Patient safety has become the touchstone of contemporary medical care. Medical errors and adverse events occur with distressing frequency, as outlined persuasively in the USA Institute of Medicine’s To err is human.1041 HCAIs are second only to medication errors as a cause of adverse events in hospitalized patients. Hospital infection control provides a mature template for patient safety with a long track record of research, evidence-based practice standards, and practice improvement efforts. Moreover, infection control professionals and hospital epidemiologists have pioneered real-time methods to detect the occurrence of HCAI and monitor compliance with infection control standards. Nonetheless, as documented in these WHO guidelines, compliance with hand hygiene – the pillar of infection control – remains woeful in the vast majority of health-care institutions. The current emphasis on hand hygiene by the WHO World Alliance for Patient Safety and many regulatory and accrediting agencies reflects the slow progress of the health professions in meeting even modest performance standards.
Donabedian’s quality paradigm of structure, process and outcome1042,1043 provides a useful framework for considering efforts to improve hand hygiene compliance. Clearly, if sinks and alcohol dispensers are not readily accessible (faulty structure) and hand hygiene is not performed (inadequate process), the risk of infection and its attendant morbidity, mortality, and cost (outcomes) will increase. Quality indicators can be developed according to Donabedian’s framework.
Hazard analysis critical control point (HACCP) is another valuable method to examine the system of patient care as it relates to hand hygiene. Originally developed to provide astronauts with pathogen-free food, HACCP is now widely employed in good manufacturing practice, food and drug safety, and blood banking. In brief, the method identifies error-prone aspects of systems (critical control points), evaluates the risk they pose, and designs them out. Critical control points are scored according to their probability of occurrence, probability of avoiding detection, and severity of downstream impact. Failure mode and effects analysis is closely related to HACCP and is being exploited increasingly in patient safety. A desirable feature of both HACCP and failure mode and effects analysis is their emphasis on system errors and their consequences. An empty alcohol dispenser, failure to educate staff in proper hand hygiene technique, and failure to practise hand hygiene after glove removal are serious failures at key points in the patient-care system. When multidisciplinary care teams map their institution’s system for hand hygiene, they not only identify error-prone critical control points and barriers to compliance, but also identify which aspects of the system are most critical to improve and monitor. This collaborative approach to identifying key quality indicators vastly improves these indicators’ local credibility and relevance and provides a guide to ongoing improvement and auditing efforts.
Failures at critical control points in the hand hygiene system can be seen as problems in the reliability of the system. The concept of reliability is the bedrock of modern manufacturing (e.g., it transformed the quality of automobile production), but has been applied to health care only recently. Reliability looks at the defect or failure rate in key aspects of production (i.e. patient care). Industry often seeks to achieve defect rates of one per million or less (a component of so-called six-sigma reliability).
While such a high degree of reliability seems impossible in many aspects of health care, it is worth noting that most institutions have hand hygiene defect rates of six per ten opportunities or greater. Moreover, these rates do not even reflect current thinking about rigorous reliability, in which the entire system either performs correctly or does not. For example, defect-free care of a central venous catheter would require selection of the optimal insertion site, perfect hand hygiene, maximal barrier precautions, correct skin preparation, and prompt removal of the catheter as soon as it is no longer needed. Failure at any one of these steps means “no credit”. Clearly, current defect rates in the hand hygiene system are no longer tolerable. Even in a setting with severely constrained resources, basic hand hygiene can and should be performed very reliably with a defect rate of less than 5–10%.
Although health-care providers – particularly managers in relatively complex organizations – will find it valuable to understand and apply Donabedian’s quality paradigm, HACCP, failure mode and effects analysis, and reliability theory, it should be relatively easy for health-care providers in virtually every setting to start evaluating, improving, and monitoring the reliability of the hand hygiene infrastructure and practice immediately. provides a variety of structure and process quality indicators that are derived directly from these WHO guidelines. Health-care providers and multidisciplinary teams (in collaboration with quality improvement and infection control experts where available) may want to begin by considering some of these indicators. The emphasis is on structure and process because the ultimate outcomes – reduced infection and antibiotic resistance rates – are likely to be linked closely with improvements in structure and process, are more time-consuming to measure, and may not be immediately discernible. Many indicators in are relatively easy to measure and provide real-time feedback to caregivers and managers.
Examples of quality indicators which may be used in relation to hand hygiene in health-care settings (not including pre-surgical hand preparation).
For example, at the most basic level, are user-friendly, clear policies in place, and are these accessible to HCWs in the workplace? Is the design of the work space, including the placement of sinks, alcohol-based handrub dispensers, and other hand hygiene equipment and supplies, conducive to compliance? Are the alcohol-based handrub dispensers conveniently placed near every bed space (or are they hiding behind the ventilator)? Are the sinks fully operational, and are soap and clean towels always available? Are alcohol-based handrub dispensers full and operational? Are appropriate education programmes available to all HCWs, including trainees and rotating personnel, and is continuing education provided on a regular basis? What is the actual attendance at these programmes and are they mandatory? Can HCWs answer basic questions about hand hygiene (either by survey or web-based learning modules), such as the indications and rationale for hand hygiene and the efficacy and relative merits of various hand hygiene products and procedures? It is particularly important to verify the competency of all HCWs in performing hand hygiene procedures – a critical certification step that is applied all too rarely, especially to doctors. Can HCWs actually demonstrate proper technique when washing hands or using alcohol-based handrubs? Are hand lotions always available to HCWs and conveniently placed?
These types of questions are asked in technical tools included in the WHO Multimodal Hand Hygiene Improvement Strategy and conceived for evaluation such as the WHO Facility Situation Analysis and the WHO Questionnaire on Ward Structure for Hand Hygiene (Implemenmtation Toolkit, available at http://www.who.int/gpsc/en/).
Quick, simple real-time checks of the health-care environment can be extremely useful for monitoring barriers to compliance, e.g. checks to see if alcohol-based handrub dispensers are full and operational.
Random audits of actual practice are indispensable (see Part III, Section 1.1). While hand hygiene practice can be considered a process of care, when it is not performed appropriately it can also be viewed as an important intermediate step in the chain leading to the colonization and infection of patients. Moreover, audit and feedback of compliance data is a major component of any multifaceted behaviour change programme. Simple graphics of compliance rates (or, alternatively, defect rates) should be prominently displayed where they can be seen during routine work. Data should be incorporated into HCW’s education and fed back in real time.
Efforts to improve hand hygiene performance will be more successful if they take advantage of basic behavioural science principles. Sustained improvement requires knowledge – do providers understand the indications and rationale for hand hygiene? Are HCWs enabled to do the right thing by ensuring that sinks or alcohol-based handrubs are available at the point of care, and has this been verified by observing HCWs’ work habits? Are staffing ratios adequate, or are HCWs so harassed that they cannot perform even the most basic procedures reliably? Are they motivated, and do they have a strong sense of self-efficacy? How do they view the unit or department’s social norms regarding hand hygiene? Can they identify an opinion leader in their unit or department who takes the lead in education and the promotion of hand hygiene? If HCWs are educated, competent, have convenient access to hand hygiene facilities and supplies, and have sufficient staffing, are they held accountable for defects in their performance?
The ultimate customer, of course, is the patient. Patients and their families can be given a “tip sheet” to help them understand their role as partners in patient safety. They should be encouraged to point out lapses in hand hygiene technique without fear of retribution. Surveys can help HCWs determine if patient perceptions match their own view of their performance (see Part V, Section 6).
In conclusion, hand hygiene is an important indicator of safety and quality of care delivered in any health-care setting, because there is substantial evidence to demonstrate the correlation between good hand hygiene practices and low HCAI rates (see Part I, Section 22). It is embedded in the HCAI planks of the 5 Million Lives Campaign (http://www.ihi.org/IHI/Programs/Campaign/) and is emphasized in the WHO Collaborating Centre on Patient Safety Solutions as one of the highest priority solutions to improve patient safety (www.who.int/patientsafety/solutions/patientsafety/en/).
