Introduction to

Water and Sanitation for

Health Facility Improvement
Tool
“WASH FIT”
Overview

1. WASH in health care facilities : global status and

activities
2. Importance of WASH in Health Care Facilities
3. WASH FIT
 Description and contents
 Methodology
 Application
Imagine delivering a baby with no
water…
 …preventing infections from
spreading…

Photo : WaterAid 2016

Or trying to provide quality care when
basic services are lacking…
06/23/2020 6
Globally, WASH services in health care facilities
are shockingly poor

• 1 in 4 lack basic water

• 1 in 5 have no sanitation
• 42% lack hand hygiene at point of care
• 40% lack systems to segregate waste
(WHO/UNICEF, 2019 Global Baseline Report)
 Responding to the Secretary General’s
global call to action on WASH in HCF

Global Targets

“WASH in health facilities are the most basic

requirements of infection prevention and
control, and of quality care.
They are fundamental to respecting the dignity
and human rights of every person who seeks
health care.”
António Guterres, UN Secretary General

8
Practical steps for improving and
sustaining services

9
 What we know works for
improving WASH in HCF

Facility level
• Accountability mechanisms and
incentives
• Engagement and empowerment of
leaders, communities and users
• Small incremental improvements (e.g.
WASH FIT)
 In your opinion…
What makes a health facility:
• Clean and safe?
• Well managed?
•Respectful of rights and
people-centered?

 What is needed to improve

the quality of care?
 What will encourage
people to visit the health care
facility?
What is the biggest problem related to WASH in HCF
in RWANDA?
And in your facility?
WASH FIT Domains

What are the key areas of environmental health

domains which are the minimum requirements to
make a facility safe?
Treatment, supply,
storage, water
quality testing, Hand hygiene,
showers, energy. environmental
cleaning and
disinfection

Latrines (e.g.
maintenance,
MHM, Facility
disability management
access), waste , leadership,
water
staffing,
management,
problem
Health care reporting
waste
management
(all stages)
Water and Sanitation for Health
Facility Improvement Tool
WASH FIT

WASH FIT is a management tool that holistically protects health and

upholds dignity through the assessment and management of risks
from insufficient or unsafe water supply, inadequate sanitation and
poor hygiene practices.

To make facilities
• Clean and safe

• Well-managed

• Respectful of rights and people-centered

Adapted from Water Safety Plan approach

 What it is What it is not
A tool for facilities to prioritize and A tool for national level
maintain WASH improvements, focusing monitoring of WASH in health
on actions care facilities
Encompasses infrastructural changes, A one-size fits all approach
maintenance and repair as well as
Anexercise that can be
behavioural changes, such as hand
hygiene behaviour completed in a day

Tobe used as part of broader quality

improvements in health care facilities
Comprehensive and systematic
 Early adopters
• Implemented in over 20 countries with different core focus
• Overall quality of care, maternal/newborn services, cholera
hotspot, outbreaks, health care waste
• Constantly learning!
What type of facilities is
WASH FIT for?

Mainly primary, and in some instances secondary, care facilities

Resource-constrained settings

E.g. health centres, health posts, or district hospitals

However, WASH FIT is a framework and the methodology can be

adapted for use in any type of facility

 
What are the benefits of
implementing WASH FIT?
Improves the day-to-day management and operation of a
facility,
Encourages a team-based approach
Engages community members
Helps identify improvement needs
Provides a framework to develop, monitor and continuously
implement an improvement plan
 The five steps

Assemble and train the .1

WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
 Assemble the team
1. Why assemble a team?
2. Why should you involve all members of the team?
3. Are there external partners you can engage?
4. What challenges may arise when assembling a team and how
will you overcome them?
5. What are the characteristics of an effective team leader?
6. What is the role of the facility manager and how should he/she
be involved?
WASH FIT team meetings

Nominate a LEADER
Hold regular meetings
 Core team: e.g. weekly
 Extended team: e.g. monthly
Document decisions made and refer back to them as needed
Agree a date for the next meeting at the end of every meeting
Discuss benefits and rewards for good team performance
Noneed to form a new team if one already exists (e.g. IPC
committee)
Leadership
WASH FIT needs leadership!
Leaders should bring vision and
commitment.
“Champions” are critical
• one committed individual can make a
huge difference in making changes,
and thereby improve the quality and
safety of health services.
 Step 2
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
Step 2: Facility assessment
 A comprehensive assessment forms the basis of WASH
FIT
 Look at the interior and exterior of facility
 Consider infrastructure
 Water supply, sanitation facilities etc.
 Behaviours, knowledge, management
In each of these situations, what information
would you need to collect and how would
you collect it??

1 2

3 4
Laos, WASH FIT training,
February 2017
Mali, WASH FIT assessments,
2016
Chad, WASH FIT assessments,
2016
Facility Assessment
Indicators
•Based on WHO Essential Environmental Health Standards (2008)
•Alignedwith Joint Monitoring Programme global indicators for
monitoring WASH in health care facilities in the Sustainable
Development Goals
•“Essential” indicators for all facilities, even the smallest
•“Additional” indicators for bigger facilities
•Three levels:
• Meets minimum standards (+++)

• Meets some but not all standards (++)

• Needs improvement (+)

•Explanatory notes for some indicators given at bottom of table - shown

by an asterix (*)
Indicators

• WASH FIT indicators are based on GLOBAL standards.

• They should be adapted to meet national standards

• Add extra indicators

• Remove indicators for smaller facilities (if not relevant)

• Make sure everyone agrees on results of assessment

Keep a record over time
• At each assessment, count numbers of indicators which Meet standards (+
++), Partially meets standards (++) and Standards not met (+)
• Enables comparisons over time
• REMEMBER: indicators will only continue to meet standards (+++) with
proper maintenance!
Example:
  Assessment 1 Assessment 2 Assessment 3 Assessment 4

Domain Date of assessment: 24th March 2016 25th September 2016    

Number of indicators
Water meeting standards 5 10    
Number of indicators
Total number of
indicators assessed:
partially meeting 4 3    
standards
13 Number of indicators not
4 0    
meeting standards

Significant
improvement made
Overall, improvements (doubled the number of
needed as less than half indicators meeting
Notes of the indicators met standards) and in no    
standards. areas are the standards
  not met. Some
additional progress
could be made.
 Step 3
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
 Step 3: Objectives
To identify what hazards (or problems) exist that prevent a facility
from providing adequate WASH services and

Identify what risks these hazards pose

For each problem that you identify, consider the risks for staff,
patients and their families

Consider what the facility is doing well and what WASH infrastructure
and protocols are already in place.
Definitions

A hazard is defined as a "condition, event, or circumstance that could

lead to or contribute to an unplanned or undesirable event." It may also
be referred to as a problem. Any indicators which do not meet the target
should be considered a potential hazard.

A risk is the potential a set of unwanted circumstances or events to

occur as the result of the hazard. All hazards have an associated risk,
however serious it may be.
Identify the strengths, problems & risks
Latrine, next to the
maternity ward
Answer

The problem is a blocked The associated risk is that users

toilet. may have to defecate in the open
(contaminating the environment
and creating a very unappealing
.health care facility)

Users may also suffer health

consequences from having to
relieve themselves of a bowel
.movement or urine

It is unpleasant to use a blocked

toilet, particularly after giving birth
when women may feel vulnerable
Identify the strengths, problems &
risks

Bin, consultation
room
Identify the strengths, problems &
risks

Only handwashing
station in consultation
room
 Identify the problems, hazards & risks

Concrete paths, facility

grounds
Identify the strengths, problems &
risks

Exterior of outpatient
department, waiting
area
Identify the problems, hazards &
risks
Step 3: Strengths, problems & risks

• Problems can relate to:

• Infrastructure
• Behavior, knowledge, lack of finances, lack of training

• They can be:

• One-off occurrences or short term
• i.e. a broken incinerator or blocked latrine

• Ongoing or long-term issues

• i.e. no access or irregular access to water within the facility and/or facility grounds
• i.e. no source of power for the incinerator
Step 3: Strengths, problems & risks
 All problems have an associated risk
 Risk can be to:
 Staff
 Patients
How serious is
 Visitors ?the risk
Vulnerable groups How easy is it to
 Pregnant women, ?address
 Elderly
 Children
 Disabled users
How easy/difficult is it to address
the risk?

Some problems are easier to address than others

Some can be done within the facility (e.g. posting hand
hygiene posters or cleaning the facility), others need external
support (e.g. installing a water supply)
Not everything can be addressed immediately so this will help
you to prioritize some actions over others.
Risk prioritisation
How easy/difficult is it to address
the risk?

Rate from easy to difficult Difficult to address

Use a sliding scale

Easier to address
How serious is the risk?

Lower risk Higher risk

Remember: the relative importance of each risk is

different for every facility and different stakeholders.
Exercise: Compare seriousness
of risk vs ease of addressing
risk
Suggested answers
Use answers to prioritize actions

Prioritize activities that are

higher risk and are easier to
address

Move on to “Higher risk

/difficult to address” and
“Lower risk/easier to address”
STEP 4.
Develop and implement an
incremental improvement plan
Improvement plan

• Prioritise and detail the actions that will be taken

Not everything can be addressed immediately

• Develop a detailed plan to implement the actions

Decide…

• What specific ACTIONS will be taken

• WHO is responsible
• What RESOURCES are required
• Technical
• Human
• Financial
• WHEN it will be done
 Improvements
• Building new infrastructure or
repairing old infrastructure

• Writing new protocols

• Staff training in new techniques

or procedures

• Improving management
methods

Improvements can be low cost

and simple but still have a big
impact
Actions & improvements
• Short, medium or long term
• Some can be done rapidly, others may need more time and
resources
• Continuous
• Focus on incremental improvements – little by little
• Change behaviours and attitudes!
• Use imagination and creativity for low cost solutions and ideas. Not
everything needs to cost money!
 Examples of WASH FIT improvements

Planting plants by HCF

entrance
Hand washing poster drawn by
The exterior of the facility is head of HCF
well-fenced, kept generally Hand hygiene promotion 4.4
clean (free from solid waste, Clear signs demonstrating gender materials clearly visible and
stagnant water, no animal and separation of latrines understandable at key places
human faeces in or around the Toilets or improved latrines clearly :2.3
.facility premises, etc separated for staff and patients and
visitors
 Example improvement plan
What specific improvement action will be Who will carry out the task What resources are When do you expect Completion date
taken to resolve the hazards identified? and is there anyone who will needed to do it? to complete this
Domain

supervise it? List people action? Once the activity has

The actions to be taken link to the hazards responsible for implementation. “Resources” could be been completed,
recorded in tool 3. staff, technical or Indicate target date. record the date of
financial. completion.

1.3 Leaks in piping will be Local engineer to be 2 days of work 1 June 2016 5 June 2016
contracted to carry out at a cost of
fixed to ensure that taps repairs to piping.
$10/day.
are working.

1.7 Drinking water stations Jacob to assign budget for $10 per station, 15th April 2016 15th April 2016
purchasing and source plus ceramic
to be bought and installed drinking- water stations.
filters at $40
in waiting areas. Idriss to ensure stations are
each. Total $50
installed in correct places.
Water

x 4needed =
$200.

1.9 Water for drinking- Jacob to assign budget for John’s time. Ongoing Treatment
purchasing and source activity. started on April
water stations will be drinking- water stations.
Treatment to 21st.
treated using ceramic John responsible for
start in April
treating water.
filtration. once materials
are available.
Step 5.
Continuously monitor the
effectiveness of the plan and make
revisions
Evaluate and improve the plan

• Essential to monitor progress

• Helps confirm progress towards the targets
• Review from time to time, as and when necessary
• Quick and easy measurements and observations
• Carry out at the same time as regular staff meetings
• Review the dangers and risks and adapt your improvement plan
accordingly
How can you make change
sustainable?
 Sustaining change
Good leaders drive change

Incentivise staff for good

performance and recognise success

Rewards and awards

Hold competitions between facilities

or between wards in the same facility
– become a 5 star facility!

Peer to peer learning

Get regular feedback from patients

and staff
Budget

Prepare a budget that reflects aims and available resources,

with potential to scale-up
Consider sustainable mechanisms of budget and financing,
e.g. reinvesting revenue
 WHO Switzerland Tel.: +xx
20, Avenue Appia Fax: +xx
1211 Geneva

Lessons from other countries

06/23/2020 67
 – WASH FIT improvements
Liberia
Range of immediate to
longer-term solutions

Improved cleanliness and

hygiene of grounds

Reminders of hygiene
behavior

Safe waste destruction-

improved incinerators
WASH FIT – Indonesia
 Lessons from
implementation
Hands-on training in facilities, with plan for roll out, implementation,
regular follow up
Leadership needed from senior facility staff
Link training to policy and financing strengthening mechanisms
Dedicated WASH budget critical
WASH & quality must be taken up by governments
Need better monitoring and analysis of progress and challenges at the
facility level
Peer-to-peer exchanges, competitions and auditing supports ongoing
improvements
Questions?
Available materials

WASH FIT guide (English, French, Laos, Arabic, Russian, Spanish)

http://www.who.int/water_sanitation_health/publications/water-
and-sanitation-for-health-facility-improvement-tool/en/

Associated training modules and guidelines for running WASH

FIT training (www.washinhcf.org/training)

WASH FIT Mobile (www.washfit.org)

Selected references

WHO (2016) Standards for improving quality of maternal and

newborn care in health facilities

http://www.who.int/maternal_child_adolescent/documents/impr
oving-maternal-newborn-care-quality/en/#

WHO (2016) Global guidelines on the prevention of surgical site

infection

http://www.who.int/gpsc/ssi-guidelines/en/

WHO Clean Care is Safer Care