23-275 / Hand Hygiene Program for the National Health System (NHS)

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI)


Patient safety system
Quality improvement project
Hand hygiene
Implementation of Patient Safety initiatives / Activities
GOP Description
Implementation level
Clinical settings
Hospitals and Primary Healthcare
1.To_improve healthcare_professionals’ and patients/visitors’ hand_hygiene_(HH) in order to reduce healthcare_associated_infections in_the_NHS.
2.To_promote WHO_HH_multimodal_strategy in_the_NHS.
1.To_promote specific actions with Health_Regions_(HR) in order to:
-Agree on common basic activities.
-Identify and select indicators_and_evaluation_tools that can be implemented at different levels
-Improve professionals’ HH education_and_training
2.To_provide HR information on WHO_initiatives_and_resources
Healthcare professionals of the NHS
Patients and citizens
1.Establish a coordination group at national level formed by MSSSI and HR technical representatives
2.Establish an organizational structure for the NHS with different functions: MSSSI, NHS coordination group, regional coordination groups, healthcare professionals in charge of the HH program at local level
3.To provide with support tools:
-WHO guidelines and materials in Spanish; evidence on HH; tools for education and training
-On-line platform for group work (e-room): sharing of resources, knowledge and experience; discussions…
-Follow-up meetings
-Specific HH area in the Patient Safety Web
-Training workshops and resources
4.Decentralized funds for HH promotion in HR
Timeframe implementation
1 year to set up the coordination team and develop an action plan
Implementation tools available
-e-Room (internal platform for group communication and work)
-Specific site in patient safety web
-WHO multimodal HH strategy tools in Spanish
-On line course
-Promotional videos
-Posters and gadgets
-Hand Hygiene Self-Assessment Framework (Spanish version) specific platform where successive self-comparisons and aggregated analysis for the different Regions can be performed
-Tools developed by Regions
Implementation cost
From 2006 to 2011, 4,200,000 € have been provided to the Health Regions for the HH program
Method used to measure the results
Indicators based on WHO recommendations which are annually collected by the Health Regions since 2009:
1.% Hospital rooms with alcohol-based hand-rub
2.% Intensive care units with alcohol-based hand-rub at the point of care
3.%Primary healthcare centres with alcohol-based hand-rub
4.% Hospitals with HH training
5.% Primary Care Centres with HH training
6. Hospital consumption of alcohol based hand-rub (litres/1000 patients-day)
7.%Hospital beds with alcohol-based hand-rub at the point of care
8.%Hospitals performing observation of WHO 5 moments for HH
9.%Hospitals performing self evaluation with WHO framework
10. % Hospitals with HH training on the five moments.
-PARTICIPATION (No. of Health Regions):
Ind.1: 13(2009); 17(2010); 18(2011)
Ind.2: 14(2009); 17(2010); not-evaluated(2011)
Ind.3: 14(2009); 17(2010); 15(2011)
Ind.4: 16(2009); 18(2010); 18(2011)
Ind.5: 12(2009); 16(2010); 14(2011)
Ind.6: 14(2009); 14(2010); 17(2011)
Ind.7: 12(2009); 12(2010); 14(2011)
Ind.8: 9(2009); 15(2010); 17(2011)
Ind.9: 14(2010); 12(2011)
Ind.10: 13(2009); 16(2010); 15(2011)
Ind.1: 50,73%(2009); 63,78%(2010); 85,49%(2011)
Ind.2: 80,80%(2009); 90,43%(2010)
Ind.3: 60.04%(2009); 63,43%(2010); 63,60%(2011)
Ind.4: 73,02%(2009); 81,25%(2010); 90,10%(2011)
Ind.5: not available(2009); 61,22%(2010); 52,44%(2011)
Ind.6: 15,21‰(2009); 14,9‰(2010); 13,35‰(2011)
Ind.7: 26,47%(2009); 52,58%(2010); 47,20%(2011)
Ind.8: 41,35%(2009); 67,33%(2010); 60,60%(2011)
Ind.9: 42,50%(2010); 47,70%(2011)
Ind.10: 57.58%(2009); 69,08%(2010); 82,60%(2011)
Analysis of the results
-Gradual increase of the Health Regions’ capacity to provide data for the indicators from hospitals, which points at a steady consolidation of the program. This is less clear in Primary Healthcare
-Hospital consumption of alcohol based hand-rub is not increasing, but the variability among Regions has decreased, which indicates an improvement in those Regions which had worse results.
-Training and self-evaluation is increasing and even though the %hospitals performing observation is lower, the total number has increased.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
High variability among the Health Regions support and investment in the program
Describe the strategies used to overcome the barriers (If needed)
-Coordination between the MSSSI and the HR in order to set up joint objectives and to obtain information at a national level.
-To invest effort on networking and resource sharing to be more efficient and motivate campaign leaders
Other information
Other information about the GOP that you would like to add (Link or attached document)
Web site: http://www.seguridaddelpaciente.es/index.php/lang-es/proyectos/financiacion-estudios/programa-higiene-manos.html