Clean Care is Safer Care: linking healthcare behaviour to health policy

Didier Pittet
MD MS
Director
Infection Control Programme
University of Geneva Hospitals and Faculty of Medicine
Geneva,
Switzerland
Lead
WHO World Alliance for Patient Safety
Global Patient Safety Challenge

The first Global Patient Safety Challenge (GPSC), launched by the World Alliance for Patient Safety in ­October 2005, aims at reducing healthcare-associated infection (HAI) worldwide by ­strengthening integrated actions in the areas of blood safety; injection safety; clinical procedure safety; and water, sanitation and waste management safety; with the promotion of hand hygiene in healthcare as the cornerstone.(1) Three action areas were identified to achieve the Clean Care is Safer Care objectives: global awareness-raising and campaigning; catalysing country commitment; and technical work to elaborate recommendations and design an implementation strategy to improve hand hygiene in healthcare.(2) Significant progress has been made in these three areas, and an unprecedented global movement focusing on hand hygiene improvement is spreading among countries throughout the world and thus making a substantial contribution to the quality of patient care.

Progress in global awareness-raising
The objective of raising global awareness on the importance of HAI and the existence of effective ­prevention strategies is being attained through a dedicated website, dissemination of information documents, scientific publications, participation in international conferences and stakeholder engagement. Unprecedented global media coverage and official ministerial participation from several countries characterised two global international events held at World Health Organization (WHO) Headquarters in Geneva: the launch of the first  GPSC in October 2005, and the one-year-on anniversary event, “A Year of Cleaner and Safer Care”, in November 2006.

Furthermore, Clean Care is Safer Care has had a presence in more than 50 international ­conferences through keynote/plenary lectures, exhibition materials, posters and scientific publications in 2006 and has been promoted to a similar degree throughout 2007. The technical and research work on different aspects of hand hygiene has led to more than 20 scientific papers published in peer-reviewed journals to date.(2–9) ­Stakeholders are important partners for the dissemination of documents and recommendations in their respective countries. A massive mobilisation of key stakeholders in the USA and Europe in 2006 is illustrated by the following examples of professional association and societies which have formally committed to the challenge: the Canadian Patient Safety Agency, Association for Professionals in Infection Control (APIC), Joint Commission on Accreditation of Healthcare Agencies, International Federation of Infection ­Control (IFIC), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Public Services International.

Mapping country commitment worldwide
The strategy to catalyse country commitment to Clean Care is Safer Care has focused on inviting WHO Member States to make a formal statement pledging their engagement to implement actions to reduce HAI at country level, and to share results and lessons learned internationally. Over the first two years of the First GPSC, the pledge has been signed by 80 ministries of health, and at least 20 additional countries have planned to do so by the end of 2007, leading to coverage of more than three-quarters of the world population. Within the first year, most pledged countries were able to document progress such as new infection control policy development, allocation of funds and human resources, inauguration of training programmes and surveillance systems, national guideline preparation and actual intervention­ implementation in healthcare settings. In the framework of the advocacy and technical activities launched by the first GPSC, more than 20 countries have already launched national or regional hand hygiene promotion campaigns, all referring to the WHO guidelines on Hand Hygiene in Health Care (Advanced Draft). More countries are expected to join this global movement and provide useful data on the feasibility and cost-effectiveness of hand hygiene promotion on a large scale.

Achievements and current challenges in technical work
Pilot testing and evaluation of the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) and an associated multimodal strategy and practical tools to implement their core recommendations is currently underway in a large number of sites in developing and developed countries worldwide. A significant effort has been made to shape such a strategy from a global perspective, taking into account cultural considerations and the necessity to merge the requirements suggested by the ­scientific ­evidence with feasibility and applicability issues in different healthcare settings.

Five key elements are considered essential minimum requirements for hand hygiene improvement on the basis of the scientific evidence: system change through the procurement or local production of alcohol-based handrubs for hand hygiene and by ensuring continuous access to safe and clean water; healthcare worker education; observation of hand hygiene practices and performance feedback; ­constant reminders in the workplace (eg, promotional posters); and active, visible participation at both institutional and individual levels to create a safety climate. Depending on local resources and culture, other activities can be further combined such as patient involvement, avoiding overcrowding and understaffing and/or facilitating hand skincare. A pilot implementation pack of practical tools (see Table 1) is available to apply all five key elements of the strategy and guide the implementation step by step. These tools address different targets: operational, advocacy and information; ­monitoring; hand hygiene ­product procurement or local production; education; and impact evaluation.

[[HHE07_table1_C12]]

A new ­revolutionary approach is proposed to address healthcare worker education. Several studies demonstrated that ­failure to comply with hand hygiene is frequently due to a poor understanding of indications to practice hand hygiene, often perceived by healthcare workers as a long list of theoretical recommendations difficult to assimilate into real-life healthcare. For this reason, the WHO recommendations for hand antisepsis have been condensed into five moments when hand hygiene is of utmost importance during the care process.(10) Through this educational module, healthcare workers are intensively trained to remember these five moments and thus promote an easier integration of the indications within the workflow.

Conclusion
For the very first time, a rigorous strategy with related tools and instructions are readily available for any hospital or healthcare setting willing to improve hand hygiene among healthcare workers. The achievement of the first GPSC objectives is progressively becoming a reality with a ­tangible development of new initiatives by countries, adoption of the hand hygiene improvement strategy by healthcare facilities and the participation of key stakeholders. The measurement of the impact of the technical work aimed at hand hygiene promotion is being undertaken through a robust testing phase and evaluation. This unprecedented global movement to raise awareness of the burden of HAI and to promote effective infection control interventions has the potential to improve the quality and safety of healthcare and to eventually save millions of patient lives.

References

1. WHO. The Global Patient Safety Challenge 2005–2006 Clean Care is Safer Care. Geneva: WHO; 2005. Available from: www.who.int
2. Pittet D, Donaldson L. Lancet 2005;366:1246-7.
3. Pittet D, Donaldson L. Infect Control Hosp Epidemiol 2005;26:891-4.
4. Pittet D. Lancet 2005;366:185-7.
5. Ahmed QA, et al. Lancet 2006;367:1025-7.
6. Pittet D, et al. Hand hygiene: still not ­sufficiently recognized in European hospitals. Hospital Health Care 2006/7. Epub: www.hospitalhealthcare.com
7. Pittet D, et al. Lancet Infect Dis 2006;6:641-52.
8. Whitby M, et al. J Hosp Infect 2007;65:1-8.
9. Larson E, et al. Am J Infect Control 2006;34:627-35.
10. Sax H, et al. J Hosp Infect 2007;67:9-21.