The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Report of the WHO Meeting on National
Hand Hygiene Campaigns
WHO Headquarters, Geneva
August 29 – 30 2007
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
"Catch on fire with enthusiasm and people
will come from miles to watch you burn"
John Wesley (1703-1791)
Cited by Margaret Tannahil (Scotland)
at the first Meeting of Hand Hygiene Campaigning Nations
Geneva
August 2007
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Executive Summary
The WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) recommend that national
governments:
•
•
•
Make improved hand hygiene adherence a national priority and consider provision of a funded,
coordinated and implemented programme of improvement.
Support strengthening of infection control capacities within health-care settings.
Promote hand hygiene at the community level to strengthen both self-protection and the protection of
others.
Since the inception of the First Global Patient Safety Challenge of the WHO World Alliance for Patient
Safety, twenty-two national or sub-national campaigns to address low compliance with hand hygiene by
health-care workers have been identified.
In August 2007, twenty-one representatives from sixteen of these countries attended the first global
gathering of campaigning nations in Geneva.
One of the key objectives of the meeting was to explore the opportunities for strengthening the global
response to health care associated infections through the solidarity of a formal partnership of nations, each
with a common aim - to address HAI through a focus (albeit not exclusive) on better hand hygiene
compliance by health care workers.
The meeting facilitated in-depth sharing of the history and progress of national/sub-national campaigns.
What emerged was a range of campaigns having several common features and differing in their extent and
stage of maturity. The challenge posed by all countries concerned sustainability, with a consensus that this
will only be achieved if hand hygiene improvement is integrated with existing infection control and patient
safety activity. Hand hygiene and patient safety were described as forming an axis of health policy and
clinical practice.
The meeting resulted in general support for strengthening the partnership of nations, with the WHO World
Alliance for Patient Safety playing a central, supportive and facilitative role. Greater partnership between
nations was seen as important in sustaining improvement and potentially assisting with spreading the
aspirations and objectives of the First Global Patient Safety Challenge beyond its current reach, particularly
to developing countries, moving the world towards cleaner, safer health care.
One of the chief outcomes of the meeting was the agreement to establish a small working group of
representatives to further scope the way forward for national campaigners. The working group will develop a
proposal for consideration by the World Alliance for Patient Safety.
What is clear is that these nations constitute the beginnings of a global partnership or movement. As a
result of national campaigns, many thousands of hospitals are taking action to change systems which have
historically not supported optimal hand hygiene compliance. This poses an opportunity to disseminate
knowledge and experiences, learn more about the critical success factors behind promotion strategies and
at the same time harmonize these efforts to improve the safety of care. This as yet untapped global
partnership further opens the door to future large scale implementation of effective infection control
interventions per se. As one of the attendees concluded, strengthening the collaboration between country
campaigning nations could become a key step on the road to a global patient safety family, where collective
wisdom results in action which benefits all.
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
List of Participants:
The target audience of the meeting included representatives from countries which have already initiated or
are in the preparation phase of national or sub-national hand hygiene improvement campaigns. In addition,
the Core Technical Group of the First Global Patient Safety Challenge were in attendance (see annex 1).
Additional attendees were comprised of members of the secretariat of the WHO World Alliance for Patient
Safety and representatives from pilot and complementary test sites.
Background Briefing Paper:
All attendees were provided with a briefing paper, ahead of the meeting, outlining the background to the
World Alliance for Patient Safety (WAPS), the First Global Patient Safety Challenge (GPSC1) and the WHO
Guidelines on Hand Hygiene in Health Care (Advanced Draft) (referred to as The Guidelines).
Goals of the meeting:
The goals of the meeting are listed in section 1 of the Briefing Paper.
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Report of Day 1: Wednesday 29th August 2007:
1. Introduction and goals of the meeting:
a. Professor Pittet welcomed attendees to the meeting.
b. Goals of the meeting:
i. To establish the different approaches and extent of current campaigns
ii. To determine best measurement parameters
iii. To determine how evaluation and other outcome-related data might be used
iv. To agree the future relationship between WHO/University Hospitals Geneva and national
campaign countries
v. To determine the feasibility and interest in establishing a formal “Club” of hand hygiene
campaign countries
vi. To determine the potential role of campaigning countries in scale-up, spread and
sustainability at a global level
vii. To determine how best to share knowledge and improve safety of patients through
national campaigning
2. Update on the First Global Patient Safety Challenge (GPSC1):
a. Professor Pittet presented an update on the background and progress of the First Global
Patient Safety Challenge.
i. The First Global Patient Safety Challenge was launched in October 2005.
ii. The objectives of the GPSC1 are:
1. Awareness raising of the issue of health care-associated infection
2. Country Commitment (through ministerial pledges)
3. Technical Guideline production including the development of an
iii.
iv.
v.
vi.
implementation strategy and tools which undergo field testing in the 6 WHO
Regions.
The main output of the GPSC1 is the WHO Guidelines on Hand Hygiene in Health Care
(Advanced Draft).
The Guidelines are underpinned by an implementation strategy which is being field
tested in 8 countries (official Pilot Sites) and over 300 Complementary Test Sites.
Local adaptation of the implementation tools is occurring in many countries.
Alcohol-based handrub at the point of care is a core component of the strategy.
3. Implementation Strategy and Tools:
a. Dr Benedetta Allegranzi, Deputy Leader of the First Global Patient Safety Challenge
outlined the implementation strategy and tools.
4. Revision of the results of the questionnaire:
a. Dr Allegranzi shared the preliminary results of the survey of country campaigning nations
carried out earlier in 2007.
b. Responses were received relating to eighteen national or sub-national campaigns:
c. A summary of the findings is presented in annex 2.
5. What do Current Campaigns Look Like - Presentations by Country Representatives:
a. All country attendees presented a brief overview of their national/sub-national campaigns.
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
b. The discussions and comments arising from the country presentations are listed in section
6-8 of this report.
c. Samples of national campaigns can be seen in annex 4.
6. Discussion and group comments:
a. There was a common agreement in relation to the challenges posed by:
i. Sustainability
ii. Strengthening the linkage between hand hygiene and national infection control
and antibiotic prescribing agendas.
iii. Strengthening the linkage between hand hygiene improvement and the national
safety agenda - however caution was expressed that this could inadvertently
diminish the need for a robust, stand-alone, infection control infrastructure.
iv. The need for robust education programmes, aligned with national policy and
other campaigns.
Day 2: Thursday 30th August 2007:
7. What do Current Campaigns Look Like - Presentations by Country Representatives:
a. Country presentations concluded with presentations by Costa Rica and India. Costa Rica
is in the planning stages of a national campaign and India are considering how best to
approach national campaigning, attending the meeting as part of its investigative phase.
8. Summary Feedback and discussion:
b. Table 1 presents a summary of the strengths, weaknesses, opportunities and threats
associated with current approaches.
c. Table 2 illustrates other major areas emerging from the presentations.
Strengths of current approaches
•
•
•
•
•
•
A national campaign is a powerful symbol, focusing
attention, elevating the priority of HH;
Where HH is linked to national strategic goals/safety
agenda - this is a strength;
Government support and allocation of funds;
Newness/creativeness of approaches;
Management support, champions and role models;
Involvement of staff in decision making;
Opportunities emerging
•
•
•
•
•
•
Potential to drive down costs of HH products;
Links between hand hygiene and accreditation;
To increase sustainability - sell this not as a campaign
to change hand hygiene but to change culture (social
marketing skills essential);
Hand hygiene campaigning must be integrated into
patient safety;
Involve NGOs - particularly for resource poor settings;
More emphasis on hand hygiene programmes being
cost-effective/require low resources;
Weaknesses in current approaches
•
•
•
•
•
•
•
Not planning for sustainability;
Lack of appreciation of the time required;
Lack of investment in infrastructure;
Unclear goals and objectives;
Low consideration of structure indicators;
Lack of integration with other IC interventions;
Management support lacking;
Threats to campaigning
•
•
•
•
•
•
Mapping exercise to avoid duplication of effort
Basic training for physicians and nurses must be
addressed in parallel to hand hygiene improvement
initiatives;
Costs of local production of WHO handrub;
One campaign is not enough for sustainability;
Assumptions that one-size-fits-all (cultural context is
important);
Lack of appreciation of the role of hand hygiene in
infection control by clinicians/managers/public;
Table 1:
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
d. Each country described a number of facilitators of national/sub-national campaigning and
these are listed in table 2.
Facilitators for national/sub-national campaigns
• Ministerial support/leadership (Plus or minus pledge)
– National edict that all hospitals run a hand hygiene campaign
• Funding (central versus local)
– eg Spain 4 million Euros/ Malaysia: annual budget allocation for handrub up to 2009
• Nosocomial infection/hand hygiene as a national priority
• Context (eg SARS)
• Building on the foundations of others (prevent wheel reinvention)
• The personal touch – role models/champions/opinion leaders/opinion formers
• An initial vision: "How to transform the hospital into a hand hygiene excellence centre?"
• Connection with existing national networks
• Mature patient safety infrastructure
Table 2
e. Critical success factors for national campaigning: a summary of the critical success
factors emerging from the discussion, is listed below:
i. Starting point - an acknowledgement of the need for culture change;
ii. Robust planning and long preparation phase;
iii. Central versus local funding;
iv. Initial pilot in small number of facilities followed by review and scale-up;
v. Provision of local teams with resources to aid implementation (capacity building),
prevention of wheel reinvention:
vi. Local adaptation;
vii. Engagement of key stakeholders;
viii. Big hospitals learn from smaller ones;
ix. Strong infection control infrastructure;
x. Hand hygiene improvement as a key performance indicator;
xi. Hand hygiene as part of accountability/governance framework;
xii. Cheap, easily available ABHR;
xiii. Hand hygiene improvement integrated/embedded within broader patient safety.
f. Some of the quotes which represent some of the emerging themes from country
campaigners are presented in annex 3.
9. Complementary Test Sites/economics of hand hygiene improvement:
g. Dr Gerald Dziekan, gave an account of the additional field testing of the implementation
strategy (Complementary Test Sites).
h. GD is also developing a tool to calculate the number of infections which an improvement
programme would have to prevent in order to break-even.
10. Next Steps:
i.
Professor Pittet summarized the meeting.
i. Further work is required to address how such a club will function, in particular
what its focus and objectives will be. Brainstorming resulted in the following
suggestions:
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
j.
1. Priority setting
2. Information sharing e.g.effectiveness/economic data.
3. Generating new ideas/creativity and innovation
4. Helping in the development of solutions to problems
5. Could become aspirational and help build and sustain motivation.
6. A clear focus on deliverables.
7. Designed to meet complex national rather than local needs.
8. Move to creation of a central repository of all tools.
9. Possibility of establishing a mechanism for identifying blind spots.
ii. Membership of the club:
1. Members should be from the national/ministerial level - i.e. need explicit
criteria for membership/terms of reference.
iii. The involvement of WHO Regional Offices in further developments was agreed
as important.
Didier Pittet finished the meeting with the following suggestions:
i. In order to expedite sharing it will be necessary for WAPS to obtain information
from countries (this meeting and the questionnaire earlier in 2007 have started
this process).
ii. Information collection should probably be on at least an annual basis, and
perhaps six-monthly.
iii. Information obtained and all results would form an accessible resource for all
members.
iv. A sub-group will develop a proposal for future direction.
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Annex 1: List of Participants:
HADI, Syed Fazle
AL-ANSARI, Huda
ALLAN, Vivienne
WILSON, Katherine
BRIEN, Susan
DOHERTY, Lorraine
GARCIA, Enrique Terol
KILPATRICK, Claire
MAKKI, Sahar (Saudi Arabia)
McCREIGHT, LIZ (Ontario Canada)
MEHTA, Geeta (India)
CHING, Patricia (Hong Kong)
TAI, Josepha (Hong Kong)
TANNAHIL, Margaret (Scotland)
URROZ, Orlando (Costa Rica)
ZAIN, Rozaini Md (Malaysia)
ZAYED, Bassem (Oman)
GRAYSON, Lindsay (Core Group)
COOKSON, Barry (Core Group)
DAMANI, Nizam (Core Group)
LARSON, Elaine (Core Group)
BOYCE, John (Core Group)
MEMISH, Ziad (Core Group)
RICHET, Herve (Core Group)
ROTTER, Manfred (Core Group)
SATTAR, Syed (Core Group)
SETO, Wing Hong (Core Group)
VOSS, Andreas (Core Group)
WIDMER, Andreas (Core Group)
STORR, Julie (GPSC1 Team & Core Group)
ALLEGRANZI, Benedetta (GPSC1 Team & Core Group)
DZIEKAN, Gerald (GPSC1 Team & Core Group)
LEOTSAKOS, Agnes (GPSC1 Team & Core Group)
BAGHERI NEJAD, Sepideh (GPSC1 Team)
SAX, Hugo (GPSC1 Team & Core Group)
PITTET, Didier (GPSC1 Team & Core Group)
CHRAITI, Marie-Noelle (GPSC1/HUG Team)
LONGTIN, Yves (GPSC1/HUG Team)
HERRAULT, Pascale (GPSC1/HUG Team)
DHARAN, Sasi (GPSC1/HUG Team)
Pakistan (observer)
Bahrain
England and Wales
England and Wales
Canada
Northern Ireland
Spain
Scotland
Saudi Arabia
Ontario, Canada
India
Hong Kong
Hong Kong
Scotland
Costa Rica
Malaysia
Oman
Australia and Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member and Saudi Arabia
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
Global Challenge Core Group Member
World Alliance for Patient Safety Secretariat
World Alliance for Patient Safety Secretariat
World Alliance for Patient Safety Secretariat
World Alliance for Patient Safety Secretariat
World Alliance for Patient Safety Secretariat
Global Challenge Core Group Member
World Alliance for Patient Safety Secretariat
Global Challenge Core Group Member
University Hospitals Geneva
World Alliance for Patient Safety Secretariat
University Hospitals Geneva
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Annex 2: Summary of Questionnaire
Elements of multimodal hand hygiene improvement strategies (1)
COUNTRY
ABHR
REMINDERS
PARTICIPAT
INFORMATION
EDUCATION
COMPLIANCE
18/18
18/18
18/18
18/18
17/18
16/18
Australia
Bahrain
Belgium
Canada
Catalunia (Sp)
England & Wales
Hong Kong (China)
Ireland
Italy
Malaysia
Northern Ireland
Norway
Oman
Ontario (Canada)
Scotland
Saudi Arabia
Spain
Switzerland
TOTAL
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Elements of multimodal hand hygiene improvement strategies (2)
COUNTRY
ABHR CONS
ADMIN
SUPP
SKIN
CARE
SAFETY
CLIMATE
INTERN GL
ADAPT
PT INVOLV
15/18
13/18
13/18
11/18
12/18
10/18
Australia
Bahrain
Belgium
Canada
Catalunia (Sp)
England & Wales
Hong Kong (China)
Ireland
Italy
Malaysia
Northern Ireland
Norway
Oman
Ontario (Canada)
Scotland
Saudi Arabia
Spain
Switzerland
TOTAL
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Main Indicators of Success
ABHR consumption
Hand hygiene compliance
Health-care workers knowledge
Health-care workers perception
HAI rates
Senior manager perception
14/18
14/18
13/18
12/18
11/18
11/18
Structure change
Soap consumption
Dedicated regular budget
Dedicated human resources
10/18
5/18
4/18
1/18
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Annex 3: Key quotes:
Summary of quotes made by country representatives
We must avoid façade building - hand hygiene campaigns may become meaningless facades if the
infrastructure and plan for sustainability is not in-built at the outset.
Hand hygiene improvement should not be part of the infection control pot, but shift more towards the
culture pot
We need to get more streetwise - there is a lot going on in the health care community and beyond and we
need to be joined-up
The problem has to be owned by all healthcare workers.
There is a need to identify important players at the outset.
Make it simple, make good compliance a habit, for this reason it is important to target children .
What is our goal, what are our targets?
User centred design, and simplicity and logic is a unique selling point
Embed hand hygiene in as many national safety initiatives as possible
Hand hygiene improvement - building on the foundations of others……. mimicking and extending the
"Geneva Approach"
Aiming to establish a Hand Hygiene Club and at the same time to integrate hand hygiene with the broader
safety agenda are not mutually exclusive goals
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The First Meeting of Hand Hygiene Campaigning Nations: WHO World Alliance for Patient Safety, August 20007
Annex 4: National/sub-national Campaigns
Scotland, UK
Switzerland
Hong Kong
Spain
Ontario, Canada
Northern Ireland
Australia
Malaysia
Oman
Saudi Arabia
England and Wales, UK
Canada
Bahrain
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