S at points of care 2. Staff educationTheoretical and practical workshop was conducted directed to These actions was maintained without changes. all HCWs categories (15 standardized slide presentations), accompanied by practical sessions encouraging good HH technique. Posters and handouts were donated by the promoters of subnational campaigns and were displayed in strategic areas previously identified by visiting the wards. Location criteria were maximal visibility during daily work and during transit within the hospitals. Posters were replaced monthly. A HH monitor team (HHMT) was created on March 2010 and included eight HCWs related to Infection Control Unit and Supervisor Nursing Department. Direct observations auditing was performed over three weeks (on June 2010) and two weeks (on October 2010). Thus, 2 evaluation periods and 25 days of monitoring were scheduled. Tables and bar graphs through were shown through informal interactive sessions on every ward at the end of evaluation period. Data were introduced in a centralized computer system for benchmarking. Institutional Commitment by administrative and nursing director Not performed These actions were maintained without changes3. Reminders (standard posters and lefts)4. AuditThe HHMT and the methodology of observation procedure was maintained, but the periodicity of audits was changed as follows: Audits were performed during 3 randomized days every 3 weeks (“3/ 3 strategy”). Thus, 17 evaluation periods and 51 days of monitoring were conducted.5. FeedbackRegularly Pamapimod site bimonthly feedback using control charts (Statistical Process Control) on every ward at institutional and individual level were provided. This support was maintained during this period Corrective actions were registered in a specific form. Modification of GS-5816 molecular weight incorrect HH habits, clarification of doubts and positive reinforcement were conducted.6. Safety institutional climate 7. Proactive corrective actionsdoi:10.1371/journal.pone.0047200.tSecondary outcome variables were bimonthly AHRs consumption (in litres per 1,000 patient-days in each ward as provided by the Pharmacy account system) and the bimonthly healthcareacquired colonisation/infection due to methicillin-resistant Staphylococcus aureus (MRSA) measured as the number of new cases per 1,000 patient-days identified from clinical, non-screening specimens as described previously [37]. Conventional microbiological procedures were used to identify MRSA isolates. Cases were identified from the infection control reports through total chart review. For MRSA rates, the preintervention period was the 2007?009 period.Data analysisData were aggregated for the pre-intervention period, phase 1 intervention period and phase 2 intervention period. Differences in HH compliance at the different periods were analysed using x2 tests for trends using Microsoft Windows SPSS (Statistical Package for the Social Sciences, 15.0). Also, time series analysis by Statistical Process Control (SPC) was performed by Minitab statistical software (MinitabH).PLOS ONE | www.plosone.orgThe Statistical Process Control (SPC) approach [38] is based on learning through data and is sustained in the theory of variation. The variability of event rates (so-called “process” in chart terminology) over time can be classified as either “natural” or “unnatural”. Natural variability (also known as “common cause” or “inherent variation” in chart terminology) is defined as the systemic or random variation inhe.S at points of care 2. Staff educationTheoretical and practical workshop was conducted directed to These actions was maintained without changes. all HCWs categories (15 standardized slide presentations), accompanied by practical sessions encouraging good HH technique. Posters and handouts were donated by the promoters of subnational campaigns and were displayed in strategic areas previously identified by visiting the wards. Location criteria were maximal visibility during daily work and during transit within the hospitals. Posters were replaced monthly. A HH monitor team (HHMT) was created on March 2010 and included eight HCWs related to Infection Control Unit and Supervisor Nursing Department. Direct observations auditing was performed over three weeks (on June 2010) and two weeks (on October 2010). Thus, 2 evaluation periods and 25 days of monitoring were scheduled. Tables and bar graphs through were shown through informal interactive sessions on every ward at the end of evaluation period. Data were introduced in a centralized computer system for benchmarking. Institutional Commitment by administrative and nursing director Not performed These actions were maintained without changes3. Reminders (standard posters and lefts)4. AuditThe HHMT and the methodology of observation procedure was maintained, but the periodicity of audits was changed as follows: Audits were performed during 3 randomized days every 3 weeks (“3/ 3 strategy”). Thus, 17 evaluation periods and 51 days of monitoring were conducted.5. FeedbackRegularly bimonthly feedback using control charts (Statistical Process Control) on every ward at institutional and individual level were provided. This support was maintained during this period Corrective actions were registered in a specific form. Modification of incorrect HH habits, clarification of doubts and positive reinforcement were conducted.6. Safety institutional climate 7. Proactive corrective actionsdoi:10.1371/journal.pone.0047200.tSecondary outcome variables were bimonthly AHRs consumption (in litres per 1,000 patient-days in each ward as provided by the Pharmacy account system) and the bimonthly healthcareacquired colonisation/infection due to methicillin-resistant Staphylococcus aureus (MRSA) measured as the number of new cases per 1,000 patient-days identified from clinical, non-screening specimens as described previously [37]. Conventional microbiological procedures were used to identify MRSA isolates. Cases were identified from the infection control reports through total chart review. For MRSA rates, the preintervention period was the 2007?009 period.Data analysisData were aggregated for the pre-intervention period, phase 1 intervention period and phase 2 intervention period. Differences in HH compliance at the different periods were analysed using x2 tests for trends using Microsoft Windows SPSS (Statistical Package for the Social Sciences, 15.0). Also, time series analysis by Statistical Process Control (SPC) was performed by Minitab statistical software (MinitabH).PLOS ONE | www.plosone.orgThe Statistical Process Control (SPC) approach [38] is based on learning through data and is sustained in the theory of variation. The variability of event rates (so-called “process” in chart terminology) over time can be classified as either “natural” or “unnatural”. Natural variability (also known as “common cause” or “inherent variation” in chart terminology) is defined as the systemic or random variation inhe.
