WHO Hand Hygiene Self-Assessment Framework Global Survey

Summary Report

From April to December 2011, health-care facilities registered for the WHO SAVE
LIVES: Clean Your Hands initiative and those participating in some national hand
hygiene campaigns were invited to participate in a global survey based on the
completion of the Hand Hygiene Self-Assessment Framework (HHSAF).

The survey objectives were three-fold:

 to assess the level of progress of health-care facilities in terms of hand
hygiene infrastructure, promotional activities, performance monitoring and
feedback, and institutional commitment, according to a range of indicators
relevant to the WHO Multimodal Hand Hygiene Improvement Strategy
summarized in a score;
 to identify gaps in hand hygiene infrastructures and activities according to
the HHSAF indicators;
 to provide feedback through summary results.

Methods
The HHSAF is a tool providing a systematic situation analysis of hand hygiene
structures, resources, promotion, and practices within a health-care facility. It
resembles a questionnaire and is structured in five sections, based on the five
components of the WHO Multimodal Hand Hygiene Improvement Strategy (namely
system change, training and education, evaluation and performance feedback,
reminders in the workplace, and institutional safety climate). The tool includes 27
indicators reflecting the key elements of each strategy component. These are
assigned values totaling 100 points within each HHSAF section, adding up to a
maximum overall score of 500 points. Based on its overall score, a facility is
assigned to one of four levels of progress:
1. Inadequate (score of 0-125): hand hygiene practices and hand hygiene
promotion are deficient. Significant improvement is required.

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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
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 2. Basic (score of 126-250): some measures are in place, but not to a
satisfactory standard. Further improvement is required.
3. Intermediate (score of 251-375): an appropriate hand hygiene promotion
strategy is in place and hand hygiene practices have improved. It is now
crucial to develop long-term plans to ensure sustained improvement and
progress.
4. Advanced (score of 376-500): hand hygiene promotion and optimal hand
hygiene practices have been sustained and/or improved, thus helping to
embed a culture of safety around hand hygiene promotion in the health-care
setting.

Advanced facilities can undergo further assessment according to 20 additional

criteria and can reach the leadership level if they satisfy at least 12 of these criteria.

Health-care facilities were invited to submit their HHSAF results to WHO through a
dedicated web site. Data were also provided by email or fax where sustained internet
access was difficult or by countries where the survey was undertaken independently
from WHO. Facilities were asked that the HHSAF be completed by professionals in
charge of infection control or senior managers fully informed about hand hygiene
activities within the institution. The analysis was performed in collaboration with the
WHO Collaborating Centre on Patient Safety (University of Geneva Hospitals,
Geneva, Switzerland) while keeping the facilities' identity confidential.

Summary results
Participating facilities
Overall, 2 119 health-care settings from 69 countries submitted their complete
HHSAF results to WHO (Table 1). Most facilities are located in upper-middle or high-
income countries.

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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
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 Table 1. Countries participating in the WHO Hand Hygiene Self-Assessment
Framework global survey
Number of
Country participating
facilities
Algeria 6
Angola 1
Argentina 24
Armenia 2
Australia 93
Austria 1
Bahrain 2
Belgium 75
Benin 1
Bolivia 1
Brazil 906
Bulgaria 1
Burundi 1
Canada 47
Chile 1
China (People's Republic of) 7
Colombia 8
Costa Rica 1
Croatia 23
Czech Republic 3
Egypt 2
Estonia 1
France 135
Germany 19
Greece 2
Hungary 1
India 8
Indonesia 1
Iran (Islamic Republic of) 64
Ireland 2
Italy 58
Jamaica 1
Japan 3
Jordan 9
Kuwait 2
Lebanon 2
Malaysia 5
Malta 1

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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
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 Mexico 2
Namibia 9
Netherlands 48
New Zealand 2
Nigeria 3
Norway 7
Paraguay 2
Peru 4
Philippines 1
Portugal 70
Republic of Serbia 40
Romania 1
Rwanda 1
Saudi Arabia 66
Senegal 27
Singapore 1
Slovenia 1
South Africa 5
Spain 65
Sudan 6
Switzerland 7
Syrian Arab Republic 1
Thailand 2
The Former Yugoslav Rep of Macedonia 1
Tunisia 1
Uganda 1
United Arab Emirates 4
United Kingdom of Great Britain and Northern Ireland 52
United States of America 129
Uruguay 1
Viet Nam 40

Information on health-care facility characteristics and the individual completing the

HHSAF was not provided by all participants as data collection took place locally and
not through the WHO online system in some countries. However, all facilities
provided completed data on the HHSAF indicators.

Regional distribution of participating health-care facilities was as follows: 1127 from

the Americas (53%; 13 countries, 19%); 615 from Europe (29%; 24 countries, 35%);
159 from the Eastern Mediterranean Region (8%; 11 countries, 16%); 152 from the

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
of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
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 Western Pacific Region (7%; 8 countries, 12%); 55 from Africa (3%; 10 countries,
14%); and 11 from South-East Asia (0.5%; 3 countries, 4%). 736/1050 facilities
(70%) were registered for the WHO “Save Lives: Clean Your Hands" initiative and
1564/2119 (74%) were involved in a national/sub-national hand hygiene promotion
campaign. Most facilities were general, non-teaching, public hospitals, delivering
acute or mixed (acute and long-term) care (Table 2).

Table 2. Characteristics of participating health-care facilities

Characteristics Total

Number of countries 69
Number of participating health-care facilities* 2119
Type of facility, n (%)
Public 747 (71)
Private 302 (29)
Facility pattern, n (%)
Teaching 232 (22)
General 813 (78)
Type of care, n (%)
Acute care 513 (48)
Long-term care 132 (12)
Acute and long-term 259 (24)
Other 172 (16)
Mean number of beds per facility (±SD) 318.2 (443.8)
*Information about the variables included in the table were not provided by all health-care facilities
SD= standard deviation

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
of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
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 HHSAF results
The overall mean score reflected intermediate level of progress (Table 3). Most
facilities were at intermediate or advanced levels (65%) of progress, with a high
proportion qualifying for the leadership level. Among the HHSAF sections, the lowest
scores concerned evaluation and feedback on hand hygiene activities and the
institutional patient safety climate.

Table 3. Overall HHSAF score and level in participating facilities

Values
Overall score, mean±SD, (range) 292.5±100.6 (0-500)
Hand hygiene level, n (%)
Inadequate 111 (5)
Basic 631 (30)
Intermediate 864 (41)
Advanced 488 (24)
Proportion of centres among leadership facilities with a 393/471 (83)
score > 12 (%)
SD= standard deviation

Apart from South-East Asia for which the sample (11 facilities; 3 countries) is not
considered representative, the highest mean score was found in Western Pacific
countries and the lowest in African countries (Table 4). The average level of progress
was intermediate in all regions, except in Africa where it was basic. The highest
proportion of facilities that qualified for the leadership criteria and which can thus be
considered reference centres, was found in the Western Pacific Region (43%).

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
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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
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 Table 4. Overall HHSAF score and levels by region
Region
Africa Americas Eastern Mediterranean

Number of countries 10 13 11
Number of participating facilities 55 1127 159
Overall score, mean±SD (range) 218.5±94.8 265.1±104.2 327.1±92.4
(0-420) (20-500) (95-495)
Hand hygiene level, n (%)
Inadequate 7 (13) 97 (9) 2 (1)
Basic 26 (48) 441 (40) 35 (22)
Intermediate 18 (33) 385 (35) 68 (44)
Advanced 3 (6) 190 (17) 51 (33)
Proportion of centres with a leadership score > 12, n (%) 2 (67) 157 (86) 45 (88)
Europe South East Asia Western Pacific
Number of countries 24 3 8
Number of participating facilities 615 11 152
Overall score, mean±SD, median (range) 324.6±76.3 364.8±61.0 351.8±89.4
(30-495) (270-490) (132.5-490)
Hand hygiene level, n (%)
Inadequate 5 (1) 0 (-) 0 (-)
Basic 101 (16) 0 (-) 28 (18)
Intermediate 340 (56) 7 (64) 46 (31)
Advanced 163 (27) 4 (36) 77 (51)
Proportion of centres with a leadership score > 12, n (%) 121 (78) 3 (75) 65 (85)

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 of any kind, either expressed or implied. The responsibility for the interpretation7and use of the
material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
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 The Figure shows the responses to some questions of the HHSAF that are related to
key indicators included in each HHSAF section were considered. Overall, 90% of
facilities declared that alcohol-based handrubs were available (but in discontinuous
supply in 8%) with 57% installed at each point of care. Ninety-eight percent of
facilities reported the existence of staff training on best hand hygiene practices. Hand
hygiene compliance was measured through direct observation in 59% of facilities and
alcohol-based handrub consumption was regularly monitored in 53%. Posters
featuring hand hygiene indications and technique were displayed in the vast majority
of facilities. In 73%, the Chief Executive Officer made a clear commitment to hand
hygiene improvement, though a hand hygiene team was established in only 53%.

Figure. Responses to HHSAF questions related to key indicators of the WHO

improvement strategy implementation
%
100
98 92
90 91
90 85
80 73
70 59
57
60 53 53
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ABHR= alcohol-based handrubs; HH= hand hygiene; HR= handrubbing; HW= handwashing

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
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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
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 Conclusions
The survey shows that the participating facilities, representing countries from all
regions of the world, are on average at a good level of progress regarding the
implementation of hand hygiene improvement strategies. However, overall 35% are
still at an inadequate or basic level and therefore need to make further significant
efforts to bring about better conditions for best hand hygiene practices and
behavioural change. The many facilities at the intermediate level (864/2119)
achieved substantial results, but have to now concentrate on actions to sustain these
over time. Finally, most facilities at advanced level (488/2119) already fulfill some
leadership criteria (393/471). These facilities should focus on consolidating their
reference position by continuing to contribute to research and innovation in the field
of hand hygiene.

It is very encouraging to note that the vast majority of facilities reported having
alcohol-based handrubs available, were undertaking staff training, and displaying
posters on hand hygiene around their facility. However, differences were detected
across the different regions, with the lowest overall score attributed to Africa. Further
substantial improvement is needed across all regions, especially in the area of
monitoring and feedback on hand hygiene activities and for the establishment of a
comprehensive patient safety climate within health-care facilities where hand hygiene
activities need to be better embedded. WHO tools corresponding to these two
essential components of the improvement strategy are available and should be used
to achieve progress.

To facilitate the interpretation of the HHSAF results and the development of local
action plans at the facility level, WHO has made available three types of Template
Action Plans according to levels of progress: inadequate/basic, intermediate, and
advanced/leadership
(http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2012/en/index.html ). These
templates offer ideas for action implementation in each of the five components of the
WHO Multimodal Hand Hygiene Improvement Strategy, to enable facilities to make
progress. They also indicate the best WHO tools to be used at different levels. To
identify the actions that best fit the local situation, managers and infection control

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
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of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
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 leaders need to identify also the key HHSAF indicators which show clear gaps in
their facility and plan the improvement targets to be achieved accordingly. The
HHSAF is designed to be used regularly (e.g. annually) to measure progress and
facilitate continuous improvement.

Acknowledgements
The data collection for this survey was possible thanks to the tremendous support of
national and sub-national hand hygiene campaign coordinators from many countries,
of WHO regional focal points for patient safety, other WHO staff from country offices
and many stakeholders around the world. Critical technical input was also provided
by the WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals
and Faculty of Medicine, Geneva, Switzerland, for the survey set up and the
statistical analysis.

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
of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for10
damages arising
from its use.
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