Major article| Volume 42, ISSUE 3, P224-230, March 2014

Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities


      The World Health Organization (WHO) launched a multimodal strategy and campaign in 2009 to improve hand hygiene practices worldwide. Our objective was to evaluate the implementation of the strategy in United States health care facilities.


      From July through December 2011, US facilities participating in the WHO global campaign were invited to complete the Hand Hygiene Self-Assessment Framework online, a validated tool based on the WHO multimodal strategy.


      Of 2,238 invited facilities, 168 participated in the survey (7.5%). A detailed analysis of 129, mainly nonteaching public facilities (80.6%), showed that most had an advanced or intermediate level of hand hygiene implementation progress (48.9% and 45.0%, respectively). The total Hand Hygiene Self-Assessment Framework score was 36 points higher for facilities with staffing levels of infection preventionists > 0.75/100 beds than for those with lower ratios (P = .01) and 41 points higher for facilities participating in hand hygiene campaigns (P = .002).


      Despite the low response rate, the survey results are unique and allow interesting reflections. Whereas the level of progress of most participating facilities was encouraging, this may reflect reporting bias, ie, better hospitals more likely to report. However, even in respondents, further improvement can be achieved, in particular by embedding hand hygiene in a stronger institutional safety climate and optimizing staffing levels dedicated to infection prevention. These results should encourage the launch of a coordinated national campaign and higher participation in the WHO global campaign.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Klevens R.M.
        • Edwards J.R.
        • Richards Jr., C.L.
        • Horan T.C.
        • Gaynes R.P.
        • Pollock D.A.
        • et al.
        Estimating health care-associated infections and deaths in US hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Allegranzi B.
        • Bagheri Nejad S.
        • Combescure C.
        • Graafmans W.
        • Attar H.
        • Donaldson L.
        • et al.
        Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.
        Lancet. 2011; 377: 228-241
        • Boyce J.M.
        • Pittet D.
        • Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force
        Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.
        MMWR Recomm Rep. 2002; 51: 1-45
      1. World Health Organization. WHO guidelines on hand hygiene in healthcare. 2009. Available from: Accessed August 27, 2013.

        • Erasmus V.
        • Daha T.J.
        • Brug H.
        • Richardus J.H.
        • Behrendt M.D.
        • Vos M.C.
        • et al.
        Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
        Infect Control Hosp Epidemiol. 2010; 31: 283-294
      2. World Health Organization. Guide to implementation: a guide to the implementation of the WHO multimodal hand hygiene improvement strategy. 2009. Available from: Accessed August 27, 2013.

      3. World Health Organization. How to improve hand hygiene: 5 critical components. 2013. Available from: Accessed August 27, 2013.

      4. World Health Organization. Hand hygiene self-assessment framework 2010. Available from: Accessed August 27, 2013.

        • Stewardson A.J.
        • Allegranzi B.
        • Perneger T.V.
        • Attar H.
        • Pittet D.
        Testing the WHO hand hygiene self-assessment framework for usability and reliability.
        J Hosp Infect. 2013; 83: 30-35
      5. World Health Organization. SAVE LIVES Clean Your Hands: WHO’s global annual campaign. 2009. Available from: Accessed August 27, 2013.

      6. World Health Organization. Clean Care is Safer Care: registration update. 2013. Available from: Accessed August 27, 2013.

        • Weissman N.W.
        • Allison J.J.
        • Kiefe C.I.
        • Farmer R.M.
        • Weaver M.T.
        • Williams O.D.
        • et al.
        Achievable benchmarks of care: the ABCs of benchmarking.
        J Eval Clin Pract. 1999; 5: 269-281
      7. World Health Organization. WHO hand hygiene self-assessment framework global survey: summary report. 2012. Available from: Accessed August 27, 2013.

        • Larson E.L.
        • Quiros D.
        • Lin S.X.
        Dissemination of the CDC’s hand hygiene guideline and impact on infection rates.
        Am J Infect Control. 2007; 35: 666-675
        • Lawton R.M.
        • Turon T.
        • Cochran R.L.
        • Cardo D.
        Prepackaged hand hygiene educational tools facilitate implementation.
        Am J Infect Control. 2006; 34: 152-154
        • Aboumatar H.
        • Ristaino P.
        • Davis R.O.
        • Thompson C.B.
        • Maragakis L.
        • Cosgrove S.
        • et al.
        Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel.
        Infect Control Hosp Epidemiol. 2012; 33: 144-151
        • Ellingson K.
        • Muder R.R.
        • Jain R.
        • Kleinbaum D.
        • Feng P.J.
        • Cunningham C.
        • et al.
        Sustained reduction in the clinical incidence of methicillin-resistant Staphylococcus aureus colonization or infection associated with a multifaceted infection control intervention.
        Infect Control Hosp Epidemiol. 2011; 32: 1-8
        • Mayer J.
        • Mooney B.
        • Gundlapalli A.
        • Harbarth S.
        • Stoddard G.J.
        • Rubin M.A.
        • et al.
        Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
        Infect Control Hosp Epidemiol. 2011; 32: 59-66
        • Siegel J.H.
        • Korniewicz D.M.
        Keeping patients safe: an interventional hand hygiene study at an oncology center.
        Clin J Oncol Nurs. 2007; 11: 643-646
        • Wisniewski M.F.
        • Kim S.
        • Trick W.E.
        • Welbel S.F.
        • Weinstein R.A.
        Chicago Antimicrobial Resistance Project. Effect of education on hand hygiene beliefs and practices: a 5-year program.
        Infect Control Hosp Epidemiol. 2007; 28: 88-91
        • Trick W.E.
        • Vernon M.O.
        • Welbel S.F.
        • Demarais P.
        • Hayden M.K.
        • Weinstein R.
        • et al.
        Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance.
        Infect Control Hosp Epidemiol. 2007; 28: 42-49
        • Ashraf M.S.
        • Hussain S.W.
        • Agarwal N.
        • Ashraf S.
        • El-Kass G.
        • Hussain R.
        • et al.
        Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers.
        Infect Control Hosp Epidemiol. 2010; 31: 758-762
        • Forrester L.A.
        • Bryce E.A.
        • Mediaa A.K.
        Clean Hands for Life: results of a large, multicentre, multifaceted, social marketing hand-hygiene campaign.
        J Hosp Infect. 2010; 74: 225-231
        • Pittet D.
        • Hugonnet S.
        • Harbarth S.
        • Mourouga P.
        • Sauvan V.
        • Touveneau S.
        • et al.
        Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
        Lancet. 2000; 356: 1307-1312
        • Magiorakos A.P.
        • Leens E.
        • Drouvot V.
        • May-Michelangeli L.
        • Reichardt C.
        • Gastmeier P.
        • et al.
        Pathways to clean hands: highlights of successful hand hygiene implementation strategies in Europe.
        Euro Surveill. 2010; 15: 6
        • Magiorakos A.P.
        • Suetens C.
        • Boyd L.
        • Costa C.
        • Cunney R.
        • Drouvot V.
        • et al.
        National hand hygiene campaigns in Europe, 2000-2009.
        Euro Surveill. 2009; 14: 30
        • Damschroder L.J.
        • Banaszak-Holl J.
        • Kowalski C.P.
        • Forman J.
        • Saint S.
        • Krein S.L.
        The role of the champion in infection prevention: results from a multisite qualitative study.
        Qual Saf Health Care. 2009; 18: 434-440
        • Saint S.
        • Conti A.
        • Bartoloni A.
        • Virgili G.
        • Mannelli F.
        • Fumagalli S.
        • et al.
        Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany.
        Qual Saf Health Care. 2009; 18: 429-433
        • White C.M.
        • Statile A.M.
        • Conway P.H.
        • Schoettker P.J.
        • Solan L.G.
        • Unaka N.I.
        • et al.
        Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
        Pediatrics. 2012; 129: e1042-e1050
        • McGuckin M.
        • Storr J.
        • Longtin Y.
        • Allegranzi B.
        • Pittet D.
        Patient empowerment and multimodal hand hygiene promotion: a win-win strategy.
        Am J Med Qual. 2011; 26: 10-17
        • McGuckin M.
        • Waterman R.
        • Shubin A.
        Consumer attitudes about health care-acquired infections and hand hygiene.
        Am J Med Qual. 2006; 21: 342-346
        • Waterman A.D.
        • Gallagher T.H.
        • Garbutt J.
        • Waterman B.M.
        • Fraser V.
        • Burroughs T.E.
        Brief report: hospitalized patients’ attitudes about and participation in error prevention.
        J Gen Intern Med. 2006; 21: 367-370
      8. World Health Organization. Tips for implementing a successful patient participation programme. 2013. Available from: Accessed August 27, 2013.

      9. World Health Organization. Tips for patients to participate in hand hygiene improvement. 2013. Available from: Accessed August 27, 2013.

        • Haley R.W.
        • Culver D.H.
        • White J.W.
        • Morgan W.M.
        • Emori T.G.
        • Munn V.P.
        • et al.
        The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
        Am J Epidemiol. 1985; 121: 182-205
        • O’Boyle C.
        • Jackson M.
        • Henly S.J.
        Staffing requirements for infection control programs in US health care facilities: Delphi project.
        Am J Infect Control. 2002; 30: 321-333
        • Mathai E.
        • Allegranzi B.
        • Kilpatrick C.
        • Bagheri Nejad S.
        • Graafmans W.
        • Pittet D.
        Promoting hand hygiene in healthcare through national/subnational campaigns.
        J Hosp Infect. 2011; 77: 294-298
        • Pittet D.
        • Donaldson L.
        Clean Care is Safer Care: a worldwide priority.
        Lancet. 2005; 366: 1246-1247
      10. World Health Organization. WHO Clean Hands Net, a network of campaigning countries 2012; Available from: Accessed August 27, 2013.

        • Sax H.
        • Allegranzi B.
        • Uckay I.
        • Larson E.
        • Boyce J.
        • Pittet D.
        “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene.
        J Hosp Infect. 2007; 67: 9-21