“The 3/3 Strategy”: A Successful Multifaceted Hospital Wide Hand Hygiene Intervention Based on WHO and Continuous Quality Improvement Methodology

Abstract

BackgroundOnly multifaceted hospital wide interventions have been successful in achieving sustained improvements in hand hygiene (HH) compliance.Methodology/Principal FindingsPre-post intervention study of HH performance at baseline (October 2007– December 2009) and during intervention, which included two phases. Phase 1 (2010) included multimodal WHO approach. Phase 2 (2011) added Continuous Quality Improvement (CQI) tools and was based on: a) Increase of alcohol hand rub (AHR) solution placement (from 0.57 dispensers/bed to 1.56); b) Increase in frequency of audits (three days every three weeks: “3/3 strategy”); c) Implementation of a standardized register form of HH corrective actions; d) Statistical Process Control (SPC) as time series analysis methodology through appropriate control charts. During the intervention period we performed 819 scheduled direct observation audits which provided data from 11,714 HH opportunities. The most remarkable findings were: a) significant improvements in HH compliance with respect to baseline (25% mean increase); b) sustained high level (82%) of HH compliance during intervention; c) significant increase in AHRs consumption over time; c) significant decrease in the rate of healthcare-acquired MRSA; d) small but significant improvements in HH compliance when comparing phase 2 to phase 1 [79.5% (95% CI: 78.2–80.7) vs 84.6% (95% CI:83.8–85.4), p<0.05]; e) successful use of control charts to identify significant negative and positive deviations (special causes) related to the HH compliance process over time (“positive”: 90.1% as highest HH compliance coinciding with the “World hygiene day”; and “negative”:73.7% as lowest HH compliance coinciding with a statutory lay-off proceeding).Conclusions/SignificanceCQI tools may be a key addition to WHO strategy to maintain a good HH performance over time. In addition, SPC has shown to be a powerful methodology to detect special causes in HH performance (positive and negative) and to help establishing adequate feedback to healthcare workers.

A multifaceted hospital-wide intervention increases hand hygiene compliance

“…Control for this was beyond the scope of this study, and we had to rely on the experience of the staff concerned. Other studies [5,6,[8][9][10] have also shown an improvement in hand hygiene compliance, with some using the WHO multimodal approach, but this study is different in that it achieved similar results over a short period of time, using ward staff working under severe resource constraints. While it can be argued that the results could be considered more scientifically sound if the study had been done over a longer period, the ability to replicate the results of intervention using this simple method has been valuable in helping to improve hand hygiene compliance and thereby reduce hospital-acquired infections.…”

“…Such interventions have changed cultural behaviours, and institutions have been successful in sustaining these improvements. [6,9,10] Materials used to implement such improvements include the CDC [4] and World Health Organization (WHO) guidelines. [11] A multifaceted hospital-wide intervention increases hand hygiene compliance Infrastructural requirements such as the availability and accessibility of hand sanitisers, alcohol-based rub solutions and dispensers must also be in place.…”

A successful multifaceted strategy to improve hand hygiene compliance rates

“…The multimodal approach to HH has been demonstrated in previous studies to be effective in improving HH, as supported in our study. 7,9,12,13 We were not able to identify which intervention led to an increase in HH compliance because this study was not designed in that fashion, but we can demonstrate a statistically significant change in HHCRs from the pre-to postintervention periods.…”

“…15 The members of the multidisciplinary team were engaged, and the team exhibited many of the characteristics that have been associated with great team performance, such as the capacity of the members to talk and listen in equal measure, engagement in energetic conversation with the team leader and with one another, continuing conversation after the formal meetings and exploring for new options and new measures outside the team, and bringing back to the multidisciplinary team potentially useful information that could be implemented. 16 Second, multimodal strategies were used, 3,[9][10][11][12][13] including increasing the number of dispensers and changing dispenser placement to increase accessibility, using covert observers to measure compliance, making providers accountable by asking the chief medical officer and chief nursing officer to send a letter to HCWs who were noncompliant, and making it clear to HCWs that by being noncomplaint they were putting the life of the patients in danger. The noncompliant HCWs had to review a slide presentation about HH and needed confirmation by the chair of the department that the review was completed.…”

“…The interventions that were implemented (Table 1) included education and training; promotion; use of visual cues on the gel dispensers to indicate malfunction or empty and placement of dispensers in high-traffic areas; visual cues in examining room reminding providers, patients, and families about the importance of HH; covert direct observation of HH by peers; rewards to the teams with highest compliance presented in hospital-wide meetings; alerts to the immediate supervisor via letters when health care provider did not comply; and regular reports to leadership, including the chief medical officer, chief nursing officer, chair caucus (all of the chairs of the different clinical departments), and board of trustees. [10][11][12][13] The monthly summary report of HHCRs was distributed to all providers within the institution for transparency in HHCRs. Monthly meetings were held with the members of the task force to review all evidence-based guidelines in HH and to discuss the necessary changes that needed to be made.…”