137-805 / Hand hygiene improvement in healthcare centers

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Madrid Health Service


Patient safety system
Program on quality and safety
Hand hygiene
Implementation of Patient Safety initiatives / Activities
GOP Description
Implementation level
Clinical settings
Primary care (269 Health centers) and 35 hospitals
Improve compliance with hand hygiene through implementing a multimodal strategy following the PDCA (Plan/Do/Check/Act) improvement cycle and based on leadership, assessment, development of training strategies and continous communication and feedback to professionals
The target population of the project were not health professionals and health in contact with patients in health centers of Madrid Health Service primary care and specialty care
Describe GOP Methodology
The six phases established to develop deployment centers were:
1. – Preparation: identifying responsible for hand hygiene in schools, groups and key people. Total: 300 professionals.
2. – Analysis and diagnosis: first observational study of compliance before the intervention (collected 18,197 hand hygiene opportunities), perception questionnaires to managers (total: 600) and professionals (total: 6000) and knowledge (total: 6000).
3 and 4. – Implementation and enforcement: developing awareness and outreach materials (25,000 units), course design with hand hygiene play-learning methodology, with 10 issues each year.
5. – Evaluation Phase: second observational study of hand hygiene compliance intervention (collected 19,496 hand hygiene opportunities)
6. – Learning and improvement: identifying strengths and areas for improvement
Timeframe implementation
Years 2010-2012 to complete the 6 stages of development
Implementation tools available
. – Document deployment strategy for hand hygiene in Madrid Health Service, which includes several tools to support implementation (surveys, outreach materials, etc.)
. – Online Program Accredited hand hygiene: with 8 units of learning and a practical part with a simulation game.
Implementation cost
Project funded by the territorial cohesion funds for 2009 from the Ministry of Health and Social Policy, to support the implementation of the Strategy on Patient Safety National Health System. Total cost: € 175,000
Method used to measure the results
-Study observation before and after the intervention
-Analysis of perception and knowledge surveys
-On-line hand hygiene course evaluation reports
-Structure and process indicators agreed with the Ministry of Health
The observational study of 2011, compared with 2010 study shows that compliance with hand hygiene has increased in the three care levels analyzed. Hospitals: 38.1% (in 2011) vs 30.8% (in 2010), primary care: 35.8% (in 2011) vs 22.2% (in 2010)
In the 2011 and 2012 editions of the online course more than 6,000 professionals have been trained. The satisfaction surveys show that a high percentage of the students would recommend the course to other professionals and what they have learned has application in the workplace
Analysis of the results
-Compliance with hand hygiene has increased in the Madrid after implementing this improvement cycle. We have a comprehensive intervention to motivate and make lifestyle changes to increase compliance, thanks to a methodology and interactive virtual simulation welfare activities as a game is a suitable tool and widely accepted. Changing habits hand hygiene passes have a strategy that integrates multimodal aspects such as leadership, assessment, training and awareness and benchmarking sustainably over time.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Low patient safety culture and resistence to change
Describe the strategies used to overcome the barriers (If needed)
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Other information
Other information about the GOP that you would like to add (Link or attached document)
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