Patient, staff empowerment and hand hygiene bundle improved and sustained hand hygiene in hospital wards

AIM

We piloted a hand hygiene (HH) project in a ward, focusing on World Health Organization moments 1 and 4. Our aim was to design highly reliable interventions to achieve >90% compliance.

METHODS

Baseline HH compliance was 57 and 67% for moments 1, 4, respectively, in 2015. After the pilot ward showed sustained improvement, we launched the 'HH bundle' throughout the hospital. This included: (i) appointment of HH champions; (ii) verbal/visual bedside reminders; (iii) patient empowerment; (iv) hand moisturisers; (v) tagging near-empty handrub (HR) bottles. Other hospital-wide initiatives included: (vi) Smartphone application for auditing; (vii) 'Speak up for Patient Safety' Campaign in 2017 for staff empowerment; (viii) making HH a key performance indicator.

RESULTS

Overall HH compliance increased from a baseline median of 79.6-92.6% in end-2019. Moments 1 and 4 improved from 71 to 92.7% and from 77.6 to 93.2%, respectively. Combined HR and hand wash consumption increased from a baseline median of 82.6 ml/patient day (PD) to 109.2 mL/PD. Health-care-associated rotavirus infections decreased from a baseline median of 4.5 per 10 000 PDs to 1.5 per 10 000 PDs over time.

CONCLUSIONS

The 'HH Bundle' of appointing HH champions, active reminders and feedback, patient education and empowerment, availability of hand moisturisers, tagging near-empty hand rub bottles together with hospital-wide initiatives including financial incentives and the 'Speak Up for Patient Safety' campaign successfully improved the overall HH compliance to >90%. These interventions were highly reliable, sustained over 4 years and also reduced health-care-associated rotavirus infection rates.

'Hybrid' top down bottom up health system innovation in rural China: A qualitative analysis

Introduction

China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China’s 3,000 rural counties were not always well addressed by national top-down reforms. China’s Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.

Materials & methods

We conducted an in-depth qualitative analysis in three ‘best practice’ counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps

Results

HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.

Conclusion

Tailoring innovations to fit local needs formed a severe challenge for the three ‘best practice’ counties studied. A ‘change of mindset’ to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside—from bottom up to top down—has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.