Anatomy of a successful multimodal hand hygiene campaign.

In 2005, in the far northeastern corner of the USA, Kirkland et al, found themselves in a situation painfully familiar to many infection control professionals worldwide, including our institution in the early 1990s. Hand hygiene compliance amongst healthcare workers in their hospital was poor, healthcare workers were unenthusiastic about the importance of hand hygiene, and quality improvement interventions were ‘not consistently supported by organisational leaders’. In response, they undertook a comprehensive hand hygiene promotion programme, which evolved over the course of 2 years, that resulted in an institutional culture change, a dramatic increase in hand hygiene compliance from 41% to 87%, and most importantly, a significant reduction in healthcare-associated infections from 4.8 to 3.3 per 1000 inpatient days. These changes were sustained during a 1-year postintervention follow-up. So how did they do it and what can we learn from them? First, Kirkland et al used wellestablished strategies with local interpretation and adaptation. Their intervention included each of the five components of WHO multimodal hand hygiene improvement strategy (table 1), and each of these components was implemented with careful attention to the local landscape and available resources, similar to the earlier ‘Geneva hand hygiene promotion model’. System change involved carefully considered installation of alcohol-based hand-rub dispensers in locations designed to suit staff workflow as assessed by a workgroup comprised of senior biomedical engineering and clinical staff. Education and training of healthcare workers was facilitated by development of an electronic learning module. This was complemented by a voluntary—and well received— hand hygiene competency certification programme. The measurement and feedback component of this initiative is particularly impressive, with hand hygiene compliance and healthcare-associated infection rates published monthly by unit on the hospital intranet. Implicit in this seemingly straightforward action is a broad range of challenges, including the significant burden of monthly hand hygiene observation sessions in each hospital ward to collect information regarding a sufficient number of hand hygiene opportunities to provide meaningful feedback. Monitoring hand hygiene compliance by direct observation is a resource intensive task, but it yields rich rewards to the infection control professionals. This team has previously reported how they used these data to provide a dynamic insight into hand hygiene behaviour in their facility, thereby facilitating targeted interventions. But perhaps even more importantly, hand hygiene observations facilitate performance feedback to the healthcare workers themselves. By our own evaluation, we tend to overestimate our own hand hygiene performance. And compared with other patient safety issues—such as wrong side surgery or medication errors—healthcare workers are rarely aware of adverse outcomes resulting from their own hand hygiene behaviour. Consider a hypothetical healthcare worker who fails to clean hands before patient contact, and whose contaminated hand transmits methicillin-resistant Staphylococcus aureus (MRSA) to a patient, leading to patient colonisation and, several weeks or months later, infection. Such an outcome is not only multifactorial, but will never be linked to the specific patient–healthcare worker interaction when transmission occurred. One important aim of performance feedback is to fill this gap, completing the feedback loop between action and its effect. While evidence regarding the best way of doing this in the field of infection control is limited, it seems reasonable to believe that increasing the frequency and narrowing the range (eg, ward rather than hospitalwide feedback) would be most effective. Perhaps another key to success for this team was a simultaneous statewide campaign; the ‘High Five for a Healthy NH’ campaign. One facet of this regional campaign was the signing of a leadership commitment memorandum, where hospital leaders agree that their organisation ‘will implement or improve upon the five identified best practices for achieving 100% compliance with proper hand hygiene’. These best practices involved the standard elements of multimodal promotion and included a ‘focus on accountability’. This public commitment to hand hygiene and patient safety may have been of particular importance to galvanise support in an institutional context where healthcare workers were sceptical about hand hygiene. But while the support from institutional leadership is key in creating an Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland, and designated as the World Health Organization Collaborating Centre on Patient Safety; External advisor, Clean Care is Safer Care, World Health Organization Patient Safety Programme, Geneva, Switzerland Correspondence to Professor Didier Pittet, Infection Control Programme, University of Geneva Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; [email protected]