The document describes a quality improvement project to increase hand hygiene compliance at a hospital. Baseline data showed compliance was only 26%. A team analyzed the problem and identified solutions. These included an awareness training program, educational materials, ensuring hand hygiene supplies, and involving leaders. Regular audits and feedback to staff on compliance will also be implemented. The plan is to improve compliance to 90% by March 2014 through these multi-pronged interventions.

1. IMPROVING HAND HYGIENE
COMPLIANCE
Quality Improvement Project using “FOCUS PDCA”
Methodology.

2. Find the problem.
• One of highest priority risk factor in the risk
assessment matrix of Infection Prevention &
Control Department program at AIGH.
• Hand hygiene is the number one step in any
infection prevention and control program.
• It is one of international patient safety goal
(no. 5).
• In our daily rounds , it was observed that hand
hygiene compliance is below expectation.

3. Risk Assessment & Prioritization
Risk Item Likelihood
Human
Impact
Material
Business
Impact
Color code
Hand Hygiene
Non-Compliance 3 5 5 RED

4. Find The Problem
• Impact of the problem:
• This “SINGLE STEP” is
• First component of STANDARD PRECAUTION.
• Decreases all health-care associated infections.
• Part of all CARE-Bundles.

5. Find the status of problem
• Hospital Wide Baseline Data Collection:
• Measurement of the perception of staff (Health
Care Workers & Senior Hospital Managers)
regarding Infection Control practices in AIGH.
• Measurement of the availability of Facility e.g.
Hand washing sinks, Hand rub dispensers, Hand
towels…etc.
• Measurement of Compliance of HCW on the 5
Moments for Hand Hygiene.

6. Perception Questionnaire
HCW Perception
Questionnaire
SHM Perception
Questionnaire

7. The perceptions of both healthcare workers and
senior managers regarding hand hygiene and
perceived effectiveness of measures for increasing
hand hygiene compliance
"In your opinion, how effective are the following
interventions to increase compliance with hand
hygiene?"

8. N= 328

9. N=17

10. Facility Survey

11. N (Beds)=
207

12. N (Sinks)=
131

13. Hand Hygiene Compliance

14. YOUR 5 MOMENTS FOR HAND HYGIENE
Clean your hands before
touching a patient when
approaching him/her!
To protect the patient
against harmful germs
carried on your hands!
Clean your hands immediately
before an aseptic task!
To protect the patient against
harmful germs, including the
patient’s own, entering his/her
body! Clean your hands after touching a
Clean your hands immediately
after an exposure risk to body
fluids (and after glove removal)!
To protect yourself and the
health-care environment from
harmful germs!
patient and his/her immediate
surroundings, when leaving the
patient’s side!
To protect yourself and the
health-care environment from
harmful germs!
Clean your hands after touching any object
or furniture in the patient’s immediate
surroundings, when leaving-even if the
patient has not been touched!
To protect yourself and the health-care
environment from harmful germs!

16. Observation Form – Basic Compliance Calculation
Facility: Period: Setting:
Prof.cat.
Prof.cat.
Prof.cat.
Prof.cat.
Total per session
Session N° Opp
(n)
HW
(n)
HR
(n)
Opp
(n)
HW
(n)
HR
(n)
Opp
(n)
HW
(n)
HR
(n)
Opp
(n)
HW
(n)
HR
(n)
Opp
(n)
HW
(n)
HR
(n)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
Calculation Act (n) =
Opp (n) =
Act (n) =
Opp (n) =
Act (n) =
Opp (n) =
Act (n) =
Opp (n) =
Act (n) =
Opp (n) =
Compliance
Compliance (%) = Actions x 100
Opportunities
Instructions for use
1. Define the setting outlining the scope for analysis and report related data according to the chosen setting.
2. Check data in the observation form. Hand hygiene actions not related to an indication should not be taken into
account and vice versa.
3. Report the session number and the related observation data in the same line. This attribution of session number
validates the fact that data has been taken into count for compliance calculation.
4. Results per professional category and per session (vertical):
4.1 Sum up recorded opportunities (opp) in the case report form per professional category: report the sum in the corresponding
cell in the calculation form.
4.2 Sum up the positive hand hygiene actions related to the total of opportunities above, making difference between handwash
(HW) and handrub (HR): report the sum in the corresponding cell in the calculation form.
4.3 Proceed in the same way for each session (data record form).
4.4 Add up all sums per each professional category and put the calculation to calculate the compliance rate (given in percent)
5. The addition of results of each line permits to get the global compliance at the end of the last right column.

17. Observation Form – Optional Calculation Form
(Indication-related compliance with hand hygiene)
Facility: Period: Setting:
Before touching a
Before clean/ aseptic
After body fluid
patient
procedure
exposure risk
After touching a
patient
After touching
patient surroundings
Session N° Indic
(n)
HW
(n)
HR
(n)
Indic
(n)
HW
(n)
HR
(n)
Indic
(n)
HW
(n)
HR
(n)
Indic
(n)
HW
(n)
HR
(n)
Indic
(n)
HW
(n)
HR
(n)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
Calculation Act (n) =
Indic1 (n) =
Act (n) =
Indic2 (n) =
Act (n) =
Indic3 (n) =
Act (n) =
Indic4 (n) =
Act (n) =
Indic5 (n) =
Ratio
act / indic
Instructions for use
1. Define the setting outlining the scope for analysis and report related data according to the chosen setting.
2. Check data in the observation form. Hand hygiene actions not related to an indication should not be taken into
account and vice versa.
3. If several indications occur within the same opportunity, each one should be considered separately as well as the
related action.
4. Report the session number and the related observation data in the same line. This attribution of session number
validates the fact that data has been taken into count for compliance calculation.
5. Results per indication (indic) and per session (vertical):
4.1 Sum up indications per indication in the observation form: report the sum in the corresponding cell in the calculation form.
4.2 Sum up positive hand hygiene actions related to the total of indications above, making the difference between handwash
(HW) and handrub (HR): report the sum in the corresponding cell in the calculation form.
4.3 Proceed in the same way for each session (observation form).
4.4 Add up all sums per each indication and put the calculation to calculate the ratio (given in percent)
 Note: This calculation is not exactly a compliance result, as the denominator of the calculation is an indication instead of an opportunity. Action is
artif icially overestimated according to each indication. How ever, the result gives an overall idea of health-care w orker’s behaviour towards each type
of indication.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty

18. N=328
N=158
N=42

19. N=114 N=33 N=91 N=72 N=39 N=179

20. N= 528

21. Moment # 3 After body fluid exposure
Moment # 2 Befor e aseptic procedur e
Moment # 4 After patient contact
Moment # 1Before patient contact
Moment # 5 After patient sur roundings
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
100
80
60
40
20
0
Pe r ce n t
Pareto Chart for I ncompliance of 5 Moments for Hand Hygiene

22. Find The Problem
• The project Mission is:
• To improve Hand Hygiene compliance from
26% to 90% by March 2014.

23. Organize The Team
• Team Leader: Infection Control Director
• Facilitator: Quality Director.
• Members:
• ICU team.
• Supervisor ICP.
• Nursing Supervisor.
• ICP.
• IC Link Nurses.
• MOH team.

24. Clarify Current Process

25. Hand Hygiene Definition
• Hand Hygiene refers to killing or removal of
microorganisms on the hands that have been
picked up by contact with patients, staff,
contaminated equipment or the environment*.
*CDC (Centers for Disease Control).

26. Steps of Hand Rub

27. Steps of Hand Washing

28. Understand The Variation

29. Select Remedies
• The team suggested the following solutions to
the problem:
• Start Awareness Training Program (HH Campaign).
• Prepare Educational Materials.
• Schedule Lectures & On Job Training.
• Ensure The Availability of HR/HW Facilities.
• Involve hospital leaders and get them on board

30. Selection Matrix
Solution Feasibility Cost
(Inverse Scoring)
Impact Score
Awareness Training Program 6 10 10 600
Provide the missing Hand Rubs 7 6 9 378
Provide the missing Sinks 5 4 9 180
Apply Educational Posters 10 8 5 400
Assign Physician Champion 10 9 8 720
Involve top management by regular
monitoring feedback
7 10 9 630
Recognition/Awarding compliant
staff
4 9 6 216

31. Selection Matrix
Solution Feasibility Cost
(Inverse Scoring)
Impact Score
Reminder from patients 4 5 6 120
Notice to non-compliant staff 8 9 6 432
Auditing by some other team 3 6 7 126
Hand print culture 8 4 7 224

32. Remedies In Order
• Assign Physician Champion (720).
• Involve top management by regular monitoring feedback
(630).
• Awareness Training Program (600).
• Notice to non-compliant staff (432).
• Apply Educational Posters (400).
• Provide the missing Hand Rubs (378).
• Hand print culture (224).
• Recognition/Awarding compliant staff (216).
• Provide the missing Sinks (180).
• Auditing by some other team (126).
• Reminder from patients (120).

33. Plan

34. Plan
ACTION RESPONSIBLE PERSON DUE DATE
Assign Physician Champion IC Committee 1 month
Involve top management
Dr. Fatma Noman Ongoing
by regular monitoring
feedback
Awareness Training
Program hospital-wide:
- Hand Hygiene Day
IC Team
May 5
-Lectures. Dr. Fatma Noman Next Month (For Doctors)
Monthly for Nurses
Focus Training Program in
ICU & NICU:
-Daily Interactive training/
Video Presentation.
IC Team Next Month
-Small group lectures. IC Team Monthly schedule
Notice to non-compliant
Dr. Fatma Noman Ongoing
staff

35. Plan
ACTION RESPONSIBLE PERSON DUE DATE
Apply Educational Posters IC Team/Admin Request to be sent within
next week
Provide the missing Hand
Rubs
IC Team/Admin Request to be sent within
next week
Hand print culture
Campaign
IC Team Start next month with
small group lectures

36. Do Pilot

37. Do (Pilot)
• ICU & NICU was identified as the areas of greatest
RISK and was selected for implying the pilot.
• Reasons:
• Vulnerable Patients.
• Complex Care.
• Confined Area.
• Easy to monitor compliance.
• Many HH opportunities.

38. ICU & NICU Hand Hygiene Campaign
• Demographic data about ICU & NICU:
 No. of ICU Beds: 12 Beds
 No. of NICU Incubators: 19
 No. of ICU Physicians: 7
 No. of NICU Physicians: 4
 No. of ICU Nurses: 36
 No. of NICU Nurses: 20
 Average no. of admissions per month for ICU: 26
 Average no. of admissions per month for NICU: 17

39. ICU & NICU Hand Hygiene Campaign
• Time Frame:
 The campaign lasted over one month (February).
• Educational Tools:
 Posters.
 Interactive Visual Training (Video).
 On job training.
 Hand Hygiene advocate badges.

40. Doctor Giving Hand Print

41. Dr. Fatima Giving On-site Training For
Hand Hygiene

42. ICU1
Dr Fatima Teaching Hand Hygiene to
Doctors

43. ICU1
HOD Giving Hand Print

44. Hand Print

45. ICU
Dr Fatima Training Doctors and staff
on Hand Hygiene

46. Hand Print Culture
Colonies Of Micro Organisms Growing

47. Meeting With Assigned Physician Champions
(Wearing HH Badge), Discussing The Status Quo
Of Hand Hygiene Compliance

48. ICN Demonstrating Trend Of Hand
Hygiene Trend To Physician Champion

49. CHECK PILOT RESULTS

50. Hand Hygiene Compliance Rate
Critical Areas
N=103
N=110

51. Act (Generalize Hospital Wide)

52. PROGRESS
PLANNED ACTIVITIES WHAT WAS DONE
Assign Physician Champion:
•Dr. Yasser Al-Basatiny…
Medical Director.
•Dr. Bashar…Medicine
•Dr. Bassam… Surgery
•Dr. Mohammad Ali….ICU
•Dr. Ebiedo… Pediatrics
•Dr. Mona Bhutta …. Obs/Gyne
•Dr. Khalid Kandeel…
Emergency Room
• A senior member doctor from each
department was assigned as Physician
champion
• The Physician Champions were provided
with a badge “I am Hand Hygiene
Advocate” to make him stand out
• He / She would act as Role model to
motivate staff of his department esp.
doctors and promote hand hygiene
practices
• He/she will be regularly provided the
compliance rate of different staff
categories

53. PROGRESS
PLANNED ACTIVITIES WHAT WAS DONE
Involve top management by
regular monitoring feedback
• Monthly Hand Hygiene compliance rate (figures
and graph) reported to Infection Control
Committee members and Medical Director(ICC
Chairperson) where It showed compliance rate
by
o Staff categories
o Unit wise
Awareness Training Program
hospital-wide:
- Hand Hygiene Day
• Distribution of hand-outs/badges
• Video show in open areas (5 Moments for Hand
Hygiene).
Lectures followed by demonstration of steps of
Hand Hygiene by Infection control nurses.
• There are 80 attendees participated.

54. PROGRESS
PLANNED ACTIVITIES WHAT WAS DONE
-Lectures. • General Orientation Day (Why Hand Hygiene So
Important).
• Monthly Orientation for new staff (5 Moments
for Hand Hygiene & The Proper Steps).
• Weekly lectures for Nurses (Hand Hygiene &
Breaking The Chain of Infection).
• These lectures done in the Multi-purpose hall
and lasted for an hour.
(Contents: Role of Hand Hygiene in preventing
HAIs, 5 moments, steps, IPSG 5, standard
precautions, Bundles of care).
-Small group lectures. • Unit-wise lectures & post – test (attendants are
asked to demonstrate back the steps with Hand
Rub)/
• (5 Moments for Hand Hygiene Video) lasting 15
to 30 minutes

55. PROGRESS
PLANNED ACTIVITIES WHAT WAS DONE
Notice to non compliant staff  Five Doctors were given a verbal feedback with
polite reminders by the Infection Control Director.
 Ten nurses and fifteen technicians given a one on
one explanation by the ICP to make them
accountable to their actions.
 No written warnings/punishments.
Apply Educational Posters  Number of posters were increased from
occasional to 400 posters all over the hospital:
• 5 Moments
• Steps of using Alcohol Hand-Rub (English and
Arabic)
• Steps of Hand wash with soap and water

56. PROGRESS
PLANNED ACTIVITIES WHAT WAS DONE
Provide the missing Hand
Rubs
 120 hand rub dispensers newly installed in
addition to the 333 functional dispensers .
Hand print culture Campaign 13 Hand imprint samples were taken from doctors ,
Nurses and others during Teaching Rounds and
The Results were demonstrated to them
To give them feedback and idea that although visibly
clean; their hands were carrying germs ..to motivate
them doing Hand Hygiene before contact with
patients and contacting Sterile sites.

57. Act (Generalize Hospital Wide)
• The first phase of the campaign/program started
on the critical areas, thereafter it was extended
to all hospital locations.
• Time Frame : lasted over a month
• Educational Tools
- Campaign posters.
- Interactive trainings.
- In service education.
- Competencies.

58. Act (Generalize Hospital Wide)

59. N=386
N=115

60. Monitoring
• After the marked improvement done by the
project, the IC team kept an eye on the
process and continuously measured the
compliance rate to hold the gains and
maintain the staff adherence to the hand
hygiene practice.

61. Target