Enhancing hand hygiene compliance to reduce healthcare-associated infections in a coronary care unit: a quality improvement initiative in a tertiary hospital in South India

Abstract

Background

Healthcare-associated infections remain a major concern in critical care environments. Hand hygiene (HH) compliance is a key preventive measure, yet maintaining consistent adherence remains challenging. A quality improvement (QI) initiative was undertaken to enhance HH practices among healthcare providers in a tertiary hospital in South India.

Methods

From August to December 2023, a QI project was implemented in Coronary Care Units (CCU) at KLE’s Dr. Prabhakar Kore Hospital. Using the Point of Care Quality Improvement (PoCQI) methodology, a multidisciplinary team applied WHO’s multimodal HH strategy through iterative Plan-Do-Study-Act (PDSA) cycles. Interventions included: (1) installation of centralised scrub stations with sterile footwear, (2) bedside multilingual posters, (3) structured staff training with night-shift monitoring and (4) real-time observation with feedback supported by leadership engagement. Weekly HH compliance and infection outcomes were tracked.

Results

Five PDSA cycles were conducted. Mean HH compliance improved from a baseline of 63.8% to 80.5% by week 20, reflecting a 26.7% relative increase and remained above 78% through week 30, confirming sustained gains postintervention. No methicillin-resistant Staphylococcus aureus, Pseudomonas or Klebsiella infections were reported during the intervention period. Blood culture positivity after 48 hours of CCU stay remained at 0%. Mortality trends varied and showed no consistent pattern attributable to the intervention.

Conclusions

Integrating WHO’s multimodal strategy with PoCQI led to a significant, low-cost improvement in HH compliance in a high-risk setting. This team-led approach demonstrated the impact of QI strategies in implementing cost-effective infection prevention practices in critical care settings.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Hand hygiene is the most effective preventive measure for healthcare-associated infections, but adherence to it in intensive care units, particularly in low-income and middle-income countries, often remains below 50%–60%. Although the WHO multimodal strategy is established, consistent implementation on the frontline remains difficult. There is little evidence on simple, low-cost quality improvement (QI) methods to improve and maintain hand hygiene in India’s coronary care units.

WHAT THIS STUDY ADDS

• This study found that implementation of the Point of Care Quality Improvement approach alongside WHO’s multimodal strategy increased hand hygiene compliance from 63.8% to over 80% in a critical care unit at a tertiary hospital. During the intervention, there were no recorded bloodstream infections with common multidrug-resistant organisms. The results indicate that context-specific, team-based interventions can lead to higher compliance rates than those typically reported for critical care units in existing literature.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The results provide evidence that frontline teams, empowered through QI methods, can implement sustainable infection prevention practices like 5 moments of handwashing with ease. Hospitals in similar settings can replicate this model to strengthen infection control in critical care. Structured QI capacity building can be incorporated into national infection prevention programmes as a method to expand hand hygiene initiatives.

Introduction

Healthcare-associated infections (HAIs) are a major challenge in intensive care units (ICUs), where critically ill patients often undergo invasive procedures and are at high risk of infection. In India, studies from tertiary hospitals have reported HAI prevalence as high as 25% in surgical ICUs, with substantial burden in medical ICUs and coronary care units (CCUs). HAIs contribute to increased morbidity, prolonged hospital stay, higher mortality and financial strain on patients and health systems. The Lancet Global Health Commission on High-Quality Health Systems highlighted HAIs as the most common preventable cause of mortality linked to poor-quality care.¹

Among the modifiable contributors to HAIs, inadequate hand hygiene (HH) compliance remains one of the most critical and persistent challenges in infection prevention. HH non-compliance has been strongly associated with the transmission of multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas and Klebsiella, all of which are of particular concern in ICUs. The WHO’s ‘Five Moments of Hand Hygiene’ provides a structured framework for improving HH practices, yet challenges related to monitoring and compliance with the Five Moments of Hand Hygiene often result in a paucity of reliable data on HH adherence, particularly in critical care settings such as CCUs in tertiary care hospitals.

ICUs present the highest frequency of HH opportunities among healthcare settings.² Daily HH opportunities in medical and surgical ICUs can reach as high as 71.6 to 73.9 per patient day, with a marked difference observed between day shifts (median 46.7) and night shifts (median 28.0). Despite this, a 2015 systematic review noted that HH compliance in ICUs remained low, with a median of 40% in contrast to higher compliance in non-ICU settings (50%–60%).³ This gap between high opportunity and low adherence highlights the need for targeted, context-specific strategies.

To guide health systems in improving HH compliance and reducing HAIs, the WHO recommends a multimodal HH improvement strategy. This strategy includes five key components: (1) system change—ensuring availability of alcohol-based hand rubs and handwashing facilities at point of care; (2) training and education (3) evaluation and feedback (4) reminders in the workplace—visual cues to prompt behaviour and (5) institutional safety climate—leadership engagement and a culture that promotes patient safety. While the WHO multimodal strategy is well-established in theory, implementing all components effectively in real-world settings remains challenging. The gap between awareness and implementation continues to limit its full potential.

In 2023, a QI initiative was launched in the CCU of a tertiary care hospital in South India. Suboptimal HH compliance in the unit was noted where the baseline compliance was 63.8% with no standardised monitoring system. These findings underscored the need for a structured improvement effort, leading to a Point of Care Quality Improvement (PoCQI) initiative to strengthen HH practices.

Context

The cardiac ICUs primarily manage postoperative cardiac surgery patients, many of whom require prolonged invasive monitoring and life-support interventions, placing them at high risk for HAIs. Despite existing infection control protocols, baseline HH compliance among healthcare providers (HCPs) stood at 63.8%. Microbiological surveillance during this period reported no cases of MRSA, Pseudomonas or Klebsiella, but overall mortality in the cardiac ICU ranged between 17.2% and 21.3%, emphasising the need to strengthen infection prevention practices.

This project was facilitated by the Nationwide Quality of Care Network (NQOCN), which provided technical mentorship and training. The programme aimed to empower clinical teams to identify local challenges, develop context-specific solutions and test by using the Plan-Do-Study-Act (PDSA) approach.

The local environment was conducive to change, given the hospital’s prior participation in QI capacity-building initiatives and the availability of trained infection control personnel. The intervention aligned closely with WHO’s multimodal strategy by combining system change (placement of hand rubs and scrub stations), training (PoCQI workshops and staff sensitisation), evaluation (real-time feedback), reminders (vernacular posters), and institutional support (leadership involvement and mentoring). PoCQI provided a practical framework to implement these components in a structured, low-cost and sustainable manner tailored to the local context.

Methods

This QI project aimed ‘To improve the compliance of 5 moments of Hand Hygiene in CCU I and III at KLEs Dr Prabhakar Kore Hospital & MRC, Belagavi in admitted patients from existing performance 63.8% to 85% from 1 August 2023 to 12 December 2023’.

The project was implemented using the PoCQI methodology, supported by training and mentoring from the NQOCN. PoCQI is a four-step method that uses a structured, team-based process that empowers frontline healthcare workers to identify local problems, analyse root causes, test change ideas using PDSA cycles, and implement successful interventions into routine practice.⁴

A multidisciplinary team including CCU staff, doctors and Intensive Care Medicine personnel underwent a structured 2-day PoCQI training conducted by mentors from NQOCN. The QI team comprised a team leader, a recorder, a communicator and members from both clinical and nursing staff. Following the identification of suboptimal HH compliance as a critical issue, the team conducted a root cause analysis (RCA) using a fishbone diagram (figure 1) and process flow mapping (online supplemental file 1). This identified gaps such as lack of visual prompts, inconsistent monitoring at night and inadequate staff engagement.

Figure 1. Fishbone diagram. CCU, coronary care unit; IV, Intravenous; IEC, information education and communication.

Drawing from these insights, the QI team developed and tested context-specific change ideas through iterative PDSA cycles (see table 1). These were tested through five short-duration PDSA cycles. After each cycle, decisions were made to adopt, adapt or abandon the changes based on observed outcomes. Details of each PDSA cycle, including interventions and timelines, are presented in table 2.

Table 1. Change ideas for improving HH compliance in cardiac ICU.

Change idea	Description	Biological plausibility
Common scrub station and footwear protocol	Installation of a centralised scrub station and introduction of sterile footwear and gowning for attendants entering CCUs.	Reduces microbial contamination introduced from external environments, particularly via footwear and unwashed hands, lowering the risk of pathogen transmission.
Development of bedside IEC materials	Co-creation of vernacular posters on WHO’s Five Moments of Hand Hygiene22; placed at each bedside for patient-facing and staff-facing reminders.	Enhances awareness and recall of HH protocols, particularly before aseptic tasks and patient contact—key moments for interrupting infection transmission.
Training and expansion of night-shift monitoring	A combined strategy involving the training of shift-in-charge nurses to observe and document HH practices using WHO audit tools during evening and night shifts. This complemented daytime monitoring done by the infection control nurse and addressed the previously unmonitored off-peak hours. Additional observers were recruited and trained to ensure continuous surveillance during all shifts.	Reinforces accountability and improves real-time adherence to HH protocols. Continuous monitoring, particularly during night shifts—when supervision is typically lower—helps reduce cross-transmission of pathogens. The act of being observed can itself improve compliance (Hawthorne effect), further supporting infection prevention efforts.

CCU, coronary care unit; HH, hand hygiene; IEC, information education and communication.

Table 2. Plan-Do-Study-Act (PDSA) cycles.

PDSA cycle	Change idea	Plan	Do	Study	Act
PDSA I 12 September 2023–16 September 2023 (5 days)	Common scrub station and footwear protocol	Instal a scrub station at the shared entry for CCU I and III, and introduce sterile footwear and gowning for attendants.	Scrub stations were installed at entry, sterile footwear and gowns made available for all entering the CCU complex. Implementation of signage in the local language to enforce sterile footwear and gowning use put up.	It was feasible to instal the scrub station and make gowns and footwear available along with signage placement. (Mean Compliance to 5 moments of HH improvement 63.8%–65.3%)	Adopted
PDSA II 12 September 2023–16 September 2023	Developing English posters (initial attempt) on 5 moments of HH to place in high traffic ICU areas.	Develop English-language posters on the Five Moments of HH and place them in high-traffic ICU areas.	Posters were developed, installed at CCU entrances and evaluated for visibility and effectiveness.	Developing and installing posters was feasible but it shows limited engagement; staff reported poor visibility and minimal effect. Compliance improvement was negligible (63.8%–64.3%).	Intervention discontinued due to poor outcome; replaced by vernacular versions. Abandoned
PDSA III 3 October 2023–10 October 2023 (7 days)	Developing vernacular bedside IEC posters focusing on 5 moments of HH	Co-develop posters in Kannada, Marathi and English depicting WHO’s Five Moments of HH with input from HCWs and community.	Posters were printed and displayed at each bedside and key CCU locations; feasibility and clarity were assessed over 7 days.	Co- development of vernacular posters was feasible and their placement at bedside and various CCU locations was successful. During this PDSA, the Mean Compliance to 5 moments of HH improved from 65.3% to 67.1%.	Adopted
PDSA IV 14 October 2023–27 October 2023	Training and empowering shift-in-charge nurses as observers to monitor 5 moments of HH.	Identify and train 12 shift-in-charge nurses over 4 training sessions (with pre and post tests) with an aim to create capacity to observe HH practices.	Training was done in 4 small batches for all 12 nurses and pre–post tests were conducted.	Four training sessions were feasible and 12 nurses were trained. The pretest scores were 9.09% which improved to 91.7% in the post test. Mean compliance rate to 5 moments of HH was improved from 67.1% to 67.7%.	Adopted
PDSA V 30 October 2023–05 November 2023	Evening/night-shift monitoring by additional nurses on 5 moments of HH.	Recruit and train 6 additional observers to monitor HH compliance during evening/night shifts.	6 additional nurses were trained to monitor HH Compliance during evening/night shifts.	Adding additional 6 nurses was feasible. Slight improvement in compliance (67.7%–67.8%); staff reported increased accountability due to being monitored.	Adopted

CCU, coronary care unit; HCWs, healthcare workers; HH, hand hygiene; IEC, information education and communication.

To support implementation, three structured on-site mentoring visits of 2-day duration each, along with interim online follow-up sessions facilitated by QI mentors, were conducted.

Quality indicators

Data on predefined process and outcome indicators were collected before and after implementation through direct observations and facility-level records. The process indicator calculation is in line with the WHO’s guidelines on HH monitoring, which recommend measuring actual HH actions against total observed opportunities as the standard method for evaluating compliance in healthcare settings.⁵

The primary process indicator was HH compliance, calculated as the number of correctly performed HH actions divided by total observed opportunities, multiplied by 100.

The outcome indicators included all-cause mortality per 1000 ICU days, blood culture positivity after 48 hours of ICU stay, and the incidence of MRSA, Klebsiella and Pseudomonas bloodstream infections per 1000 ICU days.

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$${\displaystyle {\displaystyle \begin{array}{c}\begin{array}{c}\mathrm{A}\mathrm{l}\mathrm{l}\text{-}\mathrm{c}\mathrm{a}\mathrm{u}\mathrm{s}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}\mathrm{y}\end{array}=\frac{\begin{array}{c}\mathrm{T}\mathrm{o}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{n}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{d}\mathrm{e}\mathrm{a}\mathrm{t}\mathrm{h}\mathrm{s}\\ \mathrm{i}\mathrm{n}\mathrm{t}\mathrm{h}\mathrm{e}\mathrm{c}\mathrm{a}\mathrm{r}\mathrm{d}\mathrm{i}\mathrm{a}\mathrm{c}\mathrm{I}\mathrm{C}\mathrm{U}\times 1000\end{array}}{\begin{array}{c}\mathrm{N}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{p}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{e}\mathrm{n}\mathrm{t}\mathrm{s}\mathrm{a}\mathrm{d}\mathrm{m}\mathrm{i}\mathrm{t}\mathrm{t}\mathrm{e}\mathrm{d}\\ \mathrm{i}\mathrm{n}\mathrm{t}\mathrm{h}\mathrm{e}\mathrm{s}\mathrm{a}\mathrm{m}\mathrm{e}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{i}\mathrm{o}\mathrm{d}\end{array}}\end{array}}}$$

$${\displaystyle {\displaystyle \begin{array}{c}\begin{array}{c}\mathrm{B}\mathrm{l}\mathrm{o}\mathrm{o}\mathrm{d}\mathrm{c}\mathrm{u}\mathrm{l}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\\ \mathrm{p}\mathrm{o}\mathrm{s}\mathrm{i}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{i}\mathrm{t}\mathrm{y}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{e}\end{array}=\frac{\begin{array}{c}\mathrm{N}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{b}\mathrm{l}\mathrm{o}\mathrm{o}\mathrm{d}\mathrm{c}\mathrm{u}\mathrm{l}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{p}\mathrm{o}\mathrm{s}\mathrm{i}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\\ \mathrm{a}\mathrm{f}\mathrm{t}\mathrm{e}\mathrm{r}48\mathrm{h}\mathrm{o}\mathrm{u}\mathrm{r}\mathrm{s}\mathrm{o}\mathrm{f}\mathrm{a}\mathrm{d}\mathrm{m}\mathrm{i}\mathrm{s}\mathrm{s}\mathrm{i}\mathrm{o}\mathrm{n}\end{array}}{\begin{array}{c}\mathrm{N}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r}\mathrm{o}\mathrm{f}\mathrm{b}\mathrm{l}\mathrm{o}\mathrm{o}\mathrm{d}\mathrm{c}\mathrm{u}\mathrm{l}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{p}\mathrm{o}\mathrm{s}\mathrm{i}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\\ \mathrm{a}\mathrm{f}\mathrm{t}\mathrm{e}\mathrm{r}48\mathrm{h}\mathrm{o}\mathrm{u}\mathrm{r}\mathrm{s}\mathrm{o}\mathrm{f}\mathrm{a}\mathrm{d}\mathrm{m}\mathrm{i}\mathrm{s}\mathrm{s}\mathrm{i}\mathrm{o}\mathrm{n}\end{array}}\end{array}}}$$

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of this quality improvement (QI) initiative.

Data collection and analysis

The baseline data were calculated by the infection control team using retrospective data from the infection control audit registers maintained by the hospital’s Infection Control Committee for the 3 months preceding project initiation (May–July 2023). This historical data was routinely collected as part of ongoing infection control surveillance using WHO-based HH observation checklists and was not collected de novo for this study. The infection control nurses (ICNs) collected the baseline data as part of their routine infection control surveillance responsibilities, which include HH observations. No additional staff or separate data collection exercise was undertaken beyond their regular duties. Data for the process and outcome indicators were collected weekly throughout the study period from CCU registers, infection control records and microbiology reports. Observations were recorded using WHO-based HH checklists and analysed in Microsoft Excel 365. Descriptive statistics such as average, percentage change and trend patterns were used to analyse process and outcome indicators. PDSA timelines were annotated on run charts to visually associate interventions with observed changes. Weekly run charts were used to track trends and identify shifts in compliance.

Results

Process flow

Changes in process flow were introduced to strengthen compliance with the WHO Five Moments of Hand Hygiene. Initially, HH was inconsistently practised at staff entry, particularly among ancillary staff, creating a risk of pathogen introduction into the CCU. Following implementation of change ideas—such as visual reminders and structured observation—HH was reinforced at every critical step: staff entry, before and after patient contact, after leaving patient surroundings, and before exit. These modifications integrated HH into the routine workflow, improving compliance and fostering a culture of accountability and infection prevention (online supplemental file 1).

The baseline hand-hygiene compliance was 63.8%. During the intervention phase (weeks 1–14), compliance gradually improved from 63.8 % to 70.6 %, and from week 2 onward, all 19 subsequent data points remained above the baseline median. This constitutes a shift and too-few-runs signal on the run chart (figure 2), indicating intervention-based change rather than random fluctuation. In the sustenance phase (weeks 15–20), compliance continued to rise steadily from 67.1 % to 80.5 %, reflecting a consistent upward trend and stable process control. During the extended postintervention monitoring (weeks 21–30), compliance remained consistently around ~80%, confirming that the improvement was sustained even without active mentoring support.

Figure 2. Weekly run chart of quality indicators in the coronary care unit. HH, hand hygiene; MRSA, methicillin-resistant Staphylococcus aureus.

Infection-related indicators—including incidence of Klebsiella, MRSA and Pseudomonas and blood-culture positivity—remained zero throughout, confirming effective infection-prevention practices. Mortality, initially variable, stabilised between 15% and 20% after week 10. Together, these run-chart signals demonstrate that the quality-improvement intervention achieved and sustained a significant, non-random improvement in HH compliance.

Missing data

A key data limitation in this project was the lack of disaggregated evening and night shift monitoring data. While overall HH compliance was tracked consistently throughout the intervention, shift-specific data were only available for weeks 14–16, when trained nurse observers began documenting compliance during off-peak hours. However, from weeks 17 to 20, evening and night data were not recorded separately, limiting the ability to assess sustainability of night shift compliance beyond the immediate post-training period.

As a balancing indicator, limited informal feedback from patient attendants was also obtained to guide the design and placement of multilingual information education and communication (IEC) materials and to understand their perception of HH practices in the unit. This suggests early adoption of a culture of shared responsibility and patient engagement, although the sample size was limited.

Unintended benefits and costs

No significant unintended benefits or adverse costs were observed during the course of the intervention. The project costs were categorised into external and internal components. External costs included travel of mentors for onsite mentoring and expenses for training workshops, which were fully covered by project sponsors. This amount was approximately 2.5 lacs. The remaining costs were internal, leveraging existing hospital resources such as staff time, infrastructure and routine consumables for materials and monitoring processes, and did not incur additional expenditure. The implementation of HH improvement strategies did not negatively affect other clinical operations or result in resource overuse.

Discussion

This QI initiative aimed to improve HH compliance in the cardiac ICU using a structured PoCQI approach and iterative PDSA cycles. Over the intervention and sustenance periods, HH compliance increased by 26.68% from baseline. Moreover, during the extended postintervention follow-up (weeks 21–30), HH performance remained consistently around 80%, demonstrating sustained gains beyond the active QI phase. No cases of MRSA, Pseudomonas or Klebsiella bloodstream infections were reported and the blood culture positivity rate after 48 hours during the entire project period was 0%. Although HH compliance improved significantly, mortality rates did not show a consistent reduction during the study period. Mortality in ICUs is a surrogate marker and multifactorial in origin. In complex settings such as CCUs, it may not be univariantly linked to HH compliance; however, improvements in HH have been shown to reduce HAIs in ICUs, which in turn can influence all-cause mortality.

The intervention was structured around the WHO-recommended multimodal strategy⁶ for improving HH, comprising five interlinked components: (1) system change, which included the installation of centralised scrub stations and provision of sterile footwear and gowns to ensure accessibility and compliance at entry points; (2) training and education, which was achieved through structured PoCQI workshops and targeted sessions for doctors, nurses and night-shift staff using WHO audit tools; (3) monitoring and feedback; by shift-in-charge nurses and additional observers to collect real-time data on compliance across shifts; (4) visual reminders; multilingual bedside posters were co-developed on the Five Moments of Hand Hygiene and (5) institutional safety climate; fostered through leadership commitment to infection prevention, iterative mentoring visits and feedback systems incorporating psychological safety elements. This approach used by us was aligned to the approach as detailed in a Cochrane review by Gould et al. This review concluded that multimodal interventions are more effective than single interventions in improving HH compliance.⁷

Our findings align with global experiences demonstrating the meaningful impact of multimodal strategies on HH compliance. Our study achieved an improvement from a baseline rate of 63.3% to 80.47% during the study period. In a study by González-González et al, who reported an increase in HH compliance from 39.83% to 64.81% using a multimodal strategy in a third-level hospital in Mexico.⁸ An intervention at Ahmadu Bello University Teaching Hospital in Nigeria improved HH compliance among surgical staff from 17.1% to 69% following implementation of the WHO multimodal strategy. Compliance was highest in areas with both visual and verbal reminders, emphasising the value of environmental and behavioural reinforcements.⁹ A multihospital study in Uganda demonstrated that implementing the WHO hand hygiene improvement strategy using a continuous QI (CQI) approach led to an increase in HH compliance from 19.9% to 53.8%, alongside significant improvements in IPC capacity and healthcare worker knowledge (IPCAF (infection prevention and control assessment framework) and HHSAF (hand hygiene self-assessment framework scores) (Uganda CQI study, 2023). These findings underscore the value of structured, iterative QI methods in driving sustained HH improvements in resource-constrained settings, similar to the gains achieved in our PoCQI-based initiative.^{10 11} Our study was conducted in the CCU of a tertiary care institution which already had a baseline HH compliance rate above 60%. Most of the studies cited above have achieved postintervention rates similar to our baseline rates. It is a well-known fact that improving 5 moments of HH above 75% is difficult to achieve and sustain. Even during the COVID-19 pandemic, HH compliance peaked at 92.8% but declined to 51.5% by August 2020, highlighting the challenge of sustaining high adherence.¹² However, due to the use of POCQI in our study setting, we could achieve rates above 80% which are higher than those in other contemporary studies cited above.

Although the benefits of multimodal strategies are well-established, the magnitude of improvement in HH compliance tends to be modest across the literature—typically ranging from 20% to 30%. Our findings align with other studies where similar improvements were achieved despite intensive efforts.^{13 14} This modest impact reflects the behavioural and structural complexities of ensuring consistent HH compliance. Our study encountered several challenges specific to the coronary care setting, including a high baseline compliance rate limiting further improvement (ceiling effect), behavioural fatigue among staff, and the cognitive and physical demands of performing HH at multiple critical points (‘5 Moments’). Additionally, monitoring limitations due to the Hawthorne effect—where staff alter their behaviour because they know they are being observed—high patient acuity, urgent procedures and substantial staff workload further constrained consistent HH compliance. Similar findings were observed by Chavali et al who reported that even after a year-long multimodal intervention, overall compliance plateaued at 78%, with nurses achieving only 39% compliance before aseptic procedures often missed due to task clustering and workload pressures.¹⁵ Likewise, a systematic review has identified multiple barriers such as high workload, inconveniently placed or empty AHR dispensers, lack of organisational support and poor role modelling. Additionally, psychological factors such as selective compliance operate, where HH is performed only when the perceived risk of contamination is high.^{16 17} These findings show that despite structured interventions, sustaining high HH adherence remains complex and context-dependent.¹⁸

While the WHO multimodal strategy is well-defined in terms of components, the ‘how’ of implementation is often lacking in clarity. In practice, there remains a persistent gap between knowledge of HH principles and consistent frontline implementation. QI methodologies such as PoCQI help bridge this implementation gap by enabling teams to translate broad strategies into actionable, context-specific interventions. The PoCQI methodology helped us to implement the multimodal strategy in a structured, cost-effective manner. The team conducted an RCA using fishbone diagrams and process flow mapping to identify local barriers. The gaps were addressed through context-specific interventions tested using iterative PDSA cycles. POCQI allowed the team to solve problems using existing resources, engage frontline staff in decision-making and integrate HH improvement into routine workflow without requiring major structural changes or additional funding.

The greatest gains are typically realised when HH improvement is part of a bundled care approach that includes IPC protocols, leadership engagement and staff incentives. Evidence shows that such approaches are most effective when senior clinicians visibly role model HH practices and organisations prioritise HAI prevention through adequate resourcing and accountability structures.¹⁸ Additionally, findings from recent meta-analyses highlight that involving patients in co-producing care—particularly in critical care settings—can accelerate behavioural change among HCPs, resulting in improved safety outcomes for both patients and staff.

The mean HH compliance rates vary widely across low-income and middle-income country (LMIC) and high-income settings, as has been noted, it varies from 9.1% in LMIC to 64.5% in high-income settings.¹⁹ Our study, conducted in the cardiac ICU of a resource-limited setting, surprisingly showed higher rates of improvement in HH compliance as compared with ICU settings where rates vary from 27% and 52%.²⁰ Using the PoCQI approach with iterative PDSA cycles, the team implemented a structured, low-cost and replicable multimodal HH strategy. This was probably due to the setting being that of a large tertiary care academic institution, with a strong focus on quality certification programmes, an involved infection control and monitoring team led by ICNs and frequent institutional monitoring and mentoring support provided by NQOCN through its POCQI mentoring programme directed towards the CCU or our setting was in a CCU within an LMIC, our baseline HH compliance was relatively high, and improvement rates exceeded 80%. This can be attributed to a strong institutional focus on quality (NABH-accredited), a robust infection control programme with regular mentoring by ICNs and the academic nature of the hospital with a super specialty cardiology department—all of which fostered an enabling culture for implementing the WHO multimodal HH strategy.

Several key lessons emerged from this study, the main learning is that effective team-based problem solving using a structured QI method to implement the WHOs multimodal strategy can catalyse the HH Compliance rates in challenging high burden healthcare settings in LMIC settings.

Although routine data collection for this QI study formally concluded at Week 20, extended monitoring for an additional 10 weeks (weeks 21–30) demonstrated that the improved HH practices were sustained, with compliance consistently maintained around 80%. Routine HH audits by ICNs, continued reinforcement by CCU leadership and monthly QI review meetings now serve as ongoing mechanisms to maintain compliance. These institutional processes have helped embed the improvements into routine clinical practice, supporting continuity beyond the formal project phase.

Limitations

The absence of a control group, single site and short follow-up period limits external validity. Direct observations may have introduced the Hawthorne effect, potentially affecting compliance rates. Moreover, monitoring the WHO Five Moments was labour-intensive and required trained ICNs, occasionally affecting clinical duties. Direct observation was also typically limited to entry and exit points, as observers could not discreetly follow HCPs inside the patient zone at all times, making it difficult to comprehensively assess compliance with all ‘5 Moments’.²¹ Mortality trends could also be influenced by confounders such as patient illness severity and comorbidity profiles; additionally, data related to infection-associated mortality were not captured in this study and are often challenging to obtain in critical care environments like CCUs due to reporting bias.

Conclusions

This QI initiative demonstrated that a structured, context-specific approach using the PoCQI methodology can effectively enhance HH compliance in a high-risk setting like the CCU. By implementing simple, low-cost components of a multimodal strategy—such as visual cues, staff training, real-time monitoring and iterative PDSA cycles—the team achieved a 26.68% improvement in compliance and recorded zero bloodstream infections during the intervention period.

The success of this project highlights the value of empowering frontline teams to identify problems, test solutions and sustain improvements using data-driven methods. PoCQI served as a practical framework to bridge the gap between global guidelines and local implementation. While generalisability may be limited by the single-centre design, the model offers a scalable and adaptable approach for similar settings aiming to improve infection control and patient safety through better HH practices.

The funder had no role in the design, conduct, analysis or reporting of the study.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.