According to WHO; Hand hygiene is a primary measure to reduce hospital acquired infections. It is a simple act but the lack of compliances among health care workers. World Health Organization (WHO) offers a Hand hygiene Self-assessment framework to identify area of improvements and develop action plan and strategies accordingly. Being a low/middle income country initial scoring came to be 195 points i.e., Basic level thus we aim to achieve advance level i. e. > 375.

To work on project, Plan, Do, Study, Act (PDSA) quality improvement cycle was initiated, process and outcome indicators were measured to analyze the cause and effects/fish bone diagram was used. WHO's hand hygiene self-assessment framework/tool was utilized which has five components system change, training/ education, evaluation/ feedback, reminders in workplace & institution's safety climate for Hand Hygiene. Reassessments were done periodically to document the progress over time in each component and overall to track their progress in hand hygiene resources, promotion activities, plan their actions.

After implementation of multiple strategies in each section of WHO's self-assessment framework we were able to achieve our set goal and our overall score increased from basic i.e., 195 to advance i.e., 395. In addition to that our category wise score also increased i.e., in system change from 60 to 85, in training/ education from 35 to 100, in evaluation/ feedback from 52.5 to 100, reminders in workplace from 17.5 to 45 & Institution's Safety Climate from 30 to 65.

WHO's hand hygiene self-assessment framework should be utilized by all the hospitals in lower- and middle-income country as a guide to improve their hand hygiene levels. It provides an opportunity to reflect on existing resources and helps to focus on future and challenges. It acts as a diagnostic tool, identifying key issues requiring attention and improvement.