leaders;
• other individuals or teams responsible for hand hygiene or
infection control programmes at a health-care facility; and
• patient organizations.

Implementation of the WHO Guidelines on Hand Hygiene in

Health Care requires action in a number of areas. It is important that
professionals with the ability to make key decisions that will result in
improvement are actively involved in the process of implementation
from the outset.

7
PART I GUIDE TO IMPLEMENTATION

The WHO Guidelines on Hand Hygiene in Health Care make it clear Each component deserves equally important, specific and
that it should be relatively simple for health-care providers in virtually integrated efforts to achieve effective implementation and maintenance.
every setting to immediately start and continue to evaluate and However, facilities around the world may have progressed to different
improve the reliability of hand hygiene infrastructure and practices. levels as far as hand hygiene promotion is concerned. Therefore, while
some components might be identified as the central features to start
This Guide to Implementation can therefore be used: with in some facilities, others may not be immediately relevant in others.
• at any time as a broad outline of how a hand hygiene At facilities with a very advanced level of hand hygiene promotion, some
improvement strategy might be executed; and components should nonetheless be considered for improvement and
action to ensure long-term sustainability.
• at any time as a guide for developing local action plans
to improve hand hygiene. It is important to note that implementation, evaluation and feedback
activities should be periodically rejuvenated and repeated and become
part of the quality improvement actions that will ensure sustainability.
Hand hygiene improvement is not a time-limited process: hand hygiene
WHO MULTIMODAL HAND promotion and monitoring should never be stopped
once implemented.
HYGIENE IMPROVEMENT
The five components, together with linked tools available for their
STRATEGY implementation, are described in separate sections of this guide
(Sections II.1–II.5).
The strategy components
Successful and sustained hand hygiene improvement is achieved *Point of care – The place where three elements come together:
by implementing multiple actions to tackle different obstacles and the patient, the health-care worker, and care or treatment involving
behavioural barriers. Based on the evidence and recommendations contact with the patient or his/her surroundings (within the patient
from the WHO Guidelines on Hand Hygiene in Health Care, a number zone). The concept embraces the need to perform hand hygiene
of components make up an effective multimodal strategy for hand at recommended moments exactly where care delivery takes place.
hygiene. The WHO multimodal hand hygiene improvement strategy has This requires that a hand hygiene product, e.g. alcohol-based
been proposed to translate into practice the WHO recommendations handrub, if available, will be easily accessible and as close as possible
on hand hygiene and is accompanied by a wide range of practical (e.g. within arms reach), where patient care or treatment is taking
tools (implementation toolkit) ready to use for implementation. place. Point-of-care products should be accessible without having
to leave the patient zone.
The key components of the strategy are: Availability of alcohol-based hand-rubs at the point of care is
1. System change: ensuring that the necessary infrastructure is usually achieved through staff-carried handrubs (pocket bottles),
in place to allow health-care workers to practice hand hygiene. wall-mounted dispensers, containers affixed to the patient’s bed
This includes two essential elements: or bedside table or to dressing or medicine trolleys that are taken
• access to a safe, continuous water supply as well as to into the point of care.
soap and towels;
• readily accessible alcohol-based handrub at the point of care*. The implementation toolkit
2. Training / Education: providing regular training on the importance Acknowledging the vastly different levels of awareness and the barriers
of hand hygiene, based on the “My 5 Moments for Hand to implementing hand hygiene improvement strategies from country to
Hygiene” approach, and the correct procedures for handrubbing country, and even within the same country, an implementation toolkit
and handwashing, to all health-care workers. has been developed to support health-care workers in improving hand
hygiene at their facilities, irrespective of their starting point. The Guide to
3. Evaluation and feedback: monitoring hand hygiene practices Implementation is central to the toolkit and together they aim to facilitate
and infrastructure, along with related perceptions and knowledge the process of translating the recommended components of the WHO
among health-care workers, while providing performance and multimodal hand hygiene improvement strategy into action.
results feedback to staff.
Published studies suggest that, on average, compliance with hand
4. Reminders in the workplace: prompting and reminding hygiene is around 40% (WHO Guidelines on Hand Hygiene in Health
health-care workers about the importance of hand hygiene and Care). By providing the tools to support health-care workers and others
about the appropriate indications and procedures for performing it. responsible for improving patient safety at the national and local levels,
WHO Patient Safety hopes to see compliance increase in each country
5. Institutional safety climate: creating an environment and the of the world from its current baseline.
perceptions that facilitate awareness-raising about patient
safety issues while guaranteeing consideration of hand hygiene The aim is that the increase will be observed over time until at
improvement as a high priority at all levels, including least 2020, when it is hoped that a culture of hand hygiene excellence
• active participation at both the institutional and individual levels; will be embedded in all health-care facilities. Each individual health-care
facility across the world must set its own realistic targets and action
• awareness of individual and institutional capacity to change
plans for improvement in order to reach this aim.
and improve (self-efficacy); and
• partnership with patients and patient organizations.

8
 GUIDE TO IMPLEMENTATION PART I

WHO Guidelines on Hand Hygiene in Health Care

Guide to Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy

Template Action Plan

Tools for System Tools for Training / Tools for Evaluation Tools for Reminders Tools for Institutional
Change Education and Feedback in the Workplace Safety Climate

Ward Infrastructure Slides for the Hand Hand Hygiene Technical Your 5 Moments for Template Letter to
Survey Hygiene Co-ordinator Reference Manual Hand Hygiene Poster Advocate Hand Hygiene
to Managers
Alcohol-based Slides for Education Observation Tools: How to Handrub
Handrub Planning Sessions for Trainers, Observation Form Poster Template Letter to
and Costing Tool Observers and and Compliance Communicate Hand
How to Handwash
Health-Care Workers Calculation Form Hygiene Initiatives to
Guide to Local Poster
Managers
Production: Hand Hygiene Ward Infrastructure
Hand Hygiene:
WHO-recommended Training Films Survey Guidance on Engaging
When and How Leaflet
Handrub Formulations Patients and Patient
Slides Accompanying Soap / Handrub
SAVE LIVES: Organizations in Hand
Soap / Handrub the Training Films Consumption Survey
Clean Your Hands Hygiene Initiatives
Consumption Survey
Hand Hygiene Technical Perception Survey for Screensaver
Sustaining Improvement
Protocol for Evaluation Reference Manual Health-Care Workers
– Additional Activities
of Tolerability and
Observation Form Perception Survey for for Consideration by
Acceptability of
Senior Managers Health-Care Facilities
Alcohol-based Handrub Hand Hygiene
in Use or Planned to be Why, How and Hand Hygiene SAVE LIVES:
Introduced: Method 1 When Brochure Knowledge Clean Your Hands
Questionnaire for Promotional DVD
Protocol for Evaluation Glove Use
Health-Care Workers
and Comparison Information Leaflet
of Tolerability and Protocol for Evaluation
Acceptability of Your 5 Moments for
of Tolerability and
Different Alcohol-based Hand Hygiene Poster
Acceptability of
Handrubs: Method 2 Alcohol-based Handrub
Frequently Asked
Questions in Use or Planned to be
Introduced: Method 1
Key Scientific
Publications Protocol for Evaluation
and Comparison
Sustaining Improvement of Tolerability and
– Additional Activities Acceptability of Different
for Consideration by Alcohol-based
Health-Care Facilities Handrubs: Method 2

Data Entry
Analysis Tool

Instructions for Data

Entry and Analysis

Data Summary
Report Framework

9
PART I GUIDE TO IMPLEMENTATION

The step-wise approach The main objectives to be achieved in each step are the following:

• Step 1: ensuring the preparedness of the institution. This includes

In each section dedicated to the five strategy components, obtaining the necessary resources (both human and financial),
different approaches to implementation are suggested according to putting infrastructure in place, identifying key leadership to head
various potential situations of a health-care facility. Overall, this guide the programme including a coordinator and his/her deputy.
proposes a step-wise approach as a model to gradually implement Proper planning must be done to map out a clear strategy
a comprehensive hand hygiene programme at the facility level. for the entire programme.
The target is principally a facility where a hand hygiene improvement
programme needs to be initiated, but the approach represents a cycle • Step 2: conducting baseline evaluation of hand hygiene practice,
that should be adapted locally and renewed periodically by any facility perception, knowledge and the infrastructures available.
aiming to sustain hand hygiene improvement. • Step 3: implementing the improvement programme. Ensuring
the availability of an alcohol-based handrub at the point of care
The approach includes five steps to be undertaken sequentially: is vitally important, as is conducting staff education and training
Step 1: facility preparedness – readiness for action and displaying reminders in the workplace. Well-publicized
events involving endorsement and/or signatures of commitment
Step 2: baseline evaluation – establishing knowledge from leaders and individual health-care workers will generate
of the current situation great participation.
Step 3: implementation – introducing the improvement activities • Step 4: conducting follow-up evaluation to assess the
Step 4: follow-up evaluation – evaluating the implementation impact effectiveness of the programme.

Step 5: ongoing planning and review cycle – • Step 5: developing an ongoing action plan and review cycle,
developing a plan for the next 5 years (minimum) while ensuring long-term sustainability.

The overall aim is to embed hand hygiene as an integral part of the These steps are described in detail in Part III, after an understanding
culture in the health-care facility. of each of the five strategy components has been gained.

In summary the figure below illustrates the WHO multimodal hand

hygiene improvement strategy, the “My 5 Moments for Hand Hygiene”
approach, which is key to the strategy implementation, and the
step-wise approach.

The Five Components of the WHO multimodal

The five moments for hand hygiene in health care
hand hygiene improvement strategy

1a. System change –

alcohol-based handrub at point of care

1b. System change – access to safe,

continuous water supply, soap and towels

1 4
BEFORE AFTER
TOUCHING TOUCHING
A PATIENT A PATIENT
2. Training and education

3. Evaluation and feedback

4. Reminders in the workplace

5
AFTER
TOUCHING PATIENT
SURROUNDINGS
5. Institutional safety climate

The step-wise approach

Facility Baseline Follow-up Review

Implementation
preparedness evaluation evaluation and planning

10
PART II

System change is a particularly important priority for health-

SYSTEM CHANGE care facilities starting on their journey of hand hygiene improvement
activities, assuming and expecting that the entire necessary
System change – definition and overview infrastructure is put in place promptly. However, it is also essential
that health-care facilities revisit the necessary infrastructure on a
System change is a vital component in all health-care facilities. regular basis to ensure handwashing and hand hygiene facilities live
It refers here to ensuring that the health-care facility has the up to a high standard on an ongoing basis.
necessary infrastructure in place to allow health-care workers
to perform hand hygiene.
It is essential that the health-care facility’s infrastructure
The WHO Guidelines on Hand Hygiene in Health Care state that
be assessed at an early stage in the hand hygiene improvement
compliance with hand hygiene is only possible if the health-care
journey. Support and commitment from key senior managers is
setting ensures an adequate infrastructure and if a reliable and
crucial to this. It is also a priority that an action plan to ensure
permanent supply of hand hygiene products at the right time
system change is prepared and implemented, involving all of
and at the right location is provided in accordance with the
those key health-care facility staff who will be depended upon
“My 5 Moments for Hand Hygiene” approach.
to make system change happen.
In those situations where the system is reliable and fully supportive
of hand hygiene improvement, health-care facilities will have sinks The implementation toolkit includes key tools that will help ensure
for handwashing available in each clinical setting, complete with that system change is addressed promptly and appropriately.
safe running water, soap and disposable towels along with alcohol-
based handrub available at each point of care and/or carried by
health-care workers.
Tools for system change – tool descriptions
The tools described in this section aim at directing and supporting
Health-care facilities in many parts of the developing world may not
health-care facilities in making prompt and appropriate system changes.
have piped-in tap water, or it may be available only intermittently. Soap
Some of these tools will appear also in other sections, where their
and towel availability may also be severely limited due to resource
placement will reflect their nature and function (for example, the ward
constraints. The WHO Guidelines on Hand Hygiene in Health Care
infrastructure survey appears in this section because it is useful for
acknowledge that key issues therefore need to be addressed, including
assessing the actual need for and availability of resources and products
availability of tap water (ideally drinkable) for handwashing. Where
for hand hygiene and thus to enable the achievement of system change;
tap water is not available, water “flowing” from a pre-filled container
however, by definition, it is an evaluation tool and will thus be included
with a tap is preferred; where running water is available, the possibility
in the range of tools for evaluation presented in section II.3.2).
of accessing it without needing to touch the tap with soiled hands is
preferable. When bar soap is used, small bars of soap in racks that All of these tools can be used at the start of the hand hygiene
facilitate drainage should be made available; careful hand drying improvement journey but can also be utilised to improve hand
with a single-use towel (paper or cloth) is also important. hygiene infrastructure already in place or to undertake routine or
periodic product use and infrastructure monitoring. Health-care facility
In recent years, health-care facilities in many parts of the world infrastructures can change frequently; for example, new buildings and/or
have introduced alcohol-based handrubs. If the alcohol-based handrub refurbished wards can appear, as well as changes to supplied products.
is procured from the market, the WHO Guidelines on Hand Hygiene in Therefore, the tools are applicable in a variety of circumstances.
Health Care recommend that the product meet recognised standards
for antimicrobial efficacy (ASTM or EN standards), be well tolerated
and accepted by the health-care workers and selected taking cost into
account, making sure that they are purchased in adequate quantities. In
cases where the WHO-recommended handrub formulation is produced
locally, instructions for ingredient procurement, preparation, quality
control and storage should be followed. The best type of dispensers
will need to be procured, ideally from the local market, and advice on
the safe re-use of dispensers should be followed. Dispensers should
be available at the point of care, be well-functioning and reliably and
permanently contain alcohol-based handrub. They should also be safely
mounted, placed and stored. Pocket bottles should be considered,
especially when alcohol ingestion by patients is a potential risk.

11
PART II GUIDE TO IMPLEMENTATION

The range of tools available to support the implementation

Ward Infrastructure Survey
of system change is represented in the figure below.
What A survey tool that collects data about existing
infrastructures and resources
Ward
Infrastructure Why • Because it is important to collect information
Survey about existing infrastructures and resources
in place in each clinical setting as a baseline.
This will also enable follow-up measurement
Alcohol-based of potential system changes following
Handrub implementation;
Planning and • lack of access to sinks, running water and
Costing Tool alcohol-based handrub is likely to contribute
to lower rates of compliance;
• finding out details about the ward
Guide to Local infrastructure is useful in terms of explaining
Production: current hand hygiene compliance rates.
WHO-recommended This will also help identify priorities for
Handrub system change and guide the ongoing
Formulations preparation and revision of action plans.

Where In every clinical setting where an assessment

Soap / Handrub of handwashing and handrub facilities and
Consumption resources must be conducted in the context
Survey of the hand hygiene improvement strategy
implementation.

Protocol for When • During the time allocated for baseline

Evaluation of evaluation of the existing infrastructure
Tolerability and equipment/resources for hand hygiene;
and Acceptability • at key specified follow-up intervals when
of Alcohol-based an update on this information is necessary
Handrub to maintain the required hand hygiene
in Use or Planned infrastructures. Even if the facility already
to be Introduced: conducts a hospital-wide audit of infection
Method 1 control and hand hygiene practices, this
should be considered in the action plan
for addressing system change;
Protocol for
• usually during step 1 or 2 and 4
Evaluation and
(see sections III.2.1, III.2.2, III.2.4).
Comparison
of Tolerability and
Who The survey should be completed by the hand
Acceptability of
hygiene programme co-ordinator or an identified
Different Alcohol-
and informed health-care worker within the
based Handrubs:
clinical setting (e.g. a senior nurse who can
Method 2
complete the survey while walking around
the ward).

How Completion of the form by the identified person

should be undertaken by answering questions
to obtain the relevant information while walking
round the setting. Forms should then be collated
by the identified co-ordinator.

12
 GUIDE TO IMPLEMENTATION PART II

Alcohol-based Handrub Planning and Costing Tool Guide to Local Production:

WHO-recommended Handrub Formulations
What A tool to help managerial planning to provide
What • A practical guide for use at the pharmacy
alcohol-based handrub at the point of care
bench during the preparation of WHO-
and to decide on whether:
recommended alcohol-based handrub
• to purchase alcohol-based handrub from formulations;
an established manufacturer; or
• a summary of essential background
• to produce it locally, according to the technical, safety and cost information.
WHO recommendations (see Guide to
Local Production: WHO-recommended
Why • Because in some health-care facilities
alcohol-based handrub is not available,
Handrub Formulations).
not affordable or does not meet the
necessary criteria;
Why • Because one of the nine key
recommendations arising from the • local production of handrub according
WHO Guidelines on Hand Hygiene in to the formula and methodology
Health Care is the provision of a readily- recommended by WHO can be an
accessible alcohol-based handrub at alternative to market products.
the point of patient care for use by Where In suitable production facilities; in central
health-care workers; pharmacies or dispensaries, hospital
• to ascertain the feasibility of implementing pharmacies or national drug companies.
alcohol-based handrub; When As identified and required by the health-care
• to evaluate whether the alcohol-based facility, for example based on the Alcohol-based
handrub in use conforms to the quality Handrub Planning And Costing Tool results;
criteria recommended by WHO. usually during step 1 (see section III.2.1).
Who The tool should be used by qualified
Where In the hospital management unit of the health- pharmacists; local producers of
care facility. alcohol-based handrub.
How Following the instructions from protocol
When • During the planning and development of in Part A of the tool.
an action plan to improve hand hygiene;
• when the health-care facility is in the
process of selecting or changing the Soap / Handrub Consumption Survey
alcohol-based handrub;
What A monitoring tool that captures the usage
• when the health-care facility is in the of various products intended for hand
process of evaluating the quality of the hygiene purposes.
alcohol-based handrub in use;
Why • In order to understand the baseline
• usually during step 1 (see section III.2.1).
usage of hand hygiene products, a survey
is needed before starting implementation
Who The tool should be used by senior managers, of the hand hygiene programme;
pharmacists and the hand hygiene programme
• to demonstrate the process of changing
co-ordinator at the health-care facility.
demands for hand hygiene products, this
survey needs to be repeated on a regular
How A number of tasks need to be performed to plan
basis (i.e. once a month) in the context
for this crucial step:
of a hand hygiene programme;
• Information must be gathered on any
• this is also essential for the purchasing
and all local producers of alcohol-based
department to foresee the amount of
handrubs and on regional and international
alcohol-based handrub and other products
distributors who may be interested in
to order / produce.
supplying to your market;
Where At the central purchasing department of the
• senior managers and the hand hygiene
health-care facility or at the pharmacy.
programme co-ordinator should use the
tool to compile and present all of the When Initially during the baseline evaluation (step 1, see
relevant information. III.2.1), and with once-monthly or every 3-5 months
repetition throughout the hand hygiene programme.
Who The tool should be used mainly by health-care
workers in the central purchasing department
of the facility. This task needs cooperation with
the pharmacy, central supply and possibly the
engineering departments.
How Via a monitoring sheet / protocol with blank
fields to be filled in by relevant personnel.

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PART II GUIDE TO IMPLEMENTATION

Protocol for Evaluation of Tolerability and Acceptability of Protocol for Evaluation and Comparison of Tolerability and
Alcohol-based Handrub in Use or Planned to be Introduced: Acceptability of Different Alcohol-based Handrubs: Method 2
Method 1
What A protocol to compare the tolerability and
What A protocol for evaluation of tolerability acceptability of different alcohol-based
and acceptability of a single alcohol-based handrubs. This tool includes two different
handrub product. This tool includes two different components:
components: • a questionnaire for the subjective evaluation
• a questionnaire for the subjective evaluation of hand hygiene practices, the product itself
of hand hygiene practices, the product and the skin condition following use;
itself and the skin condition following use; • a scale for the objective evaluation of
• a scale for the objective evaluation of the skins condition following use.
the skin conditions following use.
Why Tolerability and appreciation of alcohol-based
Why Tolerability and appreciation of alcohol-based handrub by health-care workers is a crucial
handrub by health-care workers is a crucial factor influencing successful implementation
factor influencing successful implementation and prolonged use.
and prolonged use.
Where In clinical settings where there is an interest
Where In clinical settings where the alcohol-based in comparing the tolerability and acceptability
handrub either has been newly distributed or of various alcohol-based handrubs (e.g. in
is in use and there is an interest in assessing the context of a product selection process).
its tolerability and acceptability. This protocol This protocol is meant to be applied in
is meant to be applied in settings where settings where an average of at least 30 hand
an average of at least 30 hand hygiene hygiene opportunities occurs daily for each
opportunities occurs daily for each health-care worker.
health-care worker.
When Testing of a new product / after the introduction
When Testing of a new product / after the introduction of the new product. The protocol design requires
of a product. The protocol design requires at at least 3–5 consecutive days of exclusive use of
least 3–5 consecutive days of exclusive use of the test product and one month of routine use.
the test product and one month of routine use.
Who User: a trained observer in collaboration with the
Who User: a trained observer in collaboration with the programme co-ordinator and the pharmacist
programme co-ordinator and the pharmacist
Population of the survey: 40 health-care workers
Population of the survey: 40 health-care workers should be selected to perform this test:
should be selected to perform this test:
• questionnaire for subjective evaluation –
• questionnaire for subjective evaluation –
health-care workers using the product,
health-care workers using the product,
involved in the survey;
involved in the survey;
• scale for objective evaluation – a trained • scale for objective evaluation – a trained
observer evaluating the health-care observer evaluating the health-care
workers involved in the survey. workers involved in the survey.

How Use this tool according to the instructions How Use this tool according to the instructions
accompanying the protocol. A similar protocol accompanying the protocol. A similar protocol
to be used to compare different products is to evaluate a single product is also available
also available (Protocol for Evaluation and (Protocol for Evaluation of Tolerability and
Comparison of Tolerability and Acceptability of Acceptability of Alcohol-based Handrub in
Different Alcohol-based Handrubs: Method 2). Use or Planned to be Introduced: Method 1).

14
 GUIDE TO IMPLEMENTATION PART II

Using the tools for system change – examples of Example 2: health-care facilities where the alcohol-based handrub is
already available but where system change goals have not been fully
possible situations at the health-care facility
achieved according to the WHO recommendations.

Example 1: health-care facilities with serious deficiencies in

Key actions:
infrastructure for hand hygiene.
• Evaluate if the alcohol-based handrub product in use complies
If your health-care facility has no or only a few sinks as well as with the quality criteria recommended by WHO in the Alcohol-based
water, soap and towel provision deficiencies: Handrub Planning and Costing Tool.
• start by using the ward infrastructure survey to assess the • Consider whether the product is actually well-tolerated and
availability and appropriateness of the infrastructure, including sinks; appreciated by health-care workers.
• according to the results, then discuss with your chief executive – If necessary, conduct the Protocol for Evaluation of Tolerability
officer (CEO)/director/ senior managers the need for complying and Acceptability of Alcohol-based Handrub in Use or Planned
with the WHO recommendations of having a sink/patient-bed ratio to be Introduced: Method 1.
of at least 1:10 and for the continuous provision of safe water, – If necessary, select a new product or evaluate local production.
soap and disposable towels at all sinks.
• Using the Ward Infrastructure Survey, determine whether the
products required for hand hygiene (alcohol-based handrub, soap
If an alcohol-based handrub is not available:
and disposable towels) are permanently available facility-wide
• use the alcohol-based handrub planning and costing tool for or only in some clinical settings.
the criteria to select such a product;
• Using the Ward Infrastructure Survey, determine whether products
• evaluate the availability of alcohol-based handrubs from the market; are appropriately positioned at the point of care according to the
definition included in this guide.
• consider the possibility of producing an alcohol-based handrub
formulation locally, either at your pharmacy or at an external facility, • Implement actions according to this assessment in order to make
according to the Guide to Local Production of WHO-recommended the products permanently available at each point of care. For
Handrub Formulations; example, make sure that the alcohol-based handrub dispensers
are located precisely at each point of care (e.g. at each bedside
• both for products procured from the market and for locally produced
and not at the room entrance). If necessary, increase the number
formulations, consider testing their tolerability and acceptability
of dispensers and also provide different types of dispensers (e.g.
by health-care workers by using the Protocol for Evaluation of
wall-mounted dispensers, pocket bottles, dispensers affixed to
Tolerability and Acceptability of Alcohol-based Handrub before
the furniture). If possible, ensure that the sink/patient-bed ratio is
introducing them widely within the facility.
well above 1:10.

• Secure an adequate annual budget to provide full hand hygiene

Criteria to consider when deciding whether to purchase
resources in all wards and departments at all times.
or produce alcohol-based handrub
Example 3: health-care facilities where system change is well advanced
Purchase from the • Availability (alcohol-based handrub is available at each point of care facility-wide,
market – criteria a safe water supply is always available, the sink/patient-bed ratio is
• Efficacy
well above 1:10, soap and disposable towels are available at each sink,
• Tolerability products are well-tolerated and accepted by health-care workers).
• Cost
Focus on long-term actions:
• Complete the Ward Infrastructure Survey at regular, pre-determined
Produce locally • Existence of suitable facilities for production
time intervals to help identify, on an on-going basis, potential
using WHO
• Existence of suitable facilities for storage deficiencies in infrastructure;
formulation –
criteria • Availability of local technical expertise • Continue to secure an adequate annual budget to provide full
(e.g. pharmacists) hand hygiene resources in all wards and departments at all times.

• Availability of raw materials

Accessing the Tools
• Availability and affordability of dispensers
www.who.int/gpsc/en/
• Overall anticipated costs

15
PART II GUIDE TO IMPLEMENTATION

TRAINING / EDUCATION Similarly, observers should receive full training and become
able to detect hand hygiene opportunities correctly according to
the method proposed by WHO and to the “My 5 Moments for Hand
Training / Education – Hygiene” approach (see also section II.3 related to evaluation and
definitions and overview feedback). Taking a rigorous approach, observers should be validated,
i.e. their capacity to carry out their tasks adequately should be
Education is a critical success factor and represents one of
confirmed by testing.
the cornerstones for improvement of hand hygiene practices.
Activities to train trainers and observers should be led by the hand
All health-care workers require full training / education on the hygiene programme co-ordinator, provided that he or she has
importance of hand hygiene, the “My 5 Moments for Hand Hygiene” good knowledge of infection control, and should take place in
approach and the correct procedures for hand washing and hand the facility preparedness phase (step 1, section III.2.1).
rubbing. By disseminating clear messages, not open to personal
The crucial role of trainers and observers should be clearly
interpretation, with a user-centred standardized approach, such
acknowledged by the health-care facility by allocating protected time to
training / education aims to induce behavioural and cultural change
these activities. Where a hospital-wide campaign is being implemented,
and ensure that competence is deep-rooted and maintained among
trainers ideally should work in pairs to ensure the maximum spread of
all staff in relation to hand hygiene.
messages in a consistent manner.

As facilities move across the hand hygiene improvement

Plans for health-care workers’ training should be made during the
continuum, it is expected that they will establish a robust programme
facility preparedness phase (step 1, section III.2.1) and should include
of education on hand hygiene and provide regular training to all
decisions about how much time will be allocated to training as well as
health-care workers, including new starts as well as regular updates
about the specific clinical settings where training / education will be
and competency checks of existing and previously-trained staff.
provided in the first instance (e.g. priority according to risk for HCAI).
At a minimum, basic training on the importance of hand hygiene is
essential to ensure patient safety in all health-care facilities.
Staff education is a key element of the implementation
phase (step 3, see section III.2.3) of a hand hygiene improvement
Education is a vital strategy element which integrates strongly
programme. In some settings where the resources that can be
with all the other essential strategy components. Indeed, without
invested in continuous training are limited, it will be necessary to
appropriate training it is unlikely that system change will lead to
provide education on basic principles of microbial transmission
behavioural change with the actual adoption of alcohol-based handrubs
and indications for hand hygiene. A problem-solving approach
and sustained improvement in hand hygiene compliance. On the other
should be employed, where trainees are presented with scenarios
hand, evaluation and feedback especially about local compliance rates
that encourage them to apply theoretical principles.
and results from the knowledge test (by raising awareness of existing
gaps and defective practices), trigger attention to the concepts targeted Staff within health-care facilities can change frequently, and existing
by education. In addition, most types of reminders are developed to staff have the pressure of remembering a number of standards they
call attention to key educational messages. Finally, building a strong must meet during their day-to-day activities. Therefore, following
and genuine institutional safety culture is inherently linked to effective an intensive induction period, training activities should be repeated
educational interventions. periodically in order to include newly recruited staff and to update
knowledge for the others.
In the context of a hand hygiene improvement programme,
the targets for training at different levels are trainers, observers and Basic educational sessions for trainers, observers and health-care
health-care workers. A top-down approach to training is recommended workers should focus on:
whereby the hand hygiene programme co-ordinator, together with
• background to WHO Patient Safety and the First Global
other key players at the facility (senior managers or a committee if
Patient Safety Challenge;
one exists), will identify the individuals capable of fulfilling the role
of trainers and observers. • definition, impact and burden of HCAI;

The trainers will be in charge of delivering training / education to • major patterns of transmission of health care-associated
health-care workers, including providing practical demonstrations pathogens, with a particular focus on hand transmission;
of how and when to perform hand hygiene according to the “My
• prevention of HCAI and the critical role of hand hygiene;
5 Moments for Hand Hygiene” approach. For these reasons, the
trainer should preferably have a basic knowledge of infection control, • WHO Guidelines on Hand Hygiene in Health Care and their
experience of education as well as of having delivered health-care implementation strategy and tools, including why, when and
at the bedside. Ideally, he or she should be an influential and credible how to perform hand hygiene in health-care.
leader (e.g. chief nurse / matron / doctor / head of another key
department or discipline). Additional sessions should be dedicated exclusively to observers,
to learn the proposed method for observation and to practice its use.
Future trainers should be briefed on the key messages to be
spread and should be supported to become familiar with the tools Facilities should consider implementing a system of checking
available for training; in most cases a formal training of the trainers on the competence of all health-care workers who have received
should be organized by the hand hygiene programme co-ordinator. hand hygiene training. This could take the form of an annual training
course or a practical hand hygiene demonstration workshop to
confirm competence in relation to correct hand hygiene techniques
at the correct moments. Utilising the hand hygiene knowledge survey
will also fulfil the purpose of checks on competence.

16
 GUIDE TO IMPLEMENTATION PART II

Tools for training / education – tool Slides for the Hand Hygiene Co-ordinator
descriptions
The key tools described in this section aim to direct and support
What A PowerPoint slide deck entitled ‘Health
health-care facilities to prepare and deliver training / education. Care Associated Infection and Hand Hygiene
Improvement’ to assist hand hygiene leads
(especially programme co-ordinators) in
The range of tools that can be used for education is
represented in the figure below: explaining the need for hand hygiene to senior
managers and other key players. In particular:

• to advocate standards of hand hygiene;

Slides for Education • to explain the importance of the “My 5
Slides for the
Sessions for Trainers, Moments for Hand Hygiene” approach;
Hand Hygiene
Observers and • to outline the facility’s action plan to
Co-ordinator
Health-Care Workers improve hand hygiene.

Hand Hygiene Slides Accompanying Why Because a representative responsible for, or

Training Films the Training Films interested in, planning initiatives to improve
hand hygiene will need to communicate the
importance of hand hygiene and the planned
Hand Hygiene Hand Hygiene activities to others.
Glove Use
Technical Reference Why, How and
Information Leaflet
Manual When Brochure
Where At meetings.

Frequently Asked Key Scientific

Questions Publications When Prior to initiating or implementing hand hygiene
improvement strategies (step 1, section III.2.1).

Sustaining
Improvement – Who The tool should be used by:
Additional Activities
• The representative responsible for planning
for Consideration by
initiatives to improve hand hygiene (the
Health-care Facilities
hand hygiene programme co-ordinator); and
• parties interested in catalysing initiatives to
Your 5 Moments for improve hand hygiene at health-care facility
Observation Tools to communicate the importance of hand
Hand Hygiene Poster
hygiene with senior managers and others.

Observation Tools – described in the evaluation and feedback section How A slide presentation by the hand hygiene co-
ordinator to others at the facility using visual
Your 5 Moments for Hand Hygiene Poster – described in the Reminders aids or paper copies, detailing the slide deck
in the workplace section template and other local information.

17
PART II GUIDE TO IMPLEMENTATION

Slides for Education Sessions for Trainers, Observers Hand Hygiene Training Films and Accompanying Slides
and Health-Care Workers
What • A series of scenarios to help convey the
What A PowerPoint slide deck including the key “My 5 Moments for Hand Hygiene” approach
concepts related to the WHO hand hygiene and the appropriate technique for hand
improvement strategy and that can be used to: rubbing and hand washing;
• train the trainers in order to make them • a PowerPoint slide set to accompany
aware of the essential learning objectives the films and explain the content and
and key messages to be transmitted to educational messages of the different
health-care workers; scenarios.
• train the observers responsible for
monitoring hand hygiene compliance at Why Because trainers and observer should achieve
the health-care facility to understand the a solid understanding of the “My 5 Moments
basic principles of hand hygiene and for Hand Hygiene” approach and all health-
the aims and methods of hand hygiene care workers within a facility should receive
observation; regular training / education on the importance
of hand hygiene, indications to perform it and
• provide comprehensive training for
the correct procedures for handrubbing and
all health-care workers.
handwashing.

Why Because trainers, observers and all health-care

Where During training sessions organised by the facility
workers within the facility should understand
for all health-care workers.
the importance of hand hygiene, the “My 5
Moments for Hand Hygiene” approach and the
correct procedures for hand rubbing and hand When • Following the presentation of the Education
washing. Sessions for Trainers, Observers and
Health-Care Workers;
Where At training sessions organised by the facility for: • at any subsequent times deemed
appropriate at local level;
• training the trainers
• during sessions to teach observers how
• training the observers
to use the observation form and to validate
• educating all health-care workers
their performance to record compliance
while evaluating health-care worker hand
When • At the start of initiating a hand hygiene hygiene practices.
improvement strategy (step 1, section III.2.1)
to train the trainers and the observers; Who Users:
• during regular training sessions for all • hand hygiene programme co-ordinator
health-care workers, including training
• trainers
for new starts and regular updates for
previously-trained health-care workers Targets:
(step 3, section III.2.3). • trainers
• observers
Who Users:
• health-care workers
• hand hygiene programme co-ordinator
• trainers
How By trainers showing the films to health-care
Targets: workers or observers during specific
• trainers designated training sessions and providing
further explanations.
• observers
• health-care workers

How A slide presentation in a single training session

of approximately 2 hours (excluding the part for
observers which requires at least one additional
hour) or split into multiple shorter sessions
depending on the local situation. More than
one session is recommended, especially for
the observers who should have an additional
session. It is recommended that the hand
hygiene training films are used during or
following the education session, in which
case the session duration increases.

18
 GUIDE TO IMPLEMENTATION PART II

Hand Hygiene Technical Reference Manual Frequently Asked Questions

What A manual introducing the importance of HCAI
What A question-and-answer document of some
and the dynamics of cross-transmission and
commonly-asked questions on hand hygiene.
explaining in details the “My 5 Moments for
Hand Hygiene” concept, the correct procedures
Why Because any professionals involved in the hand
for handrubbing and handwashing, and the
hygiene improvement programme are likely to
WHO observation method.
have questions regarding the background of
Why Because trainers should identify the key WHO Patient Safety in hand hygiene initiatives,
messages to be transmitted during educational hand hygiene and specific issues related to
sessions; all health-care workers within a facility promotion as well as the WHO multimodal hand
should understand and comply with the “My hygiene improvement strategy and on the “My 5
5 Moments for Hand Hygiene” approach and Moments for Hand Hygiene” approach.
the correct procedures for handrubbing and
handwashing; observers should learn to apply Where • In the trainers and observers training
the basic principles of observation. sessions to pre-empt common questions;
Where To the clinical settings where the hand hygiene • during the training / education sessions;
improvement strategy is being implemented.
• within a setting’s library / reference facility.
When Before or during training sessions (step 3,
section III.2.3). When At any time, both proactively to train others on
Who This tool should be used by: explanations to the “My 5 Moments for Hand
• trainers Hygiene” and as required when questions arise,

• observers
Who This tool should be used by:
• all health-care workers
• hand hygiene programme co-ordinator,
How • The hand hygiene co-ordinator trainers and observers, to help them
should distribute the manual to trainers respond to potential queries from
and observers; health-care workers;
• the trainers should distribute the manual to • all health-care workers.
health-care workers during training sessions.
How • By presenting the document during
training sessions;

Hand Hygiene Why, How and When Brochure • by referring all health-care workers with access
to the internet to the www.who.int/gpsc/en/
What A brochure including the key educational website where the Frequently Asked
messages related to why, how and when for Questions are featured. This can be
hand hygiene that health-care workers can keep done by stating this in the facility’s
and refer to after the training sessions. documents on hand hygiene or by
Why Because all health-care workers within a facility giving the web address during training /
should understand and comply with the “My education sessions.
5 Moments for Hand Hygiene” approach and
the correct procedures for handrubbing and
handwashing.
Where • In the clinical settings where the hand
hygiene improvement programme is
being implemented;
• in clinical settings where training has
already been given and short updates
or reminders are deemed necessary.
When During training sessions (step 3, section III.2.3).
Who This tool should be used by all health-care
workers in the clinical settings where the hand
hygiene improvement programme is being
implemented.
How Describe and distribute the brochure during
training sessions.

19
PART II GUIDE TO IMPLEMENTATION

Key Scientific Publications Sustaining Improvement –

What A list of peer-reviewed publications to direct Additional Activities for Consideration by Health-Care Facilities
interested parties to noteworthy data and What Guidance for health-care facilities interested in
commentaries regarding hand hygiene enhancing and sustaining existing hand hygiene
Why Because there are many additional sources improvement by organising and using additional
of information on hand hygiene that may be tools or activities as part of their long-term
of interest or use during training / educating action plans.
health-care workers Why Because some health-care facilities already
Where • During training / education sessions; have well-established hand hygiene
improvement strategies, with excellent
• within a setting’s library / reference facility.
resources and regular training and observation
When At any time, both proactively to support trainers systems in place. For these health-care
in their task and to alert health-care workers to facilities, it is critical to maintain the momentum
the background scientific information on hand and sustain the improvements that have
hygiene as required when questions around the been made.
evidence base arise.
Where In the management and infection control units
Who This tool should be used by: of the health-care facility as part of the planning
• hand hygiene programme co-ordinator, for additional activities.
trainers and observers; When Once health-care facilities have a well-
• all health-care workers interested in established infrastructure and systems for
learning more about hand hygiene training and evaluating hand hygiene and are
looking for additional activities to sustain hand
How • By presenting the list of key scientific
publications during training sessions; hygiene awareness and improvement (step 5,
section III.2.5).
• by referring all health-care workers
with access to the internet to the Who This tool should be used by the hand hygiene
www.who.int/gpsc/en/ website where programme co-ordinator or persons responsible
the Key Scientific Publication’s list is for planning, implementing and maintaining
featured. This can be done by stating this hand hygiene improvement at a health-care
in the facility’s documents on hand hygiene facility.
or by giving the web address during training How The hand hygiene co-ordinator should review
/ education sessions. the tool for guidance and ideas on how to
sustain the momentum and improvements
in hand hygiene at the facility, integrate any
selected activities into the local action plan
Glove Use Information Leaflet for hand hygiene improvement and discuss
it with senior managers and any other key
What A leaflet to explain the appropriate use of gloves professionals.
with respect to the “My 5 Moments for Hand
Hygiene” approach for presentation and / or
distribution to health-care workers to keep and
use as reference.
Why Because all health-care workers need to
understand how and when to correctly use
gloves within the “My 5 Moments for Hand
Hygiene” approach.
Where • In organised training sessions;
• in clinical settings where training has
already been given and short updates
or reminders are deemed necessary.
When During training sessions (step 3, section III.2.3).
Who This tool should be used by all health-care
workers in the clinical settings where the hand
hygiene improvement programme is being
implemented.
How Describe and distribute the leaflet during
training sessions.

20
 GUIDE TO IMPLEMENTATION PART II

Using the tools for training and education – Example 2: health-care facilities where basic staff education is
well-established that are looking to introduce additional activities
examples of possible situations at the
for sustaining hand hygiene compliance.
health-care facility
Example 1: health-care facilities offering little or no hand hygiene If your health-care facility has well-established infrastructure
training to health-care workers. and systems for training and evaluating hand hygiene, the following
additional activities should be considered to sustain hand hygiene
If your health-care facility offers little or no hand hygiene training awareness and improvement:
to health-care workers due to constraints around implementation
caused by limited or no resources, plans to address staff training • education of all health-care workers within the facility on an
should be included in an action plan in order to embed training / on-going basis, checking their competence at the same time;
education within the facility’s culture. • training new trainers and observers at a range of levels;
• basing education on feedback of evaluation data detected
At the very least, the action plan should feature: in all areas on a regular basis;
• the infrastructural constraints to proceeding with an education • ways in which to reliably present their validated hand hygiene
programme (consider the tools for system change when compliance data against HCAI rates;
documenting these constraints); • reviewing and refreshing training / education materials
• the responsibility for finalising the training / education tools to at least annually;
be used locally (based on the tools described in this section); • developing new and innovative ways to train and educate
• the steps to be taken to identify the trainers; (see Sustaining Improvement – Additional Activities for
• the priority health-care workers (areas of the facility, Consideration by Health-Care Facilities);
professional categories) to receive training; • sharing successes with other facilities and publishing findings; and
• the requirements for targeted, priority health-care worker training / • reviewing and refreshing action plans on a more regular basis
education (use the hand hygiene knowledge questionnaire in the with findings presented to all senior management teams.
tools for evaluation and feedback section to support this );
• a timeframe for initiation and completion of training of trainers, Accessing the Tools
observers and health-care workers;
www.who.int/gpsc/en/
• secured time for health-care workers to undertake training;
• incorporation of the training programme into the facility’s
financial plan.

When these parts of the action plan are in place, the first steps
in enhancing staff competence by providing basic training to every
existing and new member of staff should include the following:

• training and discussion sessions for trainers led by the hand

hygiene co-ordinator;

• use of the Education Sessions for Trainers, Observers and Health-

Care Workers to undertake training sessions with integration of
– local data on the burden of HCAI where available
– other information on the main infection control measures
that should be applied locally;

• focus on the “My 5 Moments for Hand Hygiene” approach and

on how to perform hand hygiene during sessions by utilising
the following as a minimum:

– Hand Hygiene Training Films and Accompanying Slides

– Hand Hygiene Technical Reference Manual

– Hand Hygiene Why, How and When Brochure

– Your 5 Moments for Hand Hygiene Poster

– How to Handwash and How to Handrub Posters

– Glove Use Information Leaflet.

21
PART II GUIDE TO IMPLEMENTATION

The WHO surveys are usually carried out by using hard copies of the
EVALUATION AND FEEDBACK related forms; electronic forms are not available but can be created
locally. A specific Data Entry and Analysis Tool is available for each
Evaluation and feedback – survey and includes a pre-prepared framework for data analysis.
definitions and overview Detailed Instructions for Data Entry and Analysis are also available.
Learning how to use the available databases requires some training
Evaluation and repeated monitoring of a range of indicators and time, but it is considered relatively easy.
reflecting hand hygiene practices and infrastructures as well as of
After data entry into the specific database, the hard / electronic copies
knowledge and perception of the problem of HCAI and the importance
must be kept by the hand hygiene programme co-ordinator to be made
of hand hygiene at the health-care facility is a vital component of the
available if checks need to be performed.
strategy to improve hand hygiene. Indeed, it should not be seen as
a component separated from implementation or only to be used for The best strategy for data entry is to start this process as soon as
scientific purposes, but rather as an essential step in identifying areas each tool has been used and when completed forms are available.
deserving major efforts and in feeding crucial information into the action
plan for local implementation of the most appropriate interventions. Feedback of the results of these investigations is an integral part
Continuous monitoring is very helpful in measuring the changes induced of evaluation and makes the evaluation meaningful. Indeed, after the
by implementation (e.g. alcohol-based handrub consumption trends baseline evaluation (see step 2, section III.2.2) in a facility where the
following system change) and to ascertain whether the interventions hand hygiene improvement programme is being implemented for the
have been effective in improving hand hygiene practices, perception first time, data indicating gaps in good practices and knowledge, or a
and knowledge among health-care workers and in reducing HCAI. poor perception of the problem, can be used to raise awareness and
convince health-care workers that there is a need for improvement.
The WHO multimodal hand hygiene improvement strategy On the other hand, after implementation (see step 4, section III.2),
recommends monitoring and evaluation of the following indicators: follow-up data are crucial in order to demonstrate improvement and
thereby sustain the motivation to perform good practices and to make
• hand hygiene compliance through direct observation;
continuous individual and institutional efforts. These data are also very
• ward infrastructure for hand hygiene; useful for identifying areas where further efforts are needed (e.g. certain
• health-care worker knowledge on HCAI and hand hygiene; professional categories that demonstrated limited or no improvement in
• health-care worker perception of HCAI and hand hygiene; hand hygiene compliance and/or other indicators; certain hand hygiene
indications where health-care workers hardly improved).
• soap and alcohol-based handrub consumption.

The results of the surveys can be either disseminated in written

Conducting a baseline evaluation (see step 2, section III.2.2) reports or other means of internal communication or shown during
is important across all levels of the hand hygiene improvement educational and data feedback sessions. The Data Summary Report
continuum, but it is particularly crucial for a facility where a hand Framework tool helps to organize the figures resulting from the
hygiene improvement programme is being implemented for the first analysis and to prepare slides to present the results.
time. It is needed in order to collect information that realistically
reflects current hand hygiene practices, knowledge, perception and Other means of feedback also exist, and each facility should decide
infrastructure. Following the baseline evaluation, the surveys carried how best to communicate the results of the data analysis.
out using the tools described below should be repeated post-
implementation (see step 4, section III.2.4) to follow-up progress A successful strategy would see improvements across all
and confirm that implementation of the hand hygiene initiatives measured activities, behaviours and also health-care worker perception.
translates into improvements in hand hygiene and reduction of
HCAI at the facility. Repeating the surveys will ensure consistency, Key success indicators
comparison of results and measurement of progress.
• increase in hand hygiene compliance
In facilities where hand hygiene promotion is permanently in • improvement in infection control / hand hygiene infrastructures
place, following the initial implementation period, the WHO multimodal
• increase in usage of hand hygiene products
hand hygiene improvement strategy requires at least annual cycles of
evaluation in order to achieve sustainability. Monitoring and evaluation • improved perception of hand hygiene
with feedback therefore continues over a period of years, with the • improved knowledge of hand hygiene
frequency determined by the co-ordinator and key players of the
hand hygiene programme.

Data entry and analysis are an important part of the overall

evaluation. If the facility does not have an epidemiology/statistics unit
where the data can be managed, it will be necessary to identify a person
to whom this task can be allocated. The appointed person should be
able to use basic computer programmes (e.g. Microsoft Office) and
ideally have some basic statistical analysis / epidemiology skills.

22
 GUIDE TO IMPLEMENTATION PART II

Tools for evaluation and feedback – tool Hand Hygiene Observation Tools
descriptions What A set of tools is available to conduct direct
observation of hand hygiene practices and
The range of tools available to support the implementation thus assess compliance:
of evaluation and feedback is represented in the figure below.
• an Observation Form – to be used to
collect data on hand hygiene performance
while observing health-care workers
Observation Tools:
Hand Hygiene during routine care. It also includes
Observation Forms
Technical Reference summary instructions for use;
and Compliance
Manual
Calculation Forms • two Compliance Calculation Forms
(basic and optional) – to help staff calculate
compliance rates easily, based on the
Ward Infrastructure Soap / Handrub data collected in the observation form.
Survey Consumption Survey These are linked to some tools for education
(see section III.2.2) to help the observer
acquire the necessary basic knowledge and
Perception Survey understanding of the principles and methods
Perception Survey for
for Health-Care of observation. These are:
Senior Managers
Workers
• the Hand Hygiene Technical Reference
Manual – a comprehensive training manual
to understand the basic principles of hand
Hand Hygiene
hygiene and in particular the “My 5 Moments
Knowledge
for Hand Hygiene” approach and to explain
Questionnaire for
in details the direct method for observation
Health-Care Workers
proposed by WHO; and

• the Hand Hygiene Why, How and When

Protocol for Protocol for Brochure – a handout summarizing key
Evaluation of Evaluation and principles on why, how and when to perform
Tolerability and Comparison of hand hygiene and on correct glove use.
Acceptability of Tolerability and Why Compliance with hand hygiene, when it is
Alcohol-based Acceptability of indicated during routine care, is the most valid
Handrub in Use Different Alcohol- indicator of health-care workers’ behaviour
or Planned to be based Handrubs: related to hand hygiene. It is therefore one of
Introduced: Method 1 Method 2 the most important success indicators for the
hand hygiene improvement strategy.
Where In all clinical settings where the hand hygiene
Data Entry and Instructions for Data Data Summary improvement programme is being implemented.
Analysis Tool Entry and Analysis Report Framework
When Assess baseline hand hygiene compliance in the
clinical settings where the improvement strategy
will be implemented. Baseline observations
The Data Entry and Analysis Tool, the Instructions for Data Entry must occur prior to implementation.
and Analysis and the Data Summary Report Framework are not
• During the follow-up evaluation (step 4,
described in detail in this guide.
section III.2.4), observation serves to
Ward Infrastructure Survey – described in the section related assess the impact of implementation
to system change. on hand hygiene compliance.

• Observations should then be repeated

Soap / Handrub Consumption Survey – described in the section
regularly, at least annually, to monitor
related to system change.
sustained improvement and to identify
Protocols for Evaluation of Tolerability and Acceptability of areas that need further interventions.
Alcohol-based Handrubs – Methods 1 and 2 – described in the Since it is very important that during repeated
section related to system change. monitoring the observations take place in the
same setting as in the baseline evaluation, it
Hand Hygiene Technical Reference Manual – described in the
is recommended that a list of the observed
section related to education.
settings is kept.

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PART II GUIDE TO IMPLEMENTATION

Hand Hygiene Observation Tools Perception Survey for Health-Care Workers

Who These tools should be used by the observer. What A perception questionnaire about the impact
of HCAI, the importance of hand hygiene as a
The observer should ideally be a professional preventive measure and the effectiveness of the
who has experience in delivering health care at different elements of the multimodal strategy.
the bedside. The observer must be trained to
identify the hand hygiene indications according The questionnaire is available in baseline and
to the “My 5 Moments for Hand Hygiene” follow-up versions. The follow-up version is a
approach and to use the tool. After training, the slightly-modified form of the baseline version
observer should be evaluated regarding his or and includes new questions relating to the
her capacity to detect hand hygiene compliance impact of some interventions, such as the
correctly (see education, section II.2). introduction or modification of the alcohol-
based handrub, the posters and leaflets
How The Hand Hygiene Technical Reference Manual displayed or distributed at the facility, and the
clearly explains how to use the observation and education materials.
calculation forms. Summary instructions for Why It is important to measure health-care workers’
use are also included on the back page of the perception about the importance of hand
observation form. hygiene in health care, as this has been shown
In general, between 150 and 200 opportunities to influence their willingness to embrace
for hand hygiene should be observed in each improvements. Feedback on this piece of
surveyed unit (department, service or ward). information may be useful in demonstrating that
the actual perception does not correspond to
the real burden of HCAI and the importance of
hand hygiene.

Where Across all clinical settings participating in

implementation of the improvement strategy.

When • During the time allocated for baseline

evaluation (step 2, III.2.2), to assess
the baseline perception of HCAI and hand
hygiene among health-care workers before
implementing any improvement intervention;
• during the follow-up evaluation
(step 4, III.2.4) to assess the impact
of implementation on health-care
workers’ perception.

Who User: the programme co-ordinator or any

person in charge of distributing and collecting
the questionnaire.

Population of the survey: health-care workers

in the clinical settings where the hand hygiene
programme is being implemented.

How • Anonymous distribution of the questionnaire;

• ideally through random distribution;
• if randomization is not feasible:
– if only a few wards are involved, the
questionnaire should be distributed to
all health-care workers within a 1-week
period and the completed questionnaires
should be collected 4–5 days later;
– if the programme involves many
wards or the entire health-care facility,
the questionnaire should be distributed
to all health-care workers present at
work on one specific day; it will therefore
be handed out in the morning and
collected at the end of that same day.

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 GUIDE TO IMPLEMENTATION PART II

Health-Care Workers Knowledge Survey Perception Survey For Senior Managers

What A questionnaire with technical questions to What A questionnaire to measure senior executive
assess actual knowledge of the essential managers’ perception about the impact of
aspects of hand transmission and hand HCAI, the importance of hand hygiene as a
hygiene during health care. preventive measure, the different elements
of the multimodal strategy and their vital role
The knowledge needed to answer these
in promoting hand hygiene in an institutional
questions correctly will only be acquired by
safety climate.
undertaking education and training activities.

Why Senior managers’ awareness and commitment

Why Hand hygiene is a simple measure, but its
substantially contribute to the creation of an
improvement is based on the understanding
institutional safety climate and their support
of the means of germ transmission in the
is crucial for building the basis and acquiring
health-care setting and of key indications.
the resources for the implementation of a hand
It is important to assess knowledge among
hygiene improvement programme. For this
health-care workers at baseline and after
reason it is important to assess their perception
educational and training activities.
of the importance of hand hygiene in health
care and to identify key messages that must be
Where In clinical settings where education and communicated in advocacy activities.
training activities take place.
Where In the management unit of the facility.
When The questionnaire can be distributed:
– for the baseline assessment When • During the facility preparedness phase
• either during the period immediately (step 1, section III.2.1) or during the
before starting any educational activity baseline period;
and intervention; or • during the follow-up period (step 4,
• at the beginning of each training section III.2.4) to assess the impact
session (i.e. during the beginning of implementation on senior managers’
of the implementation period). perception.
– for the follow-up assessment
Who User: the programme co-ordinator or any
• either at the beginning of each
person in charge of distributing and collecting
training session; or
the questionnaire.
• during the follow-up evaluation period
Population of the survey: the senior executive
(step 2, see section III.2.4).
managers of the facility.

Who User: the trainers or any person in charge of

How Anonymous distribution of the questionnaire.
distributing and collecting the questionnaire.
The completed questionnaires should be
Population of the survey: health-care workers collected 4–5 days later.
who will be the target of education and training
sessions about hand hygiene.

How The trainer should distribute it. If the results are

intended to remain anonymous, instructions to
create an identity code should be given to each
health-care worker to allow for self-assessment
after training has taken place. The identity code
can be known either to the user only or both to
the user and the trainer, according to locally-
established privacy requirements.

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PART II GUIDE TO IMPLEMENTATION

Using the tools for evaluation and Example 2: health-care facilities where a hand hygiene improvement
programme is already established.
feedback – examples of possible
situations at the health-care facility These facilities are already supposed to have undertaken baseline
and follow-up evaluations of the recommended indicators and
Example 1: health-care facilities embarking on a new hand hygiene to have supportive infrastructure and an ongoing education
improvement programme. programme in place. Monitoring and evaluation remain an
important feature of the enhancement or reinvigoration of an
The immediate priority of these facilities is to collect baseline existing improvement strategy and will provide on-going data
information on the indicators relevant for evaluation of hand hygiene on the progress of the strategy.
infrastructures, practices and knowledge as well as perception of
the problem of HCAI and the importance of hand hygiene at the These facilities will have to focus more on regular monitoring
health-care facility. This is of the utmost importance for identifying of knowledge, perception, infrastructures and performance of hand
the resources needed and for establishing priorities for the hand hygiene through observations in all areas of the facility, with regular
hygiene improvement programme. To gather a comprehensive reports and feedback to health-care workers on the results along
picture, all the surveys indicated above should ideally be undertaken with information on the improvements being made in hand hygiene.
during the preparedness and baseline periods. The sub-sequent step
for measuring the same indicators is the follow-up evaluation, where The frequency of conducting these surveys depends
measuring the same indicators helps in assessing the impact of on local priorities. Observations of hand hygiene practices
the strategy. should be carried out at least annually, but ideally monthly.
Considering that this plan entails the allocation of adequate time Hand hygiene product consumption, especially alcohol-based
and staff to these activities in settings with limited resources and handrub, should be recorded monthly or at time intervals that
having other priorities, the conducting of all surveys might be not allow annual trend calculations (e.g. every 3–4 months). For a
feasible. In these cases, the surveys could be limited to using the sustained improvement, a minimum 5-year cycle of review and
following tools: action planning is recommended.

It is more likely that these facilities will also undertake

monitoring and feedback of HCAI. Indeed, some facilities may
already have a well-established and valid surveillance system.
Tool When to be used
If this is the case, it will provide valuable information on the most
Perception Survey for at least at baseline reliable indicators for assessing the effectiveness of a hand hygiene
Health-Care Workers improvement strategy. The measurement of monthly incidence
trends for at least 1 year, both before and after implementation
of the hand hygiene improvement strategy, would be ideal.
Ward Infrastructure Survey at baseline and follow-up
Depending on the scope of the programme, prevalence surveys
in the areas where hand hygiene promotion takes place, before
Soap / Handrub monthly or every 3–4 months
and after implementation, may also be suitable provided that
Consumption Survey (ongoing)
an adequate sample size calculation is performed.

Observation Form at baseline and follow-up A system to monitor HCAI rates should be considered and
included in the action plan. Specific targets for improvement
in HCAI rates at the facility should be agreed upon by the hand
These facilities may not have reached the stage where hygiene team along with senior management and included in
implementation of regular evaluation, including observations the action plan.
and feedback is achievable. However, a time frame for evaluation
If local HAI rates are available, it should be possible to calculate
should be considered in long-term action plans.
the cost–effectiveness of introducing alcohol-based handrub
and possibly also of the entire improvement strategy.

Sharing lessons learned with WHO Patient Safety

WHO Patient Safety are interested in receiving feedback from the hand
hygiene co-ordinators on the process of implementation of a hand
hygiene action plan and also in receiving data on improvements made.

Contact details and an area for posting case studies on best

practice can be found on WHO Patient Safety’s website at
www.who.int/gpsc/en/.

Accessing the Tools

www.who.int/gpsc/en/

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 GUIDE TO IMPLEMENTATION PART II

REMINDERS IN THE WORKPLACE Your 5 Moments For Hand Hygiene Poster

What Poster visualizing the five moments (indications)
Reminders in the workplace – when to perform hand hygiene during health-
definitions and overview care delivery.
Why Because all health-care workers need to
Reminders in the workplace are key tools to prompt and remind visualize and endorse the key messages
health-care workers about the importance of hand hygiene and about on hand hygiene, i.e. when to perform it.
the appropriate indications and procedures for performing it. They Where To be displayed at the point of care and
are also means of informing patients and their visitors of the standard prominent areas throughout the health-care
of care that they should expect from their health-care workers with facility.
respect to hand hygiene.
When To be displayed during the implementation step
Posters are the most common type of reminder. The implementation (step 3, section III.2.3), to be kept at all times
toolkit includes three WHO-branded standard posters to visualize and replaced / refreshed as necessary.
the “My 5 Moments for Hand Hygiene” approach and the correct
Who User: the programme co-ordinator or any
procedure to perform handrubbing and handwashing.
person in charge of displaying the posters
Other types of reminders are pocket leaflets that individual health-care in all clinical settings.
workers can carry in their pockets, stickers posted at the point of care,
Targets: all health-care workers having direct
special labels including prompting slogans stuck on alcohol-based
contact with patients; the patients and their
handrub dispensers and gadgets such as badges with the hand
visitors to be aware of best hand hygiene
hygiene logo.
practices.
How Display the posters at the point of care
Reminders in the workplace should be a feature of the action plans
for facilities implementing hand hygiene improvement programmes at all and refresh when necessary, according
levels. Reminders should be used and displayed in all clinical settings of to the action plan.
the health-care facility during the implementation phase (step 3, section
III.2.3) and should be updated or refreshed regularly. Reminders can be
directed at health-care workers, patients and visitors.
How to Handrub and How to Handwash Posters

Local adaptation of the WHO reminders and development of new What Posters explaining the correct procedures
ones visualizing the WHO recommendations on hand hygiene certainly for handrubbing and handwashing that are
facilitates local uptake of the strategy by using the best terminology designed to remind health-care workers to
and images according to the culture. perform hand hygiene.
Why Because all health-care workers need to
Health-care workers will also have access to local hand hygiene
guidelines or standard operating procedures to inform and remind understand the correct procedures for
them of what good hand hygiene practice means at their place of work. handrubbing and handwashing.
Where To be displayed throughout the health-care
Tools for reminders in the workplace – tool facility in prominent areas where care takes
place. The How to Handrub Poster will be
descriptions best placed at each point of care; the How to
Handwash Poster should be displayed beside
The range of tools that can be used as reminders in the workplace each sink (which ideally should coincide with
is represented in the figure below. each point of care).
When To be displayed during the implementation step
(step 3, section III.2.3), to be kept at all times
Your 5 Moments How to How to and replaced / refreshed as necessary.
for Hand Hygiene Handrub Handwash
Who User: the programme co-ordinator or any
Poster Poster Poster
person in charge of displaying the posters
in all clinical settings.

Hand Hygiene: Targets: all health-care workers having direct

When and How contact with patients; the patients and their
Leaflet visitors to be aware of best hand hygiene
practices.
How Display the posters at the point of care and
SAVE LIVES: refresh when necessary, according to the
Clean Your Hands action plan.
Screensaver

27
PART II GUIDE TO IMPLEMENTATION

Hand Hygiene: When and How Leaflet Using the tools for reminders in the
workplace – examples of possible situations
What A pocket leaflet summarizing the key messages
related to when and how hand hygiene should
at the health-care facility
be performed Example 1: facilities embarking on a new hand hygiene improvement
programme and/or with limited resources.
Why Because all health-care workers within a facility
should understand and comply with the “My Key actions:
5 Moments for Hand Hygiene” approach and
• Evaluate current resources, including local expertise, available for
the correct procedures for handrubbing and
investing in reminding health-care workers about hand hygiene.
handwashing
• Establish the requirements and consider a timeframe for addressing
Where To be distributed in the clinical settings where these requirements.
the hand hygiene improvement programme is
• Consider the potential costs in the financial plan and secure
being implemented.
a budget.

When To be displayed during the implementation step • In the first instance, having to commit to many actions in order
(step 3, section III.2.3), ideally during training to implement a new hand hygiene improvement programme, these
sessions. facilities might decide to use the tools already available in the WHO
implementation toolkit without any adaptation.
Who This tool should be used by all health-care Example 2: facilities where the hand hygiene improvement programme
workers in the clinical settings where the hand is already well established.
hygiene improvement programme is being
implemented.
Key actions:

How Distribute the leaflet during training sessions for • Consider the adaptation of reminders to the national / local culture,
the health-care workers to keep as a personal including images, a priority in the facility action plan.
tool and reference.
• Ensure that the reminders displayed are always in good condition.

• Include in the facility long-term action plan a requirement to refresh

the reminders by changing the images and the slogans regularly.
SAVE LIVES: Clean Your Hands Screensaver • Local adaptation of the reminders could best be achieved by
challenging health-care workers to draw images for them.
What A screensaver for computer screens.
This process could be facilitated with the support of a professional
designer who would capture the health-care workers’ ideas.
Why To remind health-care workers to perform
This activity would help generate individual participation in
hand hygiene at the appropriate moments.
the programme and inspire discussions about the key messages
for hand hygiene.
Where To be displayed on computers used by
health-care workers at the facility. • Use reminders other than posters.

Sharing lessons learned with WHO Patient Safety

When At all times.
WHO Patient Safety is interested in seeing locally-produced reminders.
Who This tool should be used by all health-care Contact details and instructions for posting your reminders can be
workers with access to a computer in the found on WHO Patient Safety’s website at www.who.int/gpsc/en/
clinical settings where the hand hygiene
improvement programme is being implemented.
Accessing the Tools

How Replace the current screensaver with the www.who.int/gpsc/en/

SAVE LIVES: Clean Your Hands Screensaver
to remind all health-care workers to perform
hand hygiene.

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 GUIDE TO IMPLEMENTATION PART II

In settings where hand hygiene promotion is very advanced,

INSTITUTIONAL SAFETY CLIMATE senior managers and leaders will have repeatedly demonstrated full
commitment to hand hygiene by long-term allocation of resources and
Institutional safety climate – will be proud of the excellent standards achieved at their facility. Hand
definitions and overview hygiene will be used as a quality indicator on a regular basis. In these
settings, all health-care workers will be committed to hand hygiene and
The institutional safety climate refers to creating an environment will be fully accountable for their compliance with the “My 5 Moments
and the perceptions that facilitate awareness-raising about patient for Hand Hygiene” approach.
safety issues while guaranteeing consideration of hand hygiene
improvement as a high priority at all levels, including Particularly but not only in these settings, patients will be involved
in the creation of an institutional safety climate. Patient awareness
• active participation at both the institutional and individual levels;
and understanding of hand hygiene are indeed important aspects
• awareness of individual and institutional capacity to change to be considered in the action plans of a multimodal hand hygiene
and improve (self-efficacy); and improvement programme. Positive encouragement by patients of
health-care workers to motivate them to implement good hand hygiene
• partnership with patients and patient organizations. could improve compliance with the “My 5 Moments for Hand Hygiene”
approach. Performing correct hand hygiene in view of the patient can
At the institutional level, this component of the hand hygiene promote patient confidence and partnership between patients and
improvement strategy represents the foundation for implementing health-care workers to make care safer.
and sustaining the hand hygiene improvement programme which
must be embedded in a climate that understands and prioritizes basic
Tools for institutional safety climate – tool
safety issues.
descriptions
At the individual level, this component of the strategy is important
with respect to advocacy of hand hygiene by all health-care workers The range of tools that can be used as reminders in the
as a priority and for their motivation to practice optimal hand hygiene workplace is represented in the figure below:
as an act showing their commitment to do no harm to patients. Through
the creation of an institutional safety climate, both the institution and
each health-care worker become aware of their capacity to make a Template Letter to Template Letter
change and catalyse improvement across all indicators. Communicate Hand to Advocate
hygiene Initiatives Hand Hygiene
The creation of an institutional safety climate must be a priority to Managers to Managers
for all hand hygiene promotion, regardless of the level of progress in
hand hygiene improvement at the facility, and is essential during any
implementation phase of the programme. Much effort must be made at Guidance on
the beginning to create the motivation for embarking on hand hygiene Engaging Patients
promotion (step 1, facility preparedness phase, section III.2.1). It is and Patient
important that decision-makers and influential people are engaged in the
planning process at the earliest possible stage and
that this engagement continues during implementation and beyond.
Sustaining
On a continuum of progress, other areas of patient safety should be Improvement –
simultaneously or subsequently explored, and the safety climate must Additional Activities
become deeply-rooted in the institutional tradition and approach. This for Consideration
requires continuous progress in the development of stable systems for by Health-Care
adverse event detection and quality assessment, hand hygiene being Facilities
one of the key indicators.

Influential health-care workers and individuals can contribute greatly

SAVE LIVES:
to the successful development of a safety climate. In addition to
Clean Your Hands
professionals belonging to the facility, these influential people may
Promotional Video
come from external organizations, non-government organizations
and professional bodies that can give advice on effective strategies
to improve patient safety.

29
PART II GUIDE TO IMPLEMENTATION

Template Letter to Advocate Hand Hygiene to Managers Template Letter to Communicate Hand Hygiene Initiatives
to Managers
What A template letter for use and adaptation by a
local hand hygiene co-ordinator to aid initial What A template letter for use and adaptation by
dialogue with key decision makers concerning a local hand hygiene co-ordinator to convey
investment in hand hygiene improvement. clear messages concerning the improvement
initiatives and state explicitly where action is
required and by whom.
Why To help a local hand hygiene programme co-
ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement Why To help a local hand hygiene programme co-
initiatives within a health-care facility, to ordinator or person(s) interested in introducing
advocate and encourage commitment, or reinvigorating hand hygiene improvement
support and investment from key decision initiatives within a health-care facility, to
makers within the facility. communicate important messages concerning
the improvement initiatives to key senior
managers/leaders.
Where In the hospital management unit of
the health-care facility.
Where In the hospital management unit of the
health-care facility.
When At the initial stages of the implementation
of a hand hygiene improvement programme
(step 1, section III.2.1). When At the initial stages of a hand hygiene
improvement programme (step 1, section
III.2.1).
Who User: a local hand hygiene programme co-
ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement Who User: a local hand hygiene programme co-
initiatives within a health-care facility. ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement
Targets: senior managers of the
initiatives within a health-care facility.
health-care facility.
Targets: senior managers of the
health-care facility.
How The user can insert local information or modify
the text of the template letter to reflect local
style and send it. A similar template letter is How The user can insert local information or modify
also available to help communicate important the text of the template letter to reflect local
messages concerning the improvement style. A similar template letter is also available
initiatives to key senior managers/leaders to help in advocating and encouraging
(Template Letter to Communicate Hand commitment, support and investment in the
Hygiene Initiatives to Managers). initiative from key decision makers within the
health-care facility (Template Letter to Advocate
Hand Hygiene to Managers).

30
 GUIDE TO IMPLEMENTATION PART II

Guidance on Engaging Patients and Patient Organizations Sustaining Improvement –

in Hand Hygiene Initiatives Additional Activities for Consideration by Health-Care Facilities

What Guidance on empowering patients, engaging What Guidance for health-care facilities interested in
with patient organizations and developing a enhancing existing hand hygiene improvement
programme to educate patients and inspire on additional tools or activities that the facility
patient advocacy for hand hygiene improvement could organise as part of their long-term action
in health care. plans to maintain momentum and continue to
improve (or at least maintain) hand hygiene
improvement.
Why Because WHO Guidelines on Hand Hygiene in
Health Care encourage partnerships between
patients, their families and health-care workers Why Because for health-care facilities already having
to promote hand hygiene in health-care settings well-established hand hygiene improvement
and their input can have a positive effect on strategies, with excellent resources and regular
improvement. training and observation systems in place, it is
critical to maintain the momentum and sustain
the improvements achieved.
Where In the hospital management unit of the
health-care facility.
Where In the hospital management unit of the
health-care facility.
When Once health-care facilities have a well-
established hand hygiene improvement
programme (consider it for long-term plans When Once health-care facilities have well-established
development during step 5, see section III.2.5). infrastructure and systems for training and
observing hand hygiene (especially for long-
term plans development during step 5, see
Who This tool should be used by the hand hygiene section III.2.5).
programme co-ordinator in facilities where it is
planned to empower and engage patients or
patient organizations in hand hygiene initiatives. Who This tool should be used by the hand hygiene
programme co-ordinator, senior managers, or
persons responsible for planning, implementing
How The hand hygiene programme co-ordinator can and maintaining hand hygiene improvement
review the tool for guidance and ideas on how at a health-care facility.
to engage patients and patient organizations,
and integrate any selected activities into
their long-term action plan for hand hygiene How The hand hygiene programme co-ordinator
improvement. should review the tool for guidance and
ideas on how to sustain the momentum and
improvements in hand hygiene at their facility,
and integrate any selected activities into
their long-term action plan for hand hygiene
improvement.

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PART II GUIDE TO IMPLEMENTATION

Example 2: health-care facilities where the hand hygiene improvement

SAVE LIVES: Clean Your Hands Promotional DVD
programme is already well established.
What A short film with powerful imagery to promote
hand hygiene and the SAVE LIVES: Clean Your
Key actions:
Hands initiative.
Why To inspire all health-care workers to advocate • Prepare a long term plan featuring key actions that will ensure
and perform optimal hand hygiene during that the institutional safety climate fully reflects hand hygiene.
health-care delivery and motivate patients • Establish hand hygiene on the list of indicators for assessment
to participate in hand hygiene improvement of quality of health care delivered at the facility.
initiatives.
• Set annual goals for hand hygiene improvement (e.g. improving
Where To be shown at meetings, educational sessions
hand hygiene compliance above certain rates, according to
and public areas in a facility where patient
the local situation).
empowerment is promoted, as an impactful
way to inspire and advocate hand hygiene. • Establish reward schemes for health-care workers for optimal
When At the opening and closure of meetings in compliance with the “My 5 Moments for Hand Hygiene” approach
which a clear message is required regarding or protocol for hand hygiene based on the WHO Guidelines for
the importance of hand hygiene (e.g. education Hand Hygiene in Health Care.
sessions, training sessions, team meetings, • Review any existing activity involving patients / patient
advocacy meetings, staff briefings). organizations in health-care improvement and make a plan
Who Users: the hand hygiene programme for hand hygiene improvement.
co-ordinator, senior managers, trainers.
• Implement activities involving patients in hand hygiene promotion.
How Show the short film to health-care workers This could include the following:
or the public before providing more details
on hand hygiene initiatives to provide context – patient surveys to gain their perspective on the best way
and a powerful message about hand hygiene to participate in hand hygiene promotion;
in health care. – development and dissemination of information leaflets /
posters for patients to inform; them of the hand hygiene
Using the tools for institutional safety initiatives and how they can encourage and support them;
climate – examples of possible situations – initiatives (stands at the facility entry, activities at ward level)
at the health-care facility to catalyse patient advocacy for hand hygiene promotion;

Example 1: health-care facilities embarking on a new hand hygiene – education of patients to identify the moments when
improvement programme. health-care workers should perform hand hygiene;

– collaboration with patient organizations to assist with

Key actions: patient advocacy or education, or to lobby for funding
or improved facilities.
• Identify a co-ordinator for the hand hygiene improvement
programme and ideally a deputy and, where possible, a
dedicated hand hygiene team/committee. Accessing the Tools

• Prepare for publicizing the hand hygiene improvement www.who.int/gpsc/en/

initiatives across the facility.

• Identify internal stakeholders, senior managers, key individuals

or groups who will need to be aware of the hand hygiene
initiatives implemented at the health-care facility.

• Use template letters to seek the support of senior managers

and communicate with them and health-care workers.

• In particular, obtain finance, staff resource, support to organize

education activities from senior managers.

• Identify at least one member of staff on each ward, or in each

department (senior doctors and/or chief nurses) to be fully informed,
at the correct time, of the initiation of a hand hygiene improvement
strategy and, if possible, to be trained in general infection control.

• Make the WHO Guidelines on Hand Hygiene in Health Care

or their executive summary available in clinical settings.

• Consider a timeframe for initiating future discussions with

patient organizations or engaging patients.

• Start by placing WHO posters in key places to enhance awareness.

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PART III

Part III of the Guide to Implementation provides the following

additional elements to help the implementation of the WHO
PREPARING AN ACTION PLAN
multimodal hand hygiene improvement strategy:
The Template Action Plan is proposed to help prepare the local
• a template action plan listing what actions should be undertaken
action plan. It is very comprehensive but it does not take into account
in order to achieve the implementation of each component of the
local issues. Therefore, health-care facilities should identify elements that
strategy in facilities at both basic and advanced level of progress
apply to their local situation and amend the template by adding further
in hand hygiene promotion; and
activities to reflect local needs. The template is not intended to indicate a
• a step-wise approach as a model for implementation chronological order for undertaking the actions proposed but to give an
in health-care facilities newly committing to hand hygiene overview of all actions necessary to secure the implementation of each
improvement. strategy component, according to the details given in Part II of the guide.
It covers a wide range of actions as regards progress of hand hygiene at
facility level: from basic actions to be undertaken to inaugurate a hand
hygiene programme to advanced activities indicated in facilities where
hand hygiene promotion is very advanced. The template also helps
to identify roles and responsibilities, to establish a time line for action
execution and budget implications and to track progress.

Overall Template Action Plan

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
General

Access to the WHO Guidelines on Hand

Hygiene in Health Care on the WHO
Patient Safety website
Adapt WHO Guidelines for local
applicability while ensuring consistency
with recommendations
Access the implementation toolkit of the
WHO multimodal hand hygiene improvement
strategy on the WHO Patient Safety website
Identify a co-ordinator for the hand hygiene
improvement programme and a deputy
co-ordinator
Identify and establish a team/committee
to support the hand hygiene co-ordinator
Identify any prior initiatives or plans on
hand hygiene improvement / infection
control within the facility
Contact the CEO/director and senior
managers of the hospital to discuss actions
and activities to be implemented in line
with the current progress of hand hygiene/
infection control promotion at facility level
and with the WHO Guidelines

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PART III GUIDE TO IMPLEMENTATION

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
Agree on the scope and extent of the
activities to be acted on
Match required activity to available
human resources
If policies, standards, protocols, standard
operating procedures, care bundles, etc
are currently used in the facility, ensure one
is focused on hand hygiene and plan for
dissemination to all clinical settings/
health-care workers
System change

Review existing hand hygiene compliance

and/or HCAI information available to direct
the hand hygiene improvement programme
Analyse the current structures and resources

Ward Infrastructure Survey

Soap / Handrub Consumption Survey

Discuss with CEO/director/senior managers

how to improve infrastructures, with a
long-term aim to provide a sink in each
room, complete with safe, running water,
soap and hand towels (this will most likely
link with wider/national plans)
Discuss with CEO/director/senior managers
how to address availability of, and improving
access to, resources (to provide alcohol-
based handrub at each point of care)
Decide whether to produce or procure
alcohol-based handrub
Arrange purchase from the (local) market,
taking into account availability, efficacy,
tolerability and cost
Review the Guide to Local Production of
Alcohol-based Handrub
Discuss with relevant persons/experts the
feasibility and actions required to produce
WHO alcohol-based handrubs within
the facility, particularly affordability and
safety issues
Use the Alcohol-based Handrub Planning
and Costing Tool to develop a budget
spreadsheet for production of WHO-
recommended alcohol-based handrub
Explore with CEO/director/senior managers
the national or regional plans to provide
alcohol based handrubs to try to establish
Undertake tolerability and acceptability
exercises using protocols for evaluation
Make a financial plan of costs necessary
to address water, sinks, soap, towels and
handrub deficits and attempt to secure
an adequate annual budget for this

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 GUIDE TO IMPLEMENTATION PART III

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
If required, explore with CEO/director/senior
managers the possibility of further funding
assistance to support short, medium and
long term plans e.g. via national ministry of
health funding/donor funds/ donations from
industry/ other donations
Training / Education

Establish requirements for health-care

worker training based on local numbers,
needs and any other issues
Review/design a training / education
programme based on WHO training tools
Identify the trainers (at least one per facility)

Identify the observers

(at least one per facility)
Secure time, with support from senior
managers, for trainers and observers to be
trained and perform in their allocated roles,
e.g. written agreement
Carry out training of trainers

Carry out training of observers (trainers

and observers can receive the same
basic training in the same sessions before
observers receive additional specific training)
Set the plan, including timeframe, for
initiating, conducting and evaluating
training for health-care workers
Communicate the time commitment required
for training of health-care workers to all
mangers and staff
Establish a system for reporting on
training sessions to senior managers
including an action plan for addressing
poor or non- attendance
Incorporate the training programme
into the overall facility financial plan
Establish a system for updating training and
competency checks of trainers, e.g. annually
Establish a system for update training
and competency checks of all health-care
workers, e.g. annually
Plan to produce supplementary training
materials or organize additional activities
to maintain momentum and motivation
(e.g. organise lunchtime debates on hand
hygiene issues for health-care workers;
produce e-learning materials; establish
a buddy system to educate new starters
on hand hygiene) in the longer term
Establish a system for updating
training materials

35
PART III GUIDE TO IMPLEMENTATION

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
Evaluation and feedback

Design or review evaluation

and feedback activities including
Hand hygiene observations

Ward infrastructure surveys

Soap / handrub consumption surveys

Perception surveys for health-care workers

Perception surveys for senior managers

Health-care workers knowledge surveys

Tolerability and acceptability alcohol-based

handrub exercises
Set the plan, including timeframe,
for initiation of evaluation and
feedback activities
Include identification of all expert support
that might be required, e.g. epidemiologist,
data manager
Incorporate the evaluation and feedback
activities into the overall facility financial plan
Establish an overall system for reporting
on evaluation results to senior managers
including an action plan for addressing poor
compliance, knowledge and infrastructures
Utilise the hand hygiene technical reference
manual to produce plans for observations
Identify candidates to be observers
(if not already done so)
Establish a system for on-going training and
competency checks of observers,
e.g. annually
Conduct baseline evaluations and feed back
to key health-care staff, consider using
Data entry and analysis tool and instructions
for data entry and analysis
Data summary report framework

Prepare and disseminate a plan for on-

going observations according to an agreed
schedule, e.g. annually but ideally bi-monthly
Present results of observations each
quarter or to an agreed schedule to hand
hygiene implementation team and senior
management
Set annual targets for improvement in
hand hygiene compliance based on
agreement from all key staff and taking into
account current evidence on hand hygiene
compliance rates
Assess current information
on HCAI rates at the facility

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 GUIDE TO IMPLEMENTATION PART III

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
Establish a system to monitor HCAI rates
on an on-going basis alongside hand
hygiene compliance rates
If possible, perform cost–effectiveness
analysis to inform senior managers and
secure future investment in hand hygiene
Consider preparing a case study of
improvements in hand hygiene at the facility
for publication locally, regionally or nationally
and on the WHO Patient Safety website
Consider publishing data on hand hygiene
improvement and HCAI rates at the facility
in a peer-reviewed journal, trade journal or
internal newsletter
Consider presenting data on hand hygiene
improvement and HCAI rates at the facility at
local, national or international conferences
Reminders in the workplace

Evaluate available resources including

existing reminders and local expertise to
invest in reminders health-care workers
about hand hygiene
Establish requirements for updating or
providing new reminders
Establish costs and source funding
where required
Access and save posters and leaflets on the
WHO Patient Safety website and investigate
costs of reproduction
Provide and/or display posters
in all clinical settings
Ensure posters are in a good condition and
clearly displayed in suitable places, e.g. at
the point of care, above hand wash basins
Distribute leaflets to all health-care
workers during training and display
in all clinical settings
Plan to produce supplementary or
refreshed reminders on an on-going basis,
including innovative ideas other than
posters and leaflets
Institutional safety climate

Clarify that all other actions for ensuring

system change, training /education,
evaluation and feedback and reminders
in the workplace are taking place
Identify and secure on-going support from
key senior managers and facility managers
Prepare and send letter to advocate
hand hygiene to managers to encourage
senior managers to continue investment
in hand hygiene

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PART III GUIDE TO IMPLEMENTATION

Action Lead person Time frame Budget Progress

(start and end dates) (if applicable) (include review and
completion dates)
If possible, prepare a business case and
present to senior managers to secure
continued investment in hand hygiene
Prepare and send letter to communicate
hand hygiene initiatives to managers
Establish a committee to implement the
facility action plan
Establish regular meetings to feedback
and revise the action plan accordingly
(an already-established committee may be
chosen as the vehicle to address
hand hygiene improvement)
Prepare a plan to publicise hand hygiene
activities across the facility – where available
use internal communications expertise
Establish key staff in all areas that can be
updated and continue to publicise news of
hand hygiene activities on an on-going basis
Review existing involvement of patients
/ patient organizations in health-care
improvement activities and consider
timeframe for initiating on-going discussions/
collaborations with patient organizations
Utilize the guidance on engaging
patients and patient organizations
in hand hygiene initiatives
Consider undertaking patient surveys

Initiate patient advocacy activities (e.g.

provide hand hygiene information leaflets
to patients and plan for education sessions)
Consider implementing initiatives to
reward or acknowledge good hand
hygiene compliance by specific
health-care workers, wards or departments
Embed hand hygiene within facility
indicators and annual goals
Plan to produce supplementary training
materials or organising additional activities
to maintain momentum and motivation
(e.g. organise lunchtime debates on hand
hygiene issues for health-care workers;
produce e-learning materials; establish a
buddy system to educate new starters on
hand hygiene, use the SAVE LIVES: Clean
Your Hands promotional DVD

38
 GUIDE TO IMPLEMENTATION PART III

IMPLEMENTING THE Step 1: Facility preparedness –

readiness for action
STEP-WISE
Step 1 is meant to ensure the overall preparedness of the
APPROACH facility to put in place a hand hygiene improvement programme.
This includes getting the necessary resources (both human and financial)
The step-wise approach helps to develop and plan the hand and infrastructure in place along with the key leadership for the hand
hygiene improvement programme over time and according to a rational hygiene improvement programme, including a co-ordinator and his/her
sequence of activities. Indeed, the components of the strategy are deputy. Proper planning must be done to map out a clear strategy for
suitable for implementation in different steps according to their features. the entire programme.

This approach is proposed for consideration especially by facilities Activities to take place in step 1 are related mainly to plans and actions
newly implementing a hand hygiene improvement programme based to achieve the objectives of the strategy components 1 (system change),
on the WHO multimodal strategy. In a defined sequential order, it walks 3 (education) and 5 (institutional safety climate).
the reader through the path to be followed to implement the strategy
with a wide range of activities and the support of all tools of the WHO Please refer to the sections dedicated to these strategy components
implementation toolkit. Although testing showed that this step-wise to gather more information and to be directed to the available tools.
approach is very comprehensive and provides helpful guidance, it This step is meant to last 2 months on average.
may appear heavy and very engaging. Professionals and institutions
committing to hand hygiene improvement should be aware that hand
hygiene promotion is actually an engaging and challenging task, but Facilities are recommended to consider implementing initially in
on the other hand it results in a lot of progress in enhancing patient wards where motivation and interest are high and the health gain is
safety overall. The work load to implement a hand hygiene improvement likely to be substantial and subsequently have an impact on others.
programme depends on its scope; focusing on minimum requirements,
the burden of activities, nonetheless, can be downsized at the start
and scaling up can be undertaken gradually.

High consideration should be given to the feasibility of matching

Minimum criteria for implementation of the WHO multimodal
hand hygiene improvement strategy are listed in the figure below: required activities to available human and financial resources. In
order to demonstrate the economic benefit of the intervention and
to ascertain what funding will be required to implement the action
Multimodal Minimum criteria plan to improve hand hygiene, it may be necessary to perform an
component for implementation economic analysis and formalise a financial plan at this early stage
in establishing the scope and extent of the intervention.

1. System change: Alcohol-based handrub dispensers

Point of care positioned at the point of care in In summary, step 1 should include:
alcohol-based each clinical setting (ward or others),
handrubs or given to staff (pocket bottles) – convincing high level senior managers and key professionals at
the facility that patient safety is a crucial issue and hand hygiene
1. System change: One sink to every 10 beds improvement is of utmost importance to ensuring safe care;
Access to safe, Soap and disposable towels
continuous water available at every sink – identifying the key people to be involved in the programme
supply, soap implementation; selecting a co-ordinator, a deputy co-ordinator
and towels
and possibly a team/committee supporting them; assigning
individual tasks and deliverables;
2. Training All staff in the clinical settings
and education included in the hand hygiene
programme receive training
A programme for updating training
Hand hygiene programme co-ordinator:
over the short, medium and
long term is established
Profile: a professional who should have an understanding of hand
hygiene and infection control issues and ideally a broader experience
Two periods of evaluation (baseline on quality and safety; he/she should be well-respected and able to
3. Evaluation
and feedback and follow-up) with at least infrastructure access high-level management staff within the facility.
surveys, hand hygiene observations
and soap and alcohol-based handrub Tasks: to propose a consistent action plan to implement the hand
consumption monitoring, are undertaken hygiene improvement strategy according to the WHO Guidelines on
Hand Hygiene in Health Care and in line with the current progress of
4. Reminders in “How to” and “Your 5 Moments for hand hygiene promotion at the facility level; to discuss it with senior
the workplace Hand Hygiene” posters displayed in
clinical settings included in the hand
managers and to coordinate its implementation at all stages; in
hygiene programme addition, to lead the training of trainers and observers.
(e.g. patients rooms; staff areas;
out-patient/ambulatory departments

5. Institutional The chief executive officer, director,

safety climate senior managers and other leaders all
make a visible commitment to support
hand hygiene improvement
(e.g. announcements and/or
formal letters to staff).

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PART III GUIDE TO IMPLEMENTATION

Hand hygiene team/committee Possible methods of communication:

Profile: a group of key internal stakeholders and in particular • Word of mouth

influential leaders (head nurses, chief doctors, leads from other • Electronic (email) if available
disciplines, senior managers) along with those involved in infection
• Newsletter or similar bulletin
prevention and control.
• Formal and informal training
Tasks: to support the co-ordinator and share decision making; to
• Posters / reminders
meet regularly (at least monthly at the beginning of the programme;
then less frequently) to oversee progress, to highlight any issues or • Presentations in medical and nursing staff meetings
concerns, propose solutions, and review the emerging data. • CEO address to health-care staff

– establishing a plan to achieve the implementation of all the – preparing the necessary resources and supports to implement
strategy components or of those that are considered to be key all the strategy components, especially two (education) and
features at the facility level (especially for settings where hand four (reminders); and
hygiene promotion is already in place);
– identifying staff in charge of making data entry and analysis.
– deciding about the scope of and the extent of the implementation
(either focus on a limited number of areas or facility-wide);
Human resources required/key players involved in step 1:
– creating the conditions to make system change happen
(e.g. actions plans to make the alcohol-based handrub available • Hand hygiene programme co-ordinator
and/or ensure its appropriate location at the point of care); • Deputy co-ordinator
– identifying the trainers and the observers; • Trainers
• Observers

Trainer • Senior managers/health-care facility administrators

• Infection prevention and control professionals
Profile: a professional preferably with experience of education
and of delivering health care at the bed side. Ideally he/she should • Head nurses, chief doctors, leads from other disciplines
be an influential leader (chief nurse/matron/doctor) or the official • Central purchasing department staff, pharmacist
deputy of an influential leader and already have good knowledge • Hand hygiene committee/team
of infection control. (including the above key players, when appropriate)
Tasks: to train health-care workers on hand hygiene during step 3.
Your action checks – step 1

Observer: Have the following actions occurred? Yes/No

Coordinator appointed
Profile: a professional with experience in delivering care at the
bed-side and knowledge and understanding of the hand hygiene Practicalities of implementing the multimodal
improvement strategy. strategy assessed
Tasks: openly and objectively to observe hand hygiene practices and Key individuals and groups identified and support secured
to gather data on compliance using the “My 5 Moments for Hand (team/committee established)
Hygiene” approach and the WHO method; to provide feedback on Roles to ensure action plan completion assigned
the results to health-care workers, senior managers and other key
individuals / groups involved in the hand hygiene programme. Action plan agreed among all key players including
senior managers
Agreement reached on hospital-wide versus specific
– building the necessary knowledge and expertise (train the trainers wards-only implementation
and the observers) to carry out activities related to the strategy
Letters to advocate and communicate about hand hygiene
components 2 (education) and 3 (evaluation) planned to be
sent to senior managers
implemented in steps 2 (baseline evaluation), 3 (implementation)
and 4 (follow-up evaluation); Budget analysis undertaken

– reviewing all tools for evaluation and feedback, assign tasks Necessary funds procured to make alcohol-based handrub
and make plan for carrying out the surveys in step 2; available or improve its availability at the
point of care as well as other resources including
– developing a plan on how and to whom information concerning human-resources
the action plan and improvement will be communicated;
Decision made re: whether to purchase handrubs
commercially or manufacture in-house
Trainers and observers identified

Training of trainers and observers undertaken

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 GUIDE TO IMPLEMENTATION PART III

Step 2: Baseline evaluation – establishing – evaluating the results and making sure that they are reliable;
knowledge of the current situation – disseminating the results among key players in the hand hygiene
improvement programme;
Step 2 is meant to be focused mainly on conducting baseline
– evaluating how to use the results during step 3 (e.g. how to
evaluation of hand hygiene practice, perception, knowledge and the
present data during educational sessions, what specific actions
infrastructures available. It is very important to assess the current
should be made to improve infrastructure);
situation at the facility level in order to tailor and refine action plans
for implementation. Activities talking place in step 2 are vital also – evaluating HCAI rates related to the last 6 months/1 year if a
because they will provide reference information for any comparison local surveillance system is in place or conducing a prevalence
and assessment of progress as the multimodal strategy is being survey in the clinical settings included in the hand hygiene
implemented. During this step, specific actions that are scheduled improvement programme;
in step 1 could also be continued and/or take place to prepare for
– concluding any training for the trainers;
the implementation phase (preparation of training, procurement or
production of the alcohol-based handrub). – preparing additional training material, including the baseline
evaluation data;
Activities scheduled to take place in step 2 are related mainly
to plans and actions to achieve the objectives of strategy component 3 – reviewing the training material and making precise plans
(evaluation and feedback). for the educational sessions for health-care workers;

– getting ready for any promotion activity to be launched during step 3;

Please refer to the section dedicated to this strategy component
to gather more information and to be directed to the available tools. – finalizing the process of procuring or locally producing the
This step is meant to last 3 months on average. alcohol-based handrub; and

– getting ready for any additional system change (e.g. sink

The table below proposes, only as an indication, a sequential installation, soap/disposable towels procurement, increase
programme for conducting the surveys at the facility level. The and/or change of alcohol-based handrub dispensers).
indicated time lines are only approximate, and they will depend
on the scope of implementation at the facility level.
Human resources required/key players involved in step 2:

Ward infrastructure Week • Hand hygiene programme co-ordinator

survey (baseline) 1–2 • Deputy co-ordinator
Senior executive Week
• Trainers
managers perception 3
survey (baseline) • Observers
Health-care workers Week • Central purchasing department staff, pharmacist
perception survey 4–5
(baseline) • Epidemiologist, data manager

Hand hygiene Week • Hand hygiene committee/team

observations 6–8 (including the above key players, when appropriate)
(baseline)
Soap/handrub End of Your action checks – step 2
consumption survey Step 2; then
(baseline) monthly or
Action Yes/No
every 3–4
months Ward infrastructure survey undertaken

Health-care workers Last Senior managers perception survey undertaken

knowledge survey week or
Health-care workers perception survey undertaken
(baseline) immediately
before Consumption data collected
education
Hand hygiene observations completed
session
Health-care workers knowledge survey undertaken
In summary, step 2 should include: Data input accomplished
– conducting the infrastructure, perception and knowledge Data analysed and interpreted
surveys and collecting hand hygiene observation and
soap/handrub consumption data according to the plans; Availability of alcohol-based handrub secured

– conducting the tolerability and acceptability survey if the Actions taken for any other planned system changes
alcohol-based handrub was newly introduced or to compare Training of the trainers concluded
different products;
Educational material ready
– performing data entry and analysis as soon as each survey
is completed;

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PART III GUIDE TO IMPLEMENTATION

Step 3: implementation – introducing Human resources required/key players involved in step 3:

the improvement activities • Hand hygiene programme co-ordinator

Step 3 is the key phase to achieve improvement and it consists • Deputy co-ordinator
of implementing all the interventions planned in step1 and using the
• Trainers
core findings from step 2 to motivate improvement. Its importance is
vital for raising awareness of the burden of HCAI and the importance • Observers
of hand hygiene, to improve knowledge, to put in place elements of
• Senior managers/health-care facility administrators
system change and eventually to catalyze behavioural change.
• Infection prevention and control professionals
Activities that take place in step 3 are related mainly to plans
and actions to achieve the objectives of the strategy components: • Head nurses, chief doctors, leads from other disciplines
1 (system change), 2 (education), 4 (reminders in the work place)
• Central purchasing department staff, pharmacist
and 5 (institutional safety climate). However, some evaluation
activities are also meant to take place. • Hand hygiene committee/team

• Patients, patient organizations

Please refer to the section dedicated to these strategy
components to gather more information and to be directed • Ministerial authorities, government representatives
to the available tools.

This step is meant to last 3 months on average. Your action checks – step 3

In summary, step 3 should include: Have the following actions occurred? Yes/No
– holding a well-publicized official event launching the promotional Action plan, developed in step 1,
activities and involving endorsement and/or symbolic signatures used to guide implementation
of commitment from leaders and individual health-care workers; Baseline data and analysis fed back to staff
– distributing the alcohol-based handrub at the point of care in all WHO Guidelines on Hygiene in Health Care distributed
clinical settings involved in the programme;
Posters, other reminders and promotional
– displaying posters and distributing other reminders at the point materials distributed
of care and to health-care workers in all clinical settings involved
Educational materials distributed
in the programme;
Alcohol-based handrub distributed
– distributing the WHO Guidelines on Hand Hygiene in Health Care
or their summary in clinical settings involved in the programme; Education and training sessions undertaken
– organizing the educational sessions for all health-care workers Monthly measurement of consumption undertaken
working in the clinical settings involved in the programme,
including distributing educational material, as well as practical Alcohol-based handrub tolerability and acceptability
training on the how to perform hand hygiene; surveys undertaken
Monthly hand hygiene compliance observations
– conducting the knowledge test together with the educational
undertaken (where feasible)
sessions, if not having been carried out already in step 2;
Regular review meetings held
– ensuring that feedback of baseline evaluation data is performed
(either during educational sessions or through reports and other
means of communication); Pictures showing examples of initiatives undertaken and tools produced
by health-care facilities during the implementation step while testing the
– monitoring monthly alcohol-based handrub consumption;
WHO multimodal hand hygiene improvement strategy are accessible at:
– undertaking monthly hand hygiene observations, if feasible; www.who.int/gpsc/en/
– organizing regular meetings of the team/committee to monitor
the implementation progress, overcome potential obstacles,
and adjust plans if necessary;

– getting prepared to undertake the evaluation activities

planned in step 4.

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 GUIDE TO IMPLEMENTATION PART III

Step 4: follow-up evaluation – In summary, step 4 should include:

evaluating the implementation impact – conducting the infrastructure, perception and knowledge
surveys and collecting hand hygiene observation and
Step 4 has very important aims: to follow-up progress and soap/handrub consumption data according to the plans;
confirm that implementation of the hand hygiene initiatives translates
into improvements in hand hygiene. The surveys carried out for baseline – performing data entry and analysis as soon as each survey
evaluation during step 2 should be repeated to obtain follow-up data is completed;
adequate to compare the periods pre- and post-implementation. It is, – evaluating the results and making sure that they are reliable;
however, important to understand that since it will be carried out shortly
after implementation, this evaluation will provide information only about – maintaining activities aimed at hand hygiene improvement
the immediate impact of the programme. To gather long-term impact inaugurated in step 3 (availability of alcohol-based handrub
data it is necessary to undertake further evaluation on the basis of a and products for handwashing, reminders, concurrent education
longer follow-up and to invest in continuous monitoring of key indicators. sessions, etc) according to the local needs and plans.
Short-term impact information is, however, very crucial to aiding future
decisions and actions (step 5). It is also important to acknowledge that Human resources required/key players involved in step 4:
during step 4, hand hygiene improvement activities should continue
• Hand hygiene programme co-ordinator
according to the local action plan.
• Deputy co-ordinator
Activities to take place in step 4 are related mainly to plans
and actions to achieve the objectives of strategy component 3 • Observers
(evaluation and feedback). However, all activities aimed at hand
• Central purchasing department staff
hygiene improvement inaugurated in step 3 should be maintained
and continued to be promoted. • Hand hygiene committee/team

Please refer to the section dedicated to this strategy

Your action checks – step 4
component to gather more information and to be directed
to the available tools.
Have the following actions occurred? Yes/No
This step is meant to last 2 months on average.
Ward infrastructure survey undertaken
Only as an indication, the table below proposes a sequential Senior executive managers perception survey undertaken
order for conducting the surveys at the facility level. The indicated
time lines are only approximate and they may vary based on the Health-care workers perception survey undertaken
scope of implementation at the facility level.
Consumption data collected monthly

Hand hygiene observations completed

Ward infrastructure Week
survey (follow-up) 1–2 Health-care workers knowledge survey undertaken
Senior executive Week (if applicable)
managers perception 3 Data input accomplished
survey (follow-up)
Data analysed and interpreted
Health-care workers Week
perception survey 4–5 Activities aimed at hand hygiene improvement ongoing
(follow-up)
Hand hygiene Week
observations 6–8
(follow-up)
Soap/handrub Monthly or
consumption survey every 3–4
months
Health-care workers First week if
knowledge survey not carried
(follow-up) out in step 3

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PART III GUIDE TO IMPLEMENTATION

Step 5: ongoing planning and review cycle – Most projects are reviewed at some point to ensure that they are likely
to be delivered on time and that they meet the objectives set within the
developing a plan for the next 5 years
budget allocation. Therefore, by adopting the action planning and review
cycle approach from the outset, the hand hygiene programme can take
Step 5 is a crucial step for reviewing the entire cycle of
the lead in providing such information rather than being asked for it.
implementation put in place during the previous steps and for
developing long-term plans to ensure that improvement is sustained Activities to take place in step 5 are related mainly to plans and
and progresses. Developing and implementing action plans while actions to achieve the objectives of strategy components 3 (evaluation
ensuring that there is a constant review cycle is essential if the overall and feedback; in particular data analysis and interpretation) and 5
aim to embed hand hygiene as an integral part of the health-care (institutional safety climate).
facility culture is to be achieved long-term. Implementation plans
must be designed with the aim of achieving sustainable hand hygiene Please refer to the sections dedicated to these strategy
improvement kept in mind at all times. components and to the overall action plan to gather more
information and to be directed to the available tools.

Hand hygiene improvement is not a time-limited process: This step is meant to last 2 months on average.
hand hygiene promotion and monitoring should never be
stopped once implemented.

Planning and reviewing are crucial to the success of any

programme of work. Key actions throughout can be helpful in ensuring
that progress with plans is maintained and changes to plans are
adopted when necessary to ensure the best outcome for hand hygiene
improvement. A hand hygiene improvement strategy cannot remain
static and must be rejuvenated at set intervals, with plans to ensure
this built in from the outset. With the appropriate changes according
to the long-term action plan, the entire cycle using the step-wise
approach should be repeated over a minimum of 5 years, as
represented in the figure below.

Step Step Step Step

5 1 5 1

WHO Guide to WHO Guide to

Implementation Implementation
Step Step Step Step
4 2 4 2

Step Step
3 3

Repeat
Year 1 Year 2 minimum
5 years

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 GUIDE TO IMPLEMENTATION PART III

In summary, step 5 should include: Component Activity

– reviewing the follow-up evaluation results and evaluating System change • Establish plans for completing the
the impact on key success indicators; ward infrastructure survey at regular,
pre-determined time intervals, reporting
– identifying areas that need further improvement as well as
results to the identified groups/meetings
lessons learned in order to feed this information into future
and revising actions plans as necessary.
action plans;
• Establish a system to ensure that products
– deciding how to disseminate impact results to all health-care for hand hygiene are permanently available
workers (e.g. formal event, final written report);
at the point of care.
– preparing a report detailing the entire roll out of the programme, • Consider if any improvement is still
its impact and lessons learned; required to make products for hand
hygiene, especially alcohol-based handrubs,
– engaging senior managers and others with long-term programme
available at each point of care throughout
implementation planning to advocate further hand hygiene
the entire facility.
improvement and gather their support and input;
Training / • Establish an action plan for health-care
– establishing the available resources and matching these education workers to check each others’ competence
to the implementation plan;
following training sessions and disseminate
– preparing, finalising and gaining approval for action plan(s), this plan to identified clinical settings, while
including from those persons who will fully support execution of building in a review of this process.
the plan(s). Plans should include actions in relation to the strategic • Establish a system for identifying new
components (see template action plan) according to local priorities trainers and observers, for example ask
and progress; senior nurses to communicate the names
of health-care workers who are motivated
– preparing, finalising and gaining approval for the programme budget;
and who act as good role models.
– establishing the process for considering unexpected changes • Set regular meetings for review of available
to the plan(s) and budget; evaluation data in order to revise and target
– establishing a clear frequency for conducting evaluation surveys; training / education sessions, up-dating
these are required.
– establishing a system for data evaluation to support development
• Gather information on ways to present
of additional, targeted action plans, including deciding which
data and discuss these with health-care
staff/committee/groups will be the key players and what is
staff to ensure the best method is displayed
expected of them, e.g. careful, expert review to reveal what the
and understood in different clinical settings.
results mean in terms of the impact of hand hygiene improvement;
• Engage input from external partners
– establishing agreed review points (including programme progress such as training /education experts and
and assessment reports at specific set times); patients/patient organizations to evaluate
– establishing a system for reporting at agreed review points, the programme and to help support
including deciding which staff/committees/groups will be development of new and innovative
the key players and determining what is expected of them; training / education methods.
Evaluation • Prepare a plan for regular, preferably
– establishing additional groups/meetings involving a range of
and feedback monthly, monitoring of knowledge,
staff from the facility to analyse and reflect on all progress and
perception, infrastructures and performance
data and that ensure they feel ownership of the facility plan
through observations in all areas of the
to improve and sustain hand hygiene;
facility. This should include regular reports
– identifying key staff and planning to work with those from any and feedback of results to health-care
discipline who present themselves as role models in order to workers along with information on
use their motivation to lead and encourage others; how improvements are being made
in hand hygiene.
– establishing a plan to network with other facilities, regionally,
country-wide or internationally, in order to share successes • Establish measurement of monthly HCAI
and solutions and catalyse scaling-up; incidence trends using a valid surveillance
system if one is not already in place.
– identifying those who will help publicize the programme’s
• Conduct HCAI prevalence surveys
successes and answer enquiries about the programme from
annually in the areas where hand hygiene
external sources, e.g. the media, for example, and local/facility
interventions are taking place. This will be
communications experts.
suitable providing that an adequate sample
size calculation is performed.
The following table provides a range of examples of specific hand
hygiene activities that can be considered in step 5 as part of supporting • Establish a system for continuous
long-term plans and sustainability. recording and reporting hand hygiene
product consumption monthly, especially
alcohol-based handrub, to enable annual
trend calculations.

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PART III GUIDE TO IMPLEMENTATION

Your action checks – step 5

Component Activity
Reminders in • Gather suggestions concerning adaptations
the workplace of and ideas for new reminders from a Have the following actions occurred? Yes/No
range of motivated staff and/or patient/ Review of follow-up data performed. Schedule for
patient organizations and make a new presentation of data results prepared and shared to
action plan for development and review include all staff in formal or informal meetings or events
of these. Include a local designer in this Areas that need further improvement and lessons learned
process if possible and allocate budget identified and discussed
to this service if necessary.
Feedback to and discussion with identified, relevant
• Identify a range of staff in clinical settings groups/teams on follow-up data performed
who will take ownership of refreshing posters
Report prepared
and ensuring they are in good condition.
Institutional • Establish hand hygiene on the list of Dissemination of impact results to all health-care
safety climate indicators for assessment of quality of workers performed
health care delivered at the facility by Finalised and approved long-term action plan(s) in place
preparing a report featuring background
information on the necessity for a hand Process for considering unexpected changes
hygiene improvement, the programme to the plan(s) and/or budget in place
plans, evaluation data results and the Programme review points approved and shared
potential benefits of having hand hygiene with all relevant groups/teams
as a quality indicator. Template for progress reports/programme
• Establish a system for setting and reviewing assessment reports finalised and approved
annual goals for hand hygiene improvement Action plan review times documented, based on
at facility, department and clinical setting/ the plans for reviewing evaluation data results
ward level and include patients/patient
Meeting dates scheduled for the coming year
organization opinion in this process.
and shared with relevant groups/teams
This should also include how and where
evaluation data results will be posted. Promotional activities and interventions scheduled
for the coming year and shared with relevant groups
• Prepare a schedule of presentations and/or
initiatives (e.g. stands, promotions, rewards, System for identifying new trainers, observers, role
etc) on hand hygiene improvement and models, reminders’ placement support staff established
the reasons for successes, including and shared, with an identified review date to ensure
patients/patient organizations where staff are still active in their roles
relevant. Ensure these presentations are Plan for networking with other facilities, regionally,
given to all groups within the facility to build country-wide or internationally, established for the
on their understanding of why hand hygiene coming year
is important for ensuring a safety climate.
Ideas for scale-up and sustainability presented and
• Gather quotes and messages from a range consensus approved for inclusion in a longer-term
of staff within the facility on an on-going action plan
basis to demonstrate the commitment and
A 5-year action plan developed, following the evaluation,
motivation of everyone to ensuring a safety
implementation and review cycle described throughout
climate by improving hand hygiene practices
this guide
and preventing HCAI.

Human resources required/key players involved in step 5:

• Hand hygiene programme co-ordinator

• Deputy co-ordinator
• Trainers
• Observers
• Epidemiologist, data manager
• Senior managers/health-care facility administrators
• Infection prevention and control professionals
• Head nurses, chief doctors, leads from other disciplines
• Hand hygiene committee/team

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 GUIDE TO IMPLEMENTATION

APPENDIX
Examples of useful websites National and sub-national hand hygiene campaigns
to support implementation:
www.hha.org.au/

The National Hand Hygiene Initiative in Australia.

General websites
portal.health.fgov.be/portal/
www.hopisaffe.ch/
page?_pageid=56,11380441&_dad=portal&_schema=PORTAL
The University of Geneva Hospitals’ hand hygiene
Belgium’s national hand hygiene campaign.
improvement programme.
www.handhygiene.ca/
www.cdc.gov/cleanhands/
Canada’s national hand hygiene campaign.
The site contains advice from the US Centers for Disease Control
and Prevention (CDC) on various aspects of hand hygiene.
www.binasss.sa.cr/seguridad

www.theific.org/ Costa Rica’s national hand hygiene campaign.

The International Federation of Infection Control (IFIC) is an

www.sante-sports.gouv.fr/dossiers/sante/
umbrella organization of societies and associations of healthcare
mission-mains-propres/mission-mains-propres.html
professionals in infection control and related fields worldwide.
French campaign “Mission Mains propres”
www.apic.org/
www.calidad.salud.gob.mx/
Association for Professionals in Infection Control and
Epidemiology is an international US-based organization involved Mexico’s national hand hygiene campaign.
in infection prevention, control and hospital epidemiology in
healthcare settings around the globe. www.renomsorg.no

Norway’s national hand hygiene campaign.

www.ihi.org/IHI/Topics/HealthcareAssociatedInfections/

The Institute for Healthcare Improvement (IHI) is an independent www.justcleanyourhands.ca/

not-for-profit US-based organization helping to lead the
Ontario’s hand hygiene campaign.
improvement of health care throughout the world.

www.washyourhandsofthem.com
www.shea-online.org/
Scotland’s national hand hygiene campaign.
Society for Healthcare Epidemiology of America is an international
US-based organization focusing on a variety of disciplines and
www.swisshandhygienecampaign.ch and
activities directed at preventing and controlling infections and
www.swiss-noso.ch/
adverse outcomes and enhancing the quality of care.
Switzerland’s national hand hygiene campaign.
www.ips.uk.net/
www.npsa.nhs.uk/cleanyourhands/
Infection Prevention Society is involved in promoting the
advancement of education in infection control and prevention, England, Northern Ireland and Wales’ hand hygiene campaign.
and in particular the provision of training courses, accreditation
schemes, education materials, meetings and conferences.
Others

www.who.int/patientsafety/patients_for_patient/en/

Patients for Patient Safety (PFPS) is one of the global programmes

of the World Alliance for Patient Safety emphasizing the central
role patients and consumers can play in efforts to improve the
quality and safety of healthcare around the world.

All reasonable precautions have been taken by the World Health Organization to verify the WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members
information contained in this document. of the Infection Control Programme, for their active participation in developing this material.
However, the published material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies with the
reader. In no event shall the World Health Organization be liable for damages arising from its use.

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