The document describes a quality improvement project using the WHO Multimodal Hand Hygiene Strategy to improve hand hygiene compliance rates in a hospital in Surabaya, Indonesia. Over the period of 2015 to 2017, hand hygiene compliance increased from 72.05% to over 91.88% through implementing the five components of the WHO strategy: system change, training and education, evaluation and feedback, reminders in the workplace, and developing a safety culture. Compliance improved across all healthcare worker groups and indications for hand hygiene. The project demonstrated the effectiveness of the WHO multimodal approach for sustainably improving and maintaining higher hand hygiene standards.

1. IMPROVING HAND
HYGIENE COMPLIANCE
THROUGH WHO’s
MULTIMODAL HAND
HYGIENE IMPROVEMENT
STRATEGY
Bernadetta Indah
Mustikawati,Amd.Kep,SKM,M.Kes

2. A. Introduction
Hand hygiene is
considered the most
important measure to
reduce the transmission
of nosocomial pathogens
in healthcare settings.
01
An effective and
recommended solution
to prevent transmission
of microorganism is
improving hand hygiene
compliance in healthcare
organizations.
02
Hand hygiene compliance
of health care workers in
2014 was 73.34% which
is lower than WHO
standard (85%).
03

3. A. Introduction
The study is aims to improve
hand hygiene compliance in
hospital.
01
Therefore, there was a need
for quality improvement by
using the WHO multimodal
hand hygiene improvement
strategy to improve hand
hygiene in healthcare workers.
02

4. PROBLEM
Hand hygiene compliance of health care workers in 2014 was 73.34%
which is lower than WHO standard (85%).
WHO Multimodal Hand Hygiene Strategy – Quality improvement
• To improve hand hygiene compliance by using the
WHO Multimodal Hand Hygiene Strategy
Aims

5. A grid to assess opportunities for hand
hygiene was adapted from the WHO’s
model
.
The measurement
This study was a cross sectional with analytic
quantitative, using chi-square analysis to
determine the significance of hand hygiene
compliance improvement in healthcare workers
Study
Implementation of a multi-modal
improvement programme based on the
World Health Organization (WHO) strategy
PDSA Monitoring
We monitored the overall compliance
with hand hygiene during routine patient
care in hospital
ProcessAnalysis
WHO Multimodal Hand Hygiene Strategy – Quality improvement

6. Reflect and report of findings; lesson learned
shared so that future projects may benefit
from our projects successs and failures.
Finish
Data points were recorded in charts to keep
track of progress and ensure changes made
were indeed improvement.
Sustain
Our Project
Implementation of a multi-modal improvement programme
based on the World Health Organization (WHO) strategy,
consist of system change initiatives, training and education,
evaluation and feedback, reminders in the workplace,
institutional safety climate
WHO Multimodal Hand Hygiene Strategy – Quality improvement

7. System Change
Access to a safe, continuous water supply as well as
to soap and towels; readily accessible alcohol-based handrub at the point of care
Ward infra-
structure
survey every 6
month
Tolerability &
acceptability
ABHR (N=40)
Hand
Hygiene
policy
Schedule of
maintaining HH
facilities quarterly
Schedule of
maintaining supply
of clean, running
water monthly
1. How easily available is alcohol-
based handrub in your health-
care facility
2. What is the sink: bed ratio?
a. At least 1:10 facility-wide and 1:1 in
isolation rooms and in intensive care units
3. Is there a continuous supply of
clean, running water
4. Is soap available at each sink
5. Are single-use towels available at
each sink?
6. Is there dedicated/available
budget for the continuous
procurement of hand hygiene
products (e.g. alcohol-based
handrubs)?
Is there realistic plan in place to
improve the infrastructure6 in your
health-care facility?

8. Training and Education
Providing regular training to all health-care workers
HH training &
education
schedule
1. Regarding training of health-care
workers in your facility:
a. How frequently do health-care workers
receive training regarding hand hygiene in
your facility?
b. Is a process in place to confirm that all
health-care workers complete this training?
2. Are the following WHO
documents (available at
www.who.int/gpsc/5may/tools),
or similar local adaptations, easily
available to all health-care
workers??
3. Is a professional with adequate
skills to serve as trainer for hand
hygiene educational programmes
active within the health-care
facility?
4. Is a system in place for training
and validation of hand hygiene
compliance observers?
5. Is there is a dedicated budget that
allows for hand hygiene training?
Mandatory training for all professional catagories :
• Regular training for medical , nursing staff and all
professional every 6 month as Infection control
schedule
• Commencement of all employement in
induction program training as T&E dept schedule
• Visiting Phycisian in hospital events : Doctor
forum, AB stewardship case study presentation

9. Training and Education
Providing regular training to all health-care workers
Hand Hygiene
Technical reference
manual
E-learning HH
module
1. Regarding training of health-care
workers in your facility:
a. How frequently do health-care workers
receive training regarding hand hygiene7 in
your facility?
b. Is a process in place to confirm that all
health-care workers complete this training?
2. Are the following WHO
documents (available at
www.who.int/gpsc/5may/tools),
or similar local adaptations, easily
available to all health-care
workers??
3. Is a professional with adequate
skills8 to serve as trainer for hand
hygiene educational programmes
active within the health-care
facility?
4. Is a system in place for training
and validation of hand hygiene
compliance observers?
5. Is there is a dedicated budget that
allows for hand hygiene training?
o Training &education module,material are made according to WHO
guidelines
o System to evaluate & validate the implementation of HH training
education program : portfolio , sticker in staff’s ID card

10. Evaluation and Feedback
Monitoring hand hygiene practices, infrastructure, perceptions and
knowledge, while providing results feedback to health-care workers 1. Are regular (at least annual) ward-based
audits undertaken to assess the availability
of handrub, soap, single use towels and
other hand hygiene resources?
2. Is health care worker knowledge of the
following topics assessed at least annually
(e.g. after education sessions)?
a. The indications for hand hygiene
b. The correct technique for hand hygiene
3. Indirect Monitoring of Hand Hygiene
Compliance
a. a Is consumption of alcohol-based
handrub monitored regularly (at least
every 3 months)?
b. Is consumption of soap monitored
regularly (at least every 3 months)?
c. Is alcohol based handrub consumption at
least 20L per 1000 patient-days?
o Hand hygiene compliance audit report :
o Monthly in Executive Committee and IC dashboard
o Every 3 month in IC team meeting
o Quality Indicator patient safety goals in coordination meeting
every month
o Ward infrastructure survey result
o Every 6 month in the IC Committee meeting
o Clinical Quality Improvement audit every week
o External audit by
o ISO:9001 team annually
o Global Quality Development team annually
o Indonesia National Accreditation Committee (KARS) every 3 years

11. 4.Direct Monitoring of Hand Hygiene
Complianc
a. How frequently is direct
observation of hand hygiene
compliance performed using the
WHO Hand Hygiene Observation
tool (or similar technique)?
b.What is the overall hand hygiene
compliance rate according to the
WHO Hand Hygiene Observation
tool (or similar technique) in your
facility
5.Feedback
a Immediate feedback Is immediate
feedback given to health-care
workers at the end of each hand
hygiene compliance observation
session?
B. Systematic feedback Is regular (at
least 6 monthly) feedback of data
related to hand hygiene indicators
with demonstration of trends over
time given to:

12. Reminder in the workplace
Prompting and reminding health-care workers
1. Are the following posters (or locally produced
equivalent with similar content) displayed
a. Poster explaining the indications for hand hygiene
b. Poster explaining the correct use of handrub
c. Poster explaining correct handwashing technique
2. How frequently does a systematic audit of
all posters for evidence of damage occur,
with replacement as required?
3. Is hand hygiene promotion undertaken by
displaying and regularly updating posters
other than those mentioned above?
4. Are hand hygiene information leaflets
available on wards?
5. Are other workplace reminders located
throughout the facility? (e.g. hand
hygiene campaign screensavers, badges,
stickers, etc)
Screen saver
Poster in public
area, corridor and
point of care
Hand
Hygiene
Leaflet
IPSG Video
Paging system
Fingerprint
attendance
machine with
audio HH reminder

13. 1. With regard to a hand hygiene team
that is dedicated to the promotion and
implementation of optimal hand
hygiene practice in your facility:
a.Is such a team established
b. Does this team meet on a regular basis (at
least monthly)
c. Does this team have dedicated time to
conduct active hand hygiene promotion? (e.g.
teaching monitoring hand hygiene performance,
organizing new activities)
2. Have the following members of the
facility leadership made a clear
commitment to support hand hygiene
improvement? (e.g. a written or verbal
commitment to hand hygiene
promotion received by the majority of
health-care workers)
a. Chief executive officer
b. Medical director
c. Director of nursing
3. Are systems for identification of Hand
Hygiene Leaders from all disciplines in
place??
a. A system for designation of Hand Hygiene
champions1
b. A system for recognition and utilisation of
Hand Hygiene role models
Instutional Safety Climate for Hand Hygiene
Creating an environment and the perceptions that facilitate
awareness-raising about patient safety issues
Surveillance

14. 1. Regarding patient involvement in hand
hygiene promotion
a. Are patients informed about the importance of
hand hygiene? (e.g. with a leafletc.
b. Has a formalised programme of patient
engagement been undertaken
2. Are systems for identification of Hand
Hygiene Leaders from all disciplines in
place??
a. A system for designation of Hand Hygiene
champions1
b. A system for recognition and utilisation of Hand
Hygiene role models
3. Are initiatives to support local continuous
improvement being applied in your facility,
for example
a. Hand hygiene E-learning tools
b. A hand hygiene institutionaltarget to be achieved
is established each year
c. A system for intra-institutional sharing of reliable
and tested local innovations
d. Communications that regularly mention hand
hygiene e.g. facility newsletter, clinical meetings
e. System for personal accountability
f. A Buddy system for new employees
Instutional Safety Climate for Hand Hygiene
Creating an environment and the perceptions that facilitate
awareness-raising about patient safety issues
Patient speak up

15. Overall hand hygiene compliance in 2015 to 2017 in total 25900 opportunities
for hand hygiene were observed achieving an average compliance of 82.84% -
90% per years in 2015 to 2017. This represents an improvement from
previous audits through is below the WHO target of 85%.
Years Hand Hygiene
opportunities
Hand Hygiene
actions
Percent
compliance
2015 6736 4853 72.05
2016 12219 10188 82.81
2017 6945 6381 91.88
Table.1: Hand hygiene compliance Surabaya hospital, and overall compliance
for periods 2015 to 2017
Source from HH audit report Surabaya Hospital 2015-2017
14
o Between 2015 and 2017,
data were collected from
5184 scheduled
observation periods. We
obtained data on 25900
opportunities for hand
hygiene total. Therefore
significant increase in
compliance during the
program was found to last,
and stable compliance was
maintenad during the study
done.
o This study was a cross
sectional with analytic
quantitative, using chi-
square analysis to
determine the significance
of hand hygiene
compliance improvement
in healthcare workers
Result

16. Table.2: Hand hygiene compliance by healthcare workers in Surabaya hospital,
for periods 2015 to 2017
Source from HH audit report Surabaya Hospital 2015-2017
2015 2016 2017
HH.
OPP
HH
Action
%
compli
ance
HH.
OPP
HH
Action
%
compli
ance
HH.
OPP
HH
Action
%
complianc
e
P
Nurse 4281 3061 71.50 7556 6381 84.45 3927 3687 93.89 0.0001
Doctor
s
1806 1279 70.82 3207 2494 77.77 1932 1708 88.41 0.0001
HCA 649 513 79.04 1190 1059 88.99 883 830 94.00 0.0001
Others - - - 266 184 69.17 203 156 76.85 0.0001
13
The compliance for the different
catagories of healthcare workers
in 2015 to 2017 all increased,
representing catagories of
nursing staff compliance
significantly improved 71.50%
to 93.9% (p < 0.0001),
physicians 70.82 to 88.4% (p
<0.0001) Healtcare Assistance
(HCA) 79.4% to 94% (p<0.0001)
We start observed other
healthcare workers such as
radiologist staff, laboratory staff
and nutrision in 2016 hand
hygiene compliance was
increased 69.17% to 76.85% (p<
0.0001).
Result

17. Years Hand Hygiene
opportunities
Hand Hygiene
actions
Percent
compliance
2015 6736 4853 72.05
2016 12219 10188 82.81
2017 6945 6381 91.88
Table.1: Hand hygiene compliance Surabaya hospital, and overall compliance
for periods 2015 to 2017
Source from HH audit report Surabaya Hospital 2015-2017
14
Overall hand hygiene
compliance in 2015 to 2017
in total 25900 opportunities
for hand hygiene were
observed achieving an
average compliance of
82.84% - 90% per years in
2015 to 2017. This
represents an improvement
from previous audits
through is below the WHO
target of 85%.
Result

18. 2015 2016 2017
HH.
OPP
HH
Action
%
complia
nce
HH.
OPP
HH
Action
%
complia
nce
HH.
OPP
HH
Action
%
complianc
e
Moment 1 1591 824 51.79 2820 1930 68.44 2942 2592 88.10
Moment 2 1387 1034 74.55 2163 1690 78.13 1180 1037 87.88
Moment 3 1432 1409 98.39 2261 2223 98.28 1419 1403 98.87
Moment 4 1483 1247 84.09 2727 2499 91.64 2780 2671 96.08
Moment 5 1252 740 59.11 2317 1834 79.15 1515 1453 95.91
HCWs category and every indication, improvements during the implementation WHO multi
modal were statistically significant. For most indications, improvement occurred in Moment
1 before patient contact from 51.79 % to 88.10% and Moment 5 after patient contact from
59.11 to 95.91% with improvement intervention being concentered, and sustained
Table.3: Hand hygiene compliance by indications for hand hygiene in Surabaya hospital
and overall compliance for periods 2015 to 2017
*Sources data from infection control audit report Surabaya Hospital 2015-2017
16
WHO multi-modal consist of
5 strategy were
implemented. For every
healthcare workers
category,every indication
and unit improvement
significant
Behavioural theoriest and
interventions based on these
theories have primarily
targeted individuals. This
may be insufficient to effect
sustained change
Result

19. • Hand hygiene compliance also differed between ward type, resulting in a low overall
increased compliance on th,e emergency wards 41.14% and pediatric ward 56.95.
overall Hand hygiene compliance in ward type increased significantly in 2017
2015 2016 2017
HH.
OPP
HH
Action
%
compliance
HH.
OPP
HH
Action
%
compliance
HH.
OPP
HH
Action
%
complianc
e
Emergency
880 362 41.14 1639 1141 69.62 400 389 97.25
HD 41 34 82.93 129 116 89.92 141 119 84.40
ICU
387 313 80.88 1208 1048 86.75 749 649 86.65
Maternity
1288 734 56.99 1438 1183 82.27 460 412 89.57
Med Sur
2399 2047 85.33 4235 3756 88.69 2598 2430 93.53
OPD
637 511 80.22 1007 811 80.54 460 412 89.57
OT
638 520 81.50 1701 1328 78.07 803 729 90.78
Pediatry
295 168 56.95 441 390 88.44 340 319 93.82
RPK
171 164 95.91 421 345 81.95 176 159 90.34
Table.4: Hand hygiene compliance by Location in Surabaya hospital, and
overall compliance for periods 2015 to 2017
*Sources data from infection control audit report Surabaya Hospital 2015-2017
17
Improve adharance
was sustained and
observed across most
hospital locations, in
all types of patient
care activities, and
among most
healthcare worker
present on the ward
Result

20. 19
Lesson Learned
Median
Goal
0%
20%
40%
60%
80%
100%
120%
20062007200820092010201120122013201420152016201720182019202020212022
capaian %
WHO
Multimodal
STRATEGY
o WHO multi-modal consist of
5 strategy were
implemented. For every
healthcare workers
category,every indication and
unit improvement significant.
o Improve adharance was
sustained and observed
across most hospital
locations, in all types of
patient care activities, and
among most healthcare
worker present on the ward

21. 19
Lesson Learned

22. • Implementation of World Health Organization multimodal hand hygiene
improvement strategy improved hand hygiene compliance significantly.
20
Conclusion

23. Thank YOU