title: "The 3/3 strategy": a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
abstract: BACKGROUND
  Only multifaceted hospital wide interventions have been successful in achieving sustained improvements in hand hygiene (HH) compliance.
  
  
  RESULTS
  Pre-post intervention study of HH performance at baseline (October 2007-December 2009) and during intervention, which included two phases. Phase 1 (2010) included multimodal WHO approach. Phase 2 (2011) added Continuous Quality Improvement (CQI) tools and was based on: a) Increase of alcohol hand rub (AHR) solution placement (from 0.57 dispensers/bed to 1.56); b) Increase in frequency of audits (three days every three weeks: "3/3 strategy"); c) Implementation of a standardized register form of HH corrective actions; d) Statistical Process Control (SPC) as time series analysis methodology through appropriate control charts. During the intervention period we performed 819 scheduled direct observation audits which provided data from 11,714 HH opportunities. The most remarkable findings were: a) significant improvements in HH compliance with respect to baseline (25% mean increase); b) sustained high level (82%) of HH compliance during intervention; c) significant increase in AHRs consumption over time; c) significant decrease in the rate of healthcare-acquired MRSA; d) small but significant improvements in HH compliance when comparing phase 2 to phase 1 [79.5% (95% CI: 78.2-80.7) vs 84.6% (95% CI:83.8-85.4), p<0.05]; e) successful use of control charts to identify significant negative and positive deviations (special causes) related to the HH compliance process over time ("positive": 90.1% as highest HH compliance coinciding with the "World hygiene day"; and "negative":73.7% as lowest HH compliance coinciding with a statutory lay-off proceeding).
  
  
  CONCLUSIONS
  CQI tools may be a key addition to WHO strategy to maintain a good HH performance over time. In addition, SPC has shown to be a powerful methodology to detect special causes in HH performance (positive and negative) and to help establishing adequate feedback to healthcare workers.
authors.affiliation: Nosocomial Infection Control Unit, Delfos Medical Center, Barcelona, Catalonia, Spain. mestre.ucin@centromedicodelfos.es
authors.forename: Gabriel
authors.initials: G
authors.lastname: Mestre
authors.forename: Cristina
authors.initials: C
authors.lastname: Berbel
authors.forename: Purificación
authors.initials: P
authors.lastname: Tortajada
authors.forename: Margarita
authors.initials: M
authors.lastname: Alarcia
authors.forename: Roser
authors.initials: R
authors.lastname: Coca
authors.forename: Gema
authors.initials: G
authors.lastname: Gallemi
authors.forename: Irene
authors.initials: I
authors.lastname: Garcia
authors.forename: Mari Mar
authors.initials: MM
authors.lastname: Fernández
authors.forename: Mari Carmen
authors.initials: MC
authors.lastname: Aguilar
authors.forename: José Antonio
authors.initials: JA
authors.lastname: Martínez
authors.forename: Jesús
authors.initials: J
authors.lastname: Rodríguez-Baño
mesh_terms: D063373:Hand Hygiene / Q000379:methods* / Q000592:standards*; D006761:Hospitals; D006801:Humans; D017053:Infection Control / Q000379:methods / Q000592:standards; D058996:Quality Improvement; D014944:World Health Organization