WHO Hand Hygiene Self-Assessment Framework: Hospital Performance in the U.S. and Around the Globe

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By Kelly M. Pyrek

The World Health Organization (WHO) taught the global healthcare community that there are five critical moments in hand hygiene that can make or break infection prevention efforts. Now, using a framework provided by the WHO, hospitals around the world can conduct assessments of their hand hygiene compliance efforts within the context of the larger issues of institutional cultures of safety and other key measures impacting patient outcomes. A recent survey of U.S. healthcare facilities reveals that while great strides are being made, there is much more work to be done to boost hand hygiene monitoring and self-assessment.

     
The survey was undertaken by Laurie J. Conway, RN, MS, CIC, a graduate student at the Columbia School of Nursing, and colleagues Benedetta Allegranzi, MD, (first author of the study) of the World Health Organization World Alliance for Patient Safety; Didier Pittet, MD, MS, of the  University of Geneva Hospitals; Katherine Ellingson, PhD, of the Centers for Disease Control and Prevention (CDC); and Elaine Larson, PhD, RN, CIC, of Columbia University School of Nursing. It surveyed hospitals participating in the World Health Organization (WHO) SAVE LIVES: Clean Your Hands campaign, and Conway presented preliminary results from this project at the 2012 annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC) held in June.

  
In the preface to the World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care, Pittet, special advisor for the WHO First Global Patient Safety Challenge Clean Care is Safer Care, observes, "By their very nature, infections are caused by many different factors related to systems and processes of care provision as well as to human behavior that is conditioned by education, political and economic constraints on systems and countries, and often on societal norms and beliefs. Most infections, however, are preventable. Hand hygiene is the primary measure to reduce infections. A simple action, perhaps, but the lack of compliance among healthcare providers is problematic worldwide."

 The WHO Self-Assessment Framework is just one of the many components of the global organization's platform of strategies for hand hygiene promotion and improvement, including the WHO First Global Patient Safety Challenge, Clean Care is Safer Care, which is focusing part of its attention on improving hand hygiene standards and practices in healthcare, along with implementing successful interventions.

Healthcare facilities can track their progress in hand hygiene resources, promotion and activities, plan their actions and aim for improvement and sustainability through the use of the WHO Hand Hygiene Self-Assessment Framework. The Framework is a tool with which to obtain a situation analysis of hand hygiene promotion and practices within an individual healthcare facility, according to a set of indicators. While providing an opportunity to reflect on existing resources and achievements, the Hand Hygiene Self-Assessment Framework also helps to focus on future plans and challenges. In particular, it acts as a diagnostic tool, identifying key issues requiring attention and improvement. The results can be used to facilitate development of an action plan for the facilitys hand hygiene promotion program. Repeated use of the Hand Hygiene Self-Assessment Framework will also allow documentation of progress with time. The WHO says this tool should be a catalyst for implementing and sustaining a comprehensive hand hygiene program within a healthcare facility.

This tool should be used by professionals in charge of implementing a strategy to improve hand hygiene within a healthcare facility. If no strategy is being implemented yet, then it can also be used by professionals in charge of infection control or senior managers at the facility directorate. The framework can be used globally, by healthcare facilities at any level of progress as far as hand hygiene promotion is concerned.

The Hand Hygiene Self-Assessment Framework is divided into five components and 27 indicators. The five components -- system change, education and training, evaluation and feedback, reminders in the workplace, and institutional safety climate --  reflect the five elements of the WHO Multimodal Hand Hygiene Improvement Strategy (http://www.who.int/gpsc/5may/tools/en/index.html ) and the indicators have been selected to represent the key elements of each component. These indicators are based on evidence and expert consensus and have been framed as questions with defined answers (either Yes/No or multiple options) to facilitate self-assessment. Based on the score achieved for the five components, the facility is assigned to one of four levels of hand hygiene promotion and practice: inadequate, basic, intermediate and advanced:
- Inadequate: hand hygiene practices and hand hygiene promotion are deficient. Significant improvement is required.
- Basic: some measures are in place, but not to a satisfactory standard. Further improvement is required.
- Intermediate: an appropriate hand hygiene promotion strategy is in place and hand hygiene practices have improved. It is now crucial to develop long-term plans to ensure that improvement is sustained and progresses.
- Advanced: hand hygiene promotion and optimal hand hygiene practices have been sustained and/or improved, helping to embed a culture of safety in the healthcare setting.

Infection preventionists using the WHO Hand Hygiene Self-Assessment Framework circle the answer appropriate to their facility for each question. Each answer is associated with a score. After completing a component, the scores are added up for the answers selected to give a subtotal for that component. During the interpretation process these subtotals are then added up to calculate the overall score to identify the hand hygiene level to which the participant's healthcare facility is assigned. Within the Framework is a list of WHO implementation tools available from the WHO First Global Patient Safety Challenge to facilitate the implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (http://www.who.int/gpsc/5may/tools/en/index.html). These tools are listed in relation to the relevant indicators included in the Framework and may be useful when developing an action plan to address areas identified as needing improvement.

To access the framework tool, visit: http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf

U.S. Survey Results
Conway explains that the survey, conducted in the U.S. in the second semester of 2011, sought to evaluate the current status of hand hygiene promotion within the context of the WHO's self-assessment tool. The researchers asked survey participants if they had already completed the WHO self-assessment or whether they were planning to work with the tool, and to share information about their experience and their results.

 
Conway says the immense focus on hand hygiene compliance monitoring and state mandates and regulations regarding hand hygiene observation and compliance reporting served as impetus for the project.

 
"The primary driver of the survey is that in the U.S. there is a huge focus by hospitals and infection preventionists on hand hygiene compliance," Conway says. "There is no definitive method for monitoring that compliance among the many methods out there, and I think the jury is still out on the best, most feasible way to monitor compliance. I think feasibility is a significant component of compliance monitoring because you want to get a true idea of how hand hygiene is being performed at your institution; however, there are several ways to do it.  We know that the WHO 'five moments' is out there but so are other tools, so we wanted to know what the uptake was for the WHO framework. I am talking a lot about compliance but really, this is more about readiness and programmatic preparation." Conway adds, "We now know more definitively that without a culture of safety and without moving from 'shame and blame' into feedback and growth, you can't get good compliance. So we wanted to assess where the state of that effort was in U.S. hospitals, and the WHO hand hygiene framework is a really good framework for assessing that preparedness."
The challenge of the project was getting busy infection preventionists to complete the survey; just 129 of 2,238 invited facilities participated. Conway emphasizes that the researchers didn't take it as a sign that these professionals were checked out, but merely busy, and perhaps even too busy monitoring hand hygiene at their facility to participate! (After all, almost 46 percent of the facilities reported being registered for a national or regional hand hygiene campaign.)

"Clearly there is always a danger in self-reports of reporting bias but I think in this survey, because it was a self-assessment and because it was confidential, I don't think there is any more or less bias than normal," Conway says. "The issue here, and a weakness of the study, is the response rate. The fact that we had 5.8 percent of people responding means that it's just a snapshot. It could create a bias, in that if facilities with a lot of infection preventionists on staff or facilities that already focus on hand hygiene, they might have been more likely to respond. So it might be biased toward a really good self-assessment, but that comes from the low response rate. What it means is if it is biased in that direction, the scores may actually be lower overall in the U.S. and that indicates that we do need to focus on hand hygiene. It is an exclamation mark on the results."

Conway says there are several reasons for the low response rate that do indicate that practitioners care about hand hygiene, but that their involvement may be in other hand hygiene campaigns. "There are multiple demands on infection preventionists' time and choosing not to do the survey may actually have been a positive thing," Conway says. "It is not an excuse, it is actually an indication that they are truly under-resourced so multiple demands may have meant they simply did not have time to complete this framework. It doesn't mean they don't conduct self-assessments; in fact the Joint Commission dictates to accredited facilities that they complete a self-assessment of their entire hand hygiene program every year. I think infection preventionists who didn't engage in the survey are just doing things in a different way."

Conway continues, "The other thing is that there were other major surveys being administered in the past year and ours was one of many. But more importantly, there are two issues that might have reduced the uptake of this self-assessment and the first is these competing materials and campaigns, such as the Joint Commission's targeted solutions tool -- it is a good tool that helps facilities discover where they stand in terms of hand hygiene compliance. Those competing campaigns and collaboratives mean that the work of hand hygiene self-assessment is getting done, just not through this particular self-assessment framework. The other issue is there are measurement issues with the WHO five moments; a paper in the Journal of Hospital Infection that was published at the same time that we were conducting our survey indicated that measuring the in and out compliance might be as valid as measuring all five moments. Those issues may have affected the response rate and the uptake of this self-assessment tool. We have done a lot of thinking about this and have concluded that it's not necessarily negative, just different." 

 
The survey results yielded interesting results in terms of infection preventionist staffing -- hospitals with infection preventionist staffing of greater than 0.75 per 100 beds had more than three times the odds of having high scores for education about hand hygiene and high institutional climate scores compared to facilities with lower staffing.

"It's good fodder for going to administrators and asking for more infection prevention program staffing," Conway says. "I think we have to remember it's not cause and effect, it's association -- so we don't know whether the high staffing affects the component scores, the promotional activities and the commitment, or whether facilities that are prepared committed also staff their programs better. I think we have to really watch that. Facilities that have good infection preventionist staffing have higher education and training scores and higher institutional safety climate scores. It supports our argument for proper resourcing in infection prevention. It also shows that an investment in infection preventionists is an investment in hand hygiene compliance."

The participating facilities who took the WHO's Self-Assessment Framework reported the following scores:
- Zero of the facilities classified themselves as inadequate
- 6 percent considered themselves to be at a basic level
- 45 percent classified their hand hygiene efforts as being at an intermediate level
- 40 percent of facilities believed their self-assessment placed them at an advanced level

On average, Conway says, responding U.S. facilities reported intermediate levels of hand hygiene promotion.

She says that one aspect of the reported scores startled her. "I was surprised by the low institutional safety climate scores. We only have preliminary data right now, but it surprised me that the median score was 60 out of 100. The questions in this section of the self-assessment framework talked about whether there is a hand hygiene team at your facility -- well, in these facilities the team is members of the infection prevention team but it can also be comprised of champions in different areas of the facility. The issue may have been other systems-related issues such as patient involvement -- are there formalized patient engagement efforts in your facility? Are there targets for hand hygiene and do the administrators regularly talk about hand hygiene? Is there a system for personal accountability for hand hygiene? I think those are all critical to improving hand hygiene and we are not scoring where we should on that."
Conway says she and her co-authors are continuing to work with the data and hope to publish the full results within the next six months or so, and in addition to Conway's presentation at the APIC annual conference, the authors will present a paper at the upcoming ID Week in October in San Diego. 

 
"I am very fortunate to learn from, and work and conduct research with esteemed individuals from the global healthcare community," Conway says. "It's a dream come true."

Global Survey Results
In comparison to the aforementioned U.S. survey results, a 2011 WHO survey of more than 2,000 healthcare facilities in 69 countries found that 65 percent of them are at a good level of progress with regard to hand hygiene promotion, resources and activities, but at least 35 percent are still at an inadequate or basic level. Promising achievements in promoting hand hygiene through reminders and education of healthcare workers have occurred in more than 90 percent of healthcare facilities, but improvement is still needed in areas such as monitoring of hand hygiene practices and establishing optimal hand hygiene behavior within a strong patient safety culture.

From April to December 2011, healthcare facilities registered for the WHO SAVE LIVES: Clean Your Hands initiative and those participating in some national hand hygiene campaigns were invited to participate in a global survey based on the completion of the Hand Hygiene Self-Assessment Framework (HHSAF). The survey objectives were three-fold:
- to assess the level of progress of healthcare facilities in terms of hand hygiene infrastructure, promotional activities, performance monitoring and feedback, and institutional commitment, according to a range of indicators relevant to the WHO Multimodal Hand Hygiene Improvement Strategy summarized in a score
- to identify gaps in hand hygiene infrastructures and activities according to the HHSAF indicators
- to provide feedback through summary results

Healthcare facilities were invited to submit their HHSAF results to WHO through a dedicated web site. Data were also provided by email or fax where sustained internet access was difficult or by countries where the survey was undertaken independently from WHO. Facilities were asked that the HHSAF be completed by professionals in charge of infection control or senior managers fully informed about hand hygiene activities within the institution. The analysis was performed in collaboration with the WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals in Geneva, Switzerland, while keeping the facilities' identity confidential. The United States had 129 participating hospitals.
Regional distribution of participating healthcare facilities was as follows: 1,127 from the Americas (53 percent; 13 countries, 19 percent); 615 from Europe (29 percent; 24 countries, 35 percent); 159 from the Eastern Mediterranean Region (8 percent; 11 countries, 16 percent); 152 from the Western Pacific Region (7 percent; 8 countries, 12 percent); 55 from Africa (3 percent; 10 countries, 14 percent); and 11 from Southeast Asia (0.5 percent; 3 countries, 4 percent). Approximately 70 percent were registered for the WHO Save Lives: Clean Your Hands" initiative and 74 percent were involved in a national/sub-national hand hygiene promotion campaign. Most facilities were general, non-teaching, public hospitals, delivering acute or mixed (acute and long-term) care.

Most (65 percent) facilities were at intermediate or advanced levels of progress, with a high proportion qualifying for the leadership level. Among the HHSAF sections, the lowest scores concerned evaluation and feedback on hand hygiene activities and the institutional patient safety climate.  The highest average score was found in Western Pacific countries and the lowest in African countries. The average level of progress was intermediate in all regions, except in Africa where it was basic. The highest proportion of facilities that qualified for the leadership criteria and which can thus be considered reference centers, was found in the Western Pacific Region (43 percent).

Overall, 90 percent of facilities declared that alcohol-based handrubs were available (but in discontinuous supply in 8 percent) with 57 percent installed at each point of care. Ninety-eight percent of facilities reported the existence of staff training on best hand hygiene practices. Hand hygiene compliance was measured through direct observation in 59 percent of facilities and alcohol-based handrub consumption was regularly monitored in 53 percent. Posters featuring hand hygiene indications and technique were displayed in the vast majority of facilities. In 73 percent, the chief executive officer made a clear commitment to hand hygiene improvement, though a hand hygiene team was established in only 53 percent.

The survey shows that the participating facilities, representing countries from all regions of the world, are on average at a good level of progress regarding the implementation of hand hygiene improvement strategies. However, overall 35 percent are still at an inadequate or basic level and therefore need to make further significant efforts to bring about better conditions for best hand hygiene practices and behavioral change, according to the WHO. The many facilities at the intermediate level (864 out of 2,119) achieved substantial results, but have to now concentrate on actions to sustain these over time. Finally, most facilities at advanced level (488 out of 2,119) already fulfill some leadership criteria (393 out of 471). These facilities should focus on consolidating their reference position by continuing to contribute to research and innovation in the field of hand hygiene.

As the WHO notes, "It is very encouraging to note that the vast majority of facilities reported having alcohol-based handrubs available, were undertaking staff training, and displaying posters on hand hygiene around their facility. However, differences were detected across the different regions, with the lowest overall score attributed to Africa. Further substantial improvement is needed across all regions, especially in the area of monitoring and feedback on hand hygiene activities and for the establishment of a comprehensive patient safety climate within healthcare facilities where hand hygiene activities need to be better embedded. WHO tools corresponding to these two essential components of the improvement strategy are available and should be used to achieve progress."