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Preparation
Access and adapt the WHO Guidelines on Hand Hygiene.
Access the implementation toolkit of the WHO multimodal hand hygiene.
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. -
Contact CEO/Director
Contact the CEO/Director and senior managers of the hospital to discuss actions and activities to be implemented.
Agree on the scope and extent of the activities to be acted on.
Match required activity to available human resources.
Ensure one policy, standard, or protocol is focused on hand hygiene. -
System Change
Review existing hand hygiene compliance.
Analyse the current structures and resources:
-Ward Infrastructure Survey
-Soap/ Handrub Consumption Survey
Discuss with CEO/Director/senior managers how to improve infrastructures & improve access to resources.
Discuss financial planning. -
Establish a Training/Education System
Establish education requirements.
Review training/education program.
Identify trainers and observers and have them trained.
Set plan for initiating, conducting and evaluating training.
Communicate time commitment required for traing to managers and staff. -
Carry Out Training/Education Program
Report and address poor or non-attendance.
Establish a system for updating and competency checks of trainers and health care workers annually.
Produce supplementary materials to maintain momentum and motivation.
Establish system for updating training materials.
Establish system for updating materials. -
Evaluation/Feedback
Hand hygiene observations.
Ward infrastructure surveys.
Soap/handrub consumption surveys.
Perception Surveys for healthcare workers and mangagers.
Knowledge surveys.
Report results to senior mangers.
Set action plan to address poor compliance, knowledge or infrastructure. -
Evaluation/Feedback
Plan observations schedule (e.g. monthly)
Present observation results to senior mangement.
Set annual targets for compliance.
Assess current Health Care associated infection rates and compare to prior findings. -
Reminders in the Workplace
Display posters and signs as reminders.
Ensure posters are in good condition and displayed in suitable places (above sinks, in bathrooms, at the point of care)
Distribute brochures and leaflets to all health care workers. -
Continuing with Safety Climate
Continue the process of training, evaluating and reminding in the workplace.
Conduct patient surveys.
Involve patients in advocacy activites.
