Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study.

BACKGROUND: Health-care-associated infections are a major threat to patient safety worldwide. Transmission is mainly via the hands of health-care workers, but compliance with recommendations is usually low and effective improvement strategies are needed. We assessed the effect of WHO's strategy for improvement of hand hygiene in five countries. METHODS: We did a quasi-experimental study between December, 2006, and December, 2008, at six pilot sites (55 departments in 43 hospitals) in Costa Rica, Italy, Mali, Pakistan, and Saudi Arabia. A step-wise approach in four 3-6 month phases was used to implement WHO's strategy and we assessed the hand-hygiene compliance of health-care workers and their knowledge, by questionnaire, of microbial transmission and hand-hygiene principles. We expressed compliance as the proportion of predefined opportunities met by hand-hygiene actions (ie, handwashing or hand rubbing). We assessed long-term sustainability of core strategy activities in April, 2010. FINDINGS: We noted 21,884 hand-hygiene opportunities during 1423 sessions before the intervention and 23,746 opportunities during 1784 sessions after. Overall compliance increased from 51.0% before the intervention (95% CI 45.1-56.9) to 67.2% after (61.8-72.2). Compliance was independently associated with gross national income per head, with a greater effect of the intervention in low-income and middle-income countries (odds ratio [OR] 4.67, 95% CI 3.16-6.89; p<0.0001) than in high-income countries (2.19, 2.03-2.37; p<0.0001). Implementation had a major effect on compliance of health-care workers across all sites after adjustment for main confounders (OR 2.15, 1.99-2.32). Health-care-workers' knowledge improved at all sites with an increase in the average score from 18.7 (95% CI 17.8-19.7) to 24.7 (23.7-25.6) after educational sessions. 2 years after the intervention, all sites reported ongoing hand-hygiene activities with sustained or further improvement, including national scale-up. INTERPRETATION: Implementation of WHO's hand-hygiene strategy is feasible and sustainable across a range of settings in different countries and leads to significant compliance and knowledge improvement in health-care workers, supporting recommendation for use worldwide. FUNDING: WHO, University of Geneva Hospitals, the Swiss National Science Foundation, Swiss Society of Public Health Administration and Hospital Pharmacists.

The Chilean legacies in health care quality.

OBJECTIVE: The Chilean quality assurance (QA) program evaluation took place in July 1999, at the request of the Chilean Ministry of Health. The main objectives of the evaluation were to identify key aspects of the 8-year-old Chilean QA program that could be considered by other countries and to make strategic recommendations. SETTING: In 1991, the Ministry of Health of Chile launched a national QA program. A national-level team initiated countrywide training of health care providers in QA skills, the development of quality committees at facility levels to direct local quality improvement activities, and training of quality monitors to provide technical support for training and quality improvement activities. DESIGN: The evaluation team, consisting of two international consultants and a regional consultant from the Costa Rican Ministry of Health, visited six regions and seven health 'servicios' (geographically defined administrative units within a region). The regions and servicios were purposefully chosen to represent different geographic areas, types of facilities, and levels of performance of QA activities. The evaluation was based on a framework developed and applied by the Quality Assurance Project (Center for Human Services, USA). Group and individual interviews with staff complemented document and record reviews. RESULTS: The evaluation team found that Chile's QA program had been successful in achieving sustainability and institutionalization. Factors contributing to this success included the enabling environment, management and leadership, technical functions, and support functions. CONCLUSION: The Chilean QA program constitutes an interesting experience for consideration by other countries. Key features include its sustainability, nationwide coverage, decentralization, and alliance of quality improvement and regulation. Training results are impressive: almost 20% of Ministry of Health personnel received training, and 19 training modules are in use. Coaches are active and technically sustaining quality assurance activities nationwide.