- Open Access
Scenario-based simulation training for the WHO hand hygiene self-assessment framework
Antimicrobial Resistance & Infection Control volume 8, Article number: 58 (2019)
The WHO SAVE LIVES: Clean Your Hands global hand hygiene campaign, launched in 2009 and celebrated annually on the 5th of May, features specific calls to action seeking to increase engagement from stakeholders’ collaborations in hand hygiene improvement. WHO calls on everyone to be inspired by the global movement towards universal health coverage (UHC). Infection prevention and control (IPC), including hand hygiene, is critical to achieve UHC as it has a direct impact on quality of care and patient safety across all levels of the health services. In the framework of UHC, the theme for 5 May 2019 is “Clean care for all – it’s in your hands”. In this context, the WHO has launched a global survey to assess the current level of progress of IPC programmes and hand hygiene activities in healthcare facilities (HCFs) worldwide. This involved the creation of two tools for healthcare facilities: the WHO Infection Prevention and Control Assessment Framework (IPCAF) and the WHO Hand Hygiene Self-Assessment Framework (HHSAF). The objective of this paper is to provide case scenario-based simulation for IPC specialists to simulate and fully assimilate the correct completion of the HHSAF framework in a standardized format. The three case scenarios have been tested and are proposed for the reader to assess the HHSAF of different HCFs in a variety of contexts, even in low-resouce settings. They were designed for simulation training purposes to achieve standardization and interactive learning. These scenarios are meant to be used by professionals in charge of implementing a hand hygiene improvement strategy within their HCF, as well as for simulation and standardized training purposes prior to completing and submitting data for the 2019 WHO Global Survey. Additionally, information provided by the use of the HHSAF can easily be translated into action plans to support the implementation and improvement related to specific indicators of hand hygiene promotion. We invite all HCFs to participate in the 2019 WHO global survey and monitor the level of progress of their IPC programme and hand hygiene activities.
Too many of the vulnerable individuals admitted to health-care settings develop a health-care associated infection (HAI). This results in increased morbidity and mortality, prolonged hospital stay, and financial losses for health care systems [1, 2]. Additionally, prevention of transmission and control of multidrug-resistant organisms in health care settings are critical as the number of antibiotics available to treat these infections is limited . Many of these issues could be prevented through simple, low-cost infection prevention and control (IPC) measures such as hand hygiene performed at critical moments [4, 5].
The focus of the World Health Organization (WHO) SAVE LIVES: Clean Your Hands global campaign has been to promote best hand hygiene practices as a key component of achieving quality of care and patient safety [6,7,8,9,10,11]. This campaign, launched in 2009 and celebrated annually on the 5th of May, features specific calls to action each year, and seeks to increase engagement from stakeholders’ collaborations in strenghtening IPC programmes and improving hand hygiene. This year’s campaign theme is “Clean care for all – it’s in your hands”  (https://www.who.int/infection-prevention/campaigns/clean-hands/en/).
‘Health for All’ has been increasingly recognized in international fora as a concept firmly based on equity. Alongside a strong global momentum surrounding universal health coverage (UHC), WHO calls on everyone to contribute to the attainment of health for all populations . In the context of UHC, IPC with hand hygiene as a fundamental measure, is a key component in providing patient safety and high quality health services [12, 13].
The 2019 WHO global survey
The WHO global survey aims to assess the current level of progress of IPC programmes and hand hygiene activities in HCFs in the context of the WHO SAVE LIVES: Clean Your Hands annual hand hygiene global campaign (https://www.who.int/infection-prevention/campaigns/ipc-global-survey-2019/en/). The survey will be open until July 2019, and WHO invites all HCFs to join. The survey is based on the use of two tools at the HCF level: the WHO Infection Prevention and Control Assessment Framework (IPCAF) (https://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF?ua=1) and the WHO HHSAF (https://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1) [14, 15]
The IPCAF is a validated assessment tool that supports the implementation of the WHO recommendations on the core components of effective IPC programmes  at the acute HCF level. The goal of the framework is to assess the current IPC situation in HCFs. It is especially focused on evaluating existing IPC activities/resources, and identifying strengths and gaps that can inform future policies. It can be considered as a diagnostic tool for HCFs to detect relevant problems or shortcomings that require improvement as well as identify areas where international standards and requirements can be met [16, 17].
The HHSAF is a systematic tool with which an individual health-care facility can obtain a situational analysis of its hand hygiene promotion and practices [14, 15]. To guide future improvement WHO is launching the HHSAF again in 2019 as part of the WHO global survey (the HHSAF was previously launched in 2011 and 2015) (https://www.who.int/infection-prevention/campaigns/ipc-global-survey-2019/en/).
Assesing the level of hand hygiene at your institution
Measuring, promoting, improving, and subsequently sustaining hand hygiene standards as quality indicators for patient safety is essential . To advance this agenda, it is crucial to monitor where improvements have occurred and gaps must be addressed in hand hygiene structures, processes, resources, promotion and practices [19, 20].
WHO provides a range of tools and resources to sustain hand hygiene improvement. One is the Hand Hygiene Self-Assessment Framework (HHSAF), which is a validated tool used to quantify the status of hand hygiene promotion activities within healthcare facilities worldwide [14, 15]. Launched by WHO in 2010, the HHSAF is available in different languages; it remains the most widely used tool and the only framework aimed at tracking the level of progress of healthcare facilties in the context of hand hygiene implementation. Structured around the five components of the WHO Multimodal Hand Hygiene Improvement Strategy (see Appendix), the HHSAF assesses the interventions implemented by HCFs in the context of their adherence to WHO hand hygiene guidelines and recommendations [18,19,20]. The HHSAF analyses a number of factors within each of the five components of the multimodal strategy and scores institutions’ status as inadequate, basic, intermediate and advanced, according to the number of points obtained (see Appendix). Additionally, it directs HCFs to the WHO hand hygiene promotion tools and the template action plans (available at https://www.who.int/infection-prevention/tools/hand-hygiene/en/) that can be used to make improvement plans according to the HHSAF score and specific indicators identified as requiring attention.
Given this important focus on hand hygiene in IPC programmes, the WHO previously conducted two global surveys using the HHSAF in 2011 and 2015, inviting HCFs worldwide to submit their self-assessments . The two surveys offered a bird’s eye view of hand hygiene programmes at the HCF level and enabled better comparisons across regions and over time, prompting calls for further improvements. In 2011, the majority of HCFs participating were from developed countries and reflected an intermediate level of progress. When the survey was repeated in 2015, the overall score increased significantly (p < 0.001) in the 86 HCFs that participated in both surveys . Improvement was documented in all regions, particularly in the Eastern Mediterranean region, Europe and the Americas. The African region scored lowest, which could be indicative of a poorer IPC infrastructure, resources and basic knowledge in hand hygiene implementation and issues concerning sustainability. The disparities that emerged from the two global HHSAF surveys emphasize the need for additional improvement of hand hygiene practices, especially in low-resource settings.
Supporting hand hygiene education and training
To support education and training activities around the global survey, WHO, together with the WHO Collaborating Centre on Patient Safety, developed a body of material including an educational video (available at https://www.youtube.com/watch?v=PDz8kxrPaMk&feature=youtu.be), a promotional video (available at https://www.youtube.com/watch?v=UfH6ODLV3BI) and three case scenario-based simulations (Tables 1, 2 and 3) for IPC specialists to simulate and fully assimilate the correct completion of the HHSAF framework in a standardized format. Simulation in health care is widely used in medical education as an active learning method and it has been shown to have great potential [22,23,24].
The case scenarios presented here can be used by professionals in charge of implementing a hand hygiene improvement strategy within their facility, as well as for simulation and standardized training purposes prior to completing and submitting data for the 2009 WHO Global Survey. As proposed by the WHO Guide to Implementation, information provided through the use of the HHSAF should be translated into action plans to support the implementation and improvement related to specific indicators of hand hygiene promotion [19, 20]. HCFs worldwide should consider implementing a system of continuous assessment of hand hygiene improvement strategy  by utilizing the HHSAF tool systematically; the current recommendation by WHO and experts is to use it at least annually.
Information appropriate for each of the WHO Multimodal Hand Hygiene Improvement Strategy components has been identified in the case scenarios (Tables 1, 2 and 3). In order to simulate the completion of the HHSAF, they provide details regarding HH promotion strategy for the evaluation of resources, promotion, and practices within a given HCF. The three case scenarios took in consideration a range of HCFs around the world in a variety of contexts, regardless of the resources available. Drawing from the information provided, a score is assigned for each component and section. The sum of the maximum values in each section is 100 points, adding up to a maximum overall score of 500 points. Based on the overall score, a HCF is then assigned to one of four levels of hand hygiene implementation progress (see Appendix). The HCF presented in Table 1 scored as Advanced, and can therefore undergo further Leadership assessment according to twenty additional criteria, but since only ten of them have been met, the HCF is not classified as having reached the Leadership level. Information for baseline evaluation of hand hygiene activities within a lower income setting is presented in Table 2; based on the overall score, the HCF would be assigned as Inadequate level of progress. The HCF in Table 3 is assigned to Basic level, identifying the need for significant improvement. The use of HHSAF over time will enable HCFs to keep track of their progress and continuously set new targets for improvement.
The foremost objective of the WHO global annual campaign is to prioritize IPC in health care and the global health agenda, with hand hygiene assessment and improvement playing a fundamental role in ensuring patient safety. We invite all HCFs to be actively engaged in this important endeavour and call upon all those who can contribute towards achieving high-quality health care and universal health coverage for the improvement of public health worldwide.
“Clean care for all – it’s in your hands”
Health-care associated infection
Health care facility
Hand Hygiene Self-Assessment Framework
Infection Prevention and Control
Infection Prevention and Control Assessment Framework
Universal Health Coverage
World Health Organization
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;377:228–41.
Marchetti A, Rossiter R. Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. J Med Econ. 2013;16:1399–404.
World Health Organization. Evidence of hand hygiene to reduce transmission and infections by multi drug resistant organisms in health-care settings. 2014; Available at: (https://www.who.int/gpsc/5may/MDRO_literature-review.pdf ). Accessed 20 Feb 2019.
Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis. 2006;6:641–52.
Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821–6.
World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Geneva: World Health Organization; 2009b.
World Health Organization. Global action plan on antimicrobial resistance. 2015; Available at: http://apps.who.int/iris/handle/10665/193736 . Accessed 30 Jan 2019.
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.
Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305–15.
Pittet D, Donaldson L. Clean care is safer care: a worldwide priority. Lancet. 2005;366:1246–7.
WHO | SAVE LIVES: Clean Your Hands. WHO Available at: http://www.who.int/infection-prevention/campaigns/clean-hands/en/ . (Accessed: 27 Feb 2019).
WHO | What is universal coverage? WHO Available at: http://www.who.int/health_financing/universal_coverage_definition/en/ . Accessed: 28 Feb 2019.
Storr J, Kilpatrick C, Allegranzi B, Syed SB. Redefining infection prevention and control in the new era of quality universal health coverage. J Res Nurs. 2016;21(1):39–52.
World Health Organization. Hand Hygiene Self-Assessment Framework; 2010. https://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1. Accessed 22 Feb 2019.
Stewardson AJ, Allegranzi B, Perneger TV, Attar H, Pittet D. Testing the WHO hand hygiene self-assessment framework for usability and reliability. J Hosp Infect. 2013;83:30–5.
World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute care facility level. 2016; Available at: https://www.who.int/infection-prevention/tools/core-components/en/ . Accessed 20 Feb 2019.
World Health Organization. Infection Prevention and Control Assessment Framework at the Facility Level; 2018 https://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF?ua=1 . Accessed 22 Feb 2019.
Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013;13:843–51.
World Health Organization. Guide to implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: World Health Organization; 2009a.
Allegranzi B, Pittet D. WHO Multimodal Promotion Strategy. In: Pittet D, Boyce J, Allegranzi B, editors. Hand Hygiene: A Handbook for Medical Professionals. Chichester: Wiley; 2017. p. 357–66.
Kilpatrick C, Tartari E, Gayet-Ageron A, Storr J, Tomczyk S, Allegranzi B, et al. Global hand hygiene improvement progress: two surveys using the WHO hand hygiene self-assessment framework. J Hosp Infect. 2018;100:202–6.
Nakamura I, Fujita H, Tsukimori A, Kobayashi T, Sato A, Fukushima S, Amano K, Abe Y. Scenario-based simulation health care education for performance of hand hygiene. American journal of infection control. 2019;47(2):144–8.
Cartier V, Inan C, Zingg W, Delhumeau C, Walder B, Savoldelli GL. Simulation-based medical education training improves short and long-term competency in, and knowledge of central venous catheter insertion: a before and after intervention study. Eur J Anaesthesiol (EJA). 2016;33(8):568–74.
Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):1420–3.
We thank healthcare facilities for providing helpful information for the case scenarios.
This work is supported by the World Health Organization (WHO), Geneva, Switzerland, and the Infection Control Programme and WHO Collaborating Centre on Patient Safety (SPCI/WCC), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; hand hygiene research activities at the SPCI/WCC are also supported by the Swiss National Science Foundation (grant no. 32003B_163262).
Availability of data and materials
The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. WHO takes no responsibility for the information provided or the views expressed in this paper.
Ethics approval and consent to participate
Consent for publication
All listed authors declare no financial support, grants, financial interests or consultancy that could lead to conflicts of interest. Didier Pittet works with WHO in the context of the WHO initiative ‘Private Organizations for Patient Safety – Hand Hygiene’. The aim of this WHO initiative is to harness industry strengths to align and improve implementation of WHO recommendations for hand hygiene in health care in different parts of the world, including in least developed countries. In this instance, companies/industry with a focus on hand hygiene and infection control related advancement have the specific aim of improving access to affordable hand hygiene products as well as through education and research.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Hand Hygiene Self-Assessment Framework
About this article
Cite this article
Tartari, E., Fankhauser, C., Peters, A. et al. Scenario-based simulation training for the WHO hand hygiene self-assessment framework. Antimicrob Resist Infect Control 8, 58 (2019). https://doi.org/10.1186/s13756-019-0511-9
- Infection prevention and control
- Hand hygiene
- Healthcare-associated infection
- Antimicrobial resistance
- Multimodal promotion
- Universal health coverage
- Patient safety
- World Health Organization