Infection control at an urban hospital in Manila, Philippines: a systems engineering assessment of barriers and facilitators
Mitchell et al. Antimicrobial Resistance and Infection Control
Infection control at an urban hospital in Manila, Philippines: a systems engineering assessment of barriers and facilitators
Kaitlin F. Mitchell 0 3
Anna K. Barker 0 3
Cybele L. Abad 2
Nasia Safdar 0 1 4
0 Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison , Madison, WI , USA
1 William S. Middleton Memorial Veterans Hospital , Madison, WI , USA
2 Department of Medicine, Division of Infectious Diseases , The Medical City, Pasig , Philippines
3 Department of Population Health Sciences, University of Wisconsin-Madison , Madison, WI , USA
4 Infection Control Department, University of Wisconsin-Madison , 5221 Medical Foundation Centennial Building, 1685 Highland Ave, Madison, WI 53705 , USA
Background: Healthcare facilities in low- and middle-income countries, including the Philippines, face substantial challenges in achieving effective infection control. Early stages of interventions should include efforts to understand perceptions held by healthcare workers who participate in infection control programs. Methods: We performed a qualitative study to examine facilitators and barriers to infection control at an 800-bed, private, tertiary hospital in Manila, Philippines. Semi-structured interviews were conducted with 22 nurses, physicians, and clinical pharmacists using a guide based on the Systems Engineering Initiative for Patient Safety (SEIPS). Major facilitators and barriers to infection control were reported for each SEIPS factor: person, organization, tasks, physical environment, and technology and tools. Results: Primary facilitators included a robust, long-standing infection control committee, a dedicated infection control nursing staff, and innovative electronic hand hygiene surveillance technology. Barriers included suboptimal dissemination of hand hygiene compliance data, high nursing turnover, clinical time constraints, and resource limitations that restricted equipment purchasing. Conclusions: The identified facilitators and barriers may be used to prioritize possible opportunities for infection control interventions. A systems engineering approach is useful for conducting a comprehensive work system analysis, and maximizing resources to overcome known barriers to infection control in heavily resource-constrained settings.
Systems Engineering Initiative for Patient Safety; Philippines; Infection control; Hand hygiene; Intervention implementation
No health care facility in the world is immune to the
burden of hospital-acquired infections (HAIs). Those in
lowand middle-income countries such as the Philippines
experience especially high rates of HAIs [
], perhaps due
to the added challenges they face in achieving effective
infection control. These challenges include a higher
prevalence of multi-drug resistant organisms (MDROs),
lack of HAI surveillance, antibiotic overuse and misuse,
and international migration of their healthcare workforce
]. Assessing and improving the quality of infection
control policies, hand hygiene, and HAI surveillance in
these settings is critical .
In order to develop effective interventions, it is
essential to understand how the work system in a healthcare
setting may impede successful implementation [
Systems Engineering Initiative for Patient Safety, or
SEIPS framework, is well suited for its ability to analyze
the impacts of a work system on both patient and
organizational outcomes [
]. The work system includes
the components of person (e.g. skills, motivation, and
needs), tasks (e.g. job content), tools and technologies
(e.g. information technologies or medical devices), the
physical environment (e.g. layout and work station
design), and organizational components (e.g. patient safety
culture and communication). This model has been used
to improve patient safety in a variety of healthcare
contexts, including both outpatient and inpatient
Although the Philippines has a high HAI burden, an
understanding of the facilitators and barriers to hospital
infection control in this country is lacking [
address this gap, we used the SEIPS framework to evaluate
barriers and facilitators to infection control at a private,
tertiary hospital located in Manila.
The study was conducted at a private, 800-bed, tertiary
hospital in Manila, Philippines. The facility is one of five
hospitals in the Philippines accredited by the Joint
Commission International. It employs 1000 physicians
and over 2000 allied medical and administrative staff, and
handles both routine and complex cases in many
departments. The hospital has an infection control program that
was established in 1986, and at the time of our study
included six dedicated infection control nursing staff.
Infection control policies are implemented and reviewed by the
Hospital Infection Control Executive Committee. The
facility has designated medical floors for those needing
airborne isolation (e.g. pulmonary tuberculosis).
We completed a total of 22 semi-structured interviews
with physicians (n = 10; three male, seven female),
nurses including infection control staff (n = 10; two
male, eight female), and clinical pharmacists (n = 2; two
female). Potential participants were selected by
convenience sampling to cover a range of job types, experience
levels, and clinical departments. Subjects who were
available during the time investigators were conducting
interviews were asked if they could participate and were
identified on clinical wards by members of the research
team. A few participants, including the two clinical
pharmacists, were approached and recruited directly.
Departments included cardiology, clinical pharmacy,
gastroenterology, infection control, internal medicine,
obstetrics and gynecology, oncology, pediatrics, and
pulmonary medicine. Most participants worked in general
wards in these departments, although two worked in the
emergency department and two worked in the intensive
care units (ICUs). Criteria for inclusion were formal
employment by the hospital and active involvement in patient
care. Status as a medical or nursing student or as a
nonEnglish speaker were criteria for exclusion, although no
potential participants were excluded for these reasons.
Interview questions were adapted for context from an
interview guide our group previously used to study
facilitators and barriers to infection control at a large,
private hospital in Gurgaon, India [
]. The questions
were based on the SEIPS framework and included
questions in the categories for work systems: person,
organization, task, physical environment, and technology
and tools. Interviews were audio recorded and typically
lasted ten to twenty minutes in length. No identifiable
information was collected. Preliminary analysis was
conducted throughout the study to refine the interview
guide and assess theoretical saturation. No further
interviews were completed once theoretical saturation was
All interviews were transcribed. Interview transcripts were
independently coded in NVivo software (Version 11, QSR
International) by two individuals to identify trends,
following a previously described method for line-by-line coding
]. The two versions of coding were compared and
found to have high inter-rater reliability. As a quality
improvement project, this study was granted exemption
from review by the UW-Madison Institutional Review
Board and received expedited review and approval at the
Data were categorized based on the SEIPS model work
system (Fig. 1 and Table 1).
The multiple roles of the hospital’s infection control
nursing staff were regarded as having a positive impact
on the infection control process. They conducted HAI
surveillance through review of medical records and
bedside follow-up of high-risk patients. Infection control
staff monitored hand hygiene compliance by performing
daily audits through direct observation on each ward,
and they also reviewed video footage of provider entry
and exit from patient rooms using the hospital’s
closedcircuit television system (Table 1, quotations 1 and 2).
The infection control nurses and their duties were
viewed with respect, and were regarded by other clinical
staff as a vital component of the healthcare process
(Table 1, quotation 3).
Another person-level factor was differing hand hygiene
compliance between healthcare worker types. Both
doctors and nurses reported that nurses had the highest
hand hygiene compliance, while attending physicians
had the lowest (Table 1, quotation 3). It was also noted
that amongst the doctors, older consulting physicians
tended to be the least compliant. This behavior was
suggested to have a magnified impact on hand hygiene
practices, as the senior physicians set “an example” for
others (Table 1, quotation 5). Several doctors reported
CCTV data reporting
High levels of HAIs and antibiotic
misuse throughout the Philippines
Role of Infection
improve hand hygiene
Infection Control Policies
access to hand
in different wards
that verbal reminders, either from nurses or other
physicians, would be a useful strategy to improve hand
hygiene. However, it was also noted that the success of
reminders would depend on the social dynamic between
individual healthcare workers, as some attending
physicians were more likely to be amenable to receiving
feedback than others (Table 1, quotation 6).
The hospital’s infection control executive committee was
recognized as the organizational body that develops
fundamental infection control guidelines such as those for
hand hygiene, antimicrobial stewardship, and contact and
other precautions. The representation of multiple
departments on the committee was described as a necessary
aspect of developing these guidelines (Table 1, quotation 7).
These policies were monitored by the infection control
staff, described above. The committee also organized
promotional events and offered training for hand hygiene
(Table 1, quotation 8). The committee and infection
control guidelines could be called upon to resolve any
disputes regarding appropriate patient care pertinent to
infection control (Table 1, quotation 9). For example, they
could be consulted for decisions regarding the appropriate
placement of patients on the hospital’s isolation ward.
The hospital has prioritized funding and staffing for
laboratory facilities, which were vital for performing
tests to inform patient treatment plans and infection
control surveillance. The turnaround time and
communication of lab results through electronic reports
were described favorably (Table 1, quotation 10).
Efficient laboratory testing was thought to be particularly
important for detecting antibiotic-resistant infections
in patients who may have been exposed in the
community, or another healthcare setting, prior to
admission (Table 1, quotation 11).
There was considerable variation in the
patient-toprovider ratios described across hospital departments,
based on patient complexity and length of stay. The
number of patients per nurse was estimated to be 1:1 or
2:1 in the ICUs, 5:1 or 6:1 in the obstetrics/gynecology
and cancer wards, and approximately 16:1 in the
cardiology ward. Several providers noted that a lack of time
due to high patient volumes was a major barrier to hand
hygiene compliance (Table 1, quotation 12).
Very high rates of nursing staff turnover also
contributed to a high clinical workload. One nurse estimated
that within the past six months, thirty out of ninety
1: “We’re doing surveillance for infection control…
like gathering data for patients who have risk
devices. We’re also checking the environment…
to make sure that infection control policies are
2: “The infection control people visit us… they
monitor us… they check everything on a daily
3: “[Healthcare workers are] amenable with the
infection control rules… because they’re for
4: “It’s the nurses who do the hand hygiene more
than the doctors”
5: “When [the consultants] go in and we follow,
we forget to wash too.”
6: “I think it needs to be a team effort, like a
constant reminder… the head nurses talk to
you: ‘Doctor, you need to wash your hands’.
I think it’s very helpful, you need to do that…
But there are some doctors here who don’t
really become too friendly with the nurses.
They really set the barrier between them.”
7: “HICEC is divided into committees… the
executive committee makes the policies…
we also have the nurses and staff from all
different departments. Whenever we make
a policy we make sure that all of
[the representatives] approve.”
8: “It’s part of the infection control committee
responsibilities to do regular lectures on hand
9: “We can coordinate with HICEC if we have a
misunderstanding with the doctors… because
we have a set of admitting guidelines for what
is allowed in our ward, so sometimes we just
have to tell the doctors that. You can also ask
HICEC [to do that].”
11: “We try our best to prevent [resistant infections]
here… but other doctors in other places, and
the lay people, don’t have any idea what
antibiotic resistance means.”
12: “There are times we have to see one patient,
just remove the gloves, and move onto the
next patient, so there’s no [time for] alcohol
13: “[Nurses] get their training and then leave after
about two to three years.”
14: “We teach them all the standard precautions
and diseases that any nurse could encounter.”
15: “The baby-friendly [obstetrics/gynecology ward]
is much better with the hand hygiene because
they have their own station there.”
16: “The alcohol rub is more in the station, where
the medications are prepared [by the nurses]…
so it’s not really that accessible to us.”
10: Attending Physician, Gastroenterology 10: “[The lab] immediately informs us… so that
we can treat right away.”
High Patient Volumes
12: Resident, Emergency Medicine
Training of New Nursing Staff 13: Resident, first year
Layout and Access to Hand
14: Head Nurse, Emergency Medicine
15: Head Nurse, Internal Medicine
16: Resident, Emergency Medicine
HICEC hospital infection control executive committee, CCTV closed circuit television, RFID radio frequency identification
nurses had left the emergency department staff. The
emigration of skilled healthcare workers from the
Philippines was described as common; many nurses were
motivated to move for higher-paying jobs abroad, leaving
vacant positions that required continual resources to fill
(Table 1, quotation 13). Most newly-hired nurses began
jobs at this hospital directly out of nursing school, and
needed a considerable amount of on-the-job infection
control training (Table 1, quotation 14).
Variations in the layout and quantity of hand hygiene
supplies were believed to affect hand hygiene feasibility
in certain departments. Alcohol-based hand rub
dispensers were reported to be located outside of patient
rooms, though the emergency department and ICU had
additional dispensers located within patient rooms or
cubicles. Sinks for handwashing were positioned at the
nursing stations on most wards. However, the airborne
isolation floor, emergency department isolation room,
obstetrics/gynecology ward, and one select floor of
private rooms had additional sinks within patient rooms.
Several nurses described that the additional hand
hygiene locations were an asset for those units (Table 1,
Multiple doctors stated that even though there were
alcohol-based hand rub dispensers on every ward, these
dispensers could not always be used conveniently
(Table 1, quotation 16). Another barrier to the
availability of hand hygiene supplies was the occasional theft of
sanitizer or whole dispensers by patients, which was
reported in multiple areas including the emergency
department (Table 1, quotation 17). Several providers
believed that the hospital could increase hand hygiene
compliance by providing personal alcohol-based hand
rub dispensers to each healthcare worker (Table 1,
Technology and tools
This facility employed multiple technologies for hand
hygiene auditing. A closed circuit television surveillance
system was used to collect video footage of healthcare
worker hand hygiene practices at the time of entry and
exit from patient rooms. Although infection control
nurses frequently reviewed the video footage, the data
were not effectively communicated to clinical staff.
Several doctors and nurses believed this footage was rarely
or never reviewed. Others had received department-level
feedback of hand hygiene compliance, but felt that
reporting of compliance data to individual providers
would be more helpful (Table 1, quotations 19 and 20).
Radio-frequency identification (RFID) badges utilized
in the ICU were another innovative technology at this
facility. These badges were detected by sensors on
alcohol-based hand rub dispensers that recorded the
duration and frequency of hand hygiene occurrences.
The badges also provided instant reminder alarms for
healthcare workers to perform hand hygiene (Table 1,
quotation 21). All ICU nurses wore their own badge,
allowing for individual compliance data to be tracked
and reported in real-time on a television monitor
prominently displayed in the ICU. However, visiting
healthcare providers, including those that provided consults in
the ICU, shared group RFID badges and their hand
hygiene could not be monitored individually.
Medical trolleys were available on the airborne
isolation ward of the hospital, and proved a useful tool for
improving hand hygiene compliance for this area. The
trolleys provided a place to set down medical supplies,
making it easier for nurses to perform hand hygiene
prior to entering the patient’s room. Several nurses
expressed that having medical trolleys available on all
wards would help improve hand hygiene throughout the
hospital (Table 1, quotation 22). However, this would
require the purchasing of trolleys out of the budget for
each additional unit.
Our study design centered on the perspectives of
healthcare providers to optimize future infection control
interventions. Using the SEIPS model, we have framed
multiple barriers and facilitators that were reported by
nurses, doctors, and pharmacists at a private hospital in
The long-established prioritization of an infection
control program at this hospital is an organizational
strength that is often lacking from the infrastructure of
healthcare facilities in low- and middle-income countries
]. The representation of multiple departments on
the program’s executive committee is aligned with a
World Health Organization recommendation that
hospital infection control policies be developed by a
multidisciplinary team . This program is especially
important given the high prevalence of HAIs and
inappropriate usage of antibiotics throughout the
], which likely introduce external
factors into an institutional work system where infection
surveillance, laboratory testing, and disease management
are otherwise very consistent (External Environment in
Fig. 1). The overall purpose and processes of the
infection control executive committee were well-received by
healthcare providers, likely because the long-standing
policies have become a normal part of the hospital’s
culture during the past thirty years. Previous studies
support this notion, showing that institutional etiquette and
social norms can influence overall compliance with
infection control programs .
The facility’s infection control nursing staff is another
asset that was acknowledged to have a positive impact
on patient outcomes. The six-person team at this
800bed hospital surpasses the Centers for Disease Control
recommendation of at least one full-time infection
control staff for the first 100 beds, and another staff member
for each additional 250 beds [
]. Infection control staff
frequently utilize one of the tool-level factors identified
in our study, the closed circuit television system, for
hand hygiene surveillance. However, several providers
felt that reporting the results of compliance data to large
groups was ineffective for improving hand hygiene at the
individual level. Implementing a monitor display may
prove useful, as previous video surveillance interventions
have found that continuously displaying the results of
hand hygiene behavior on a monitor can yield a
sustained improvement in compliance rates [
Our study found that the prominent monitor display
of RFID badge data in the hospital’s ICU may be an
effective way to ensure individual accountability for hand
hygiene compliance. One weakness of this system is the
use of a shared ‘guest’ badges by all clinicians who visit
the ICU from other departments. This could be
addressed by providing regularly visiting providers with
their own badges. While this type of system can provide
powerful feedback to providers, implementing the
badges throughout an entire institution could be
]. Acquiring new equipment can be
difficult in a resource-constrained facility, especially since
increased patient charges are often the primary means of
covering such costs. This was a concern among nurses
in the discussion of medical trolley purchases. While
trolleys are a useful tool in the airborne isolation unit,
their absence in other floors is a barrier to hand hygiene
compliance. Purchasing additional trolleys would likely
be less costly than adding more RFID badges.
Prioritizing the purchase of new trolleys at an organizational
level, rather than on a ward-by-ward basis, could rapidly
improve hand hygiene feasibility for healthcare workers.
The high turnover of nursing staff is also concerning,
as it necessitates constant training and use of
educational resources. A systematic review of nurses’
motivational factors in numerous developing countries
identified key factors for successful retention packages
]. In addition to financial incentives, these packages
must include ways of strengthening healthcare workers’
motivation through personal recognition and career
Another reported barrier was the low hand hygiene
compliance of attending physicians compared to nurses,
a trend that is consistent with numerous institutions
]. One potential reason for this is the
minimal time physicians have between patients during
rounds. As several subjects suggested, providing
personal portable dispensers of alcohol-based hand rub is
potentially low-cost, time-saving, and would also prevent
theft concerns. This type of intervention has been
successful in other facilities, resulting in up to a 64%
increase in hand hygiene compliance [
Implementing a verbal reminder process for hand
hygiene could be another helpful practice. Several
interviews suggested having the providers with the best
compliance, the nurses, remind others to perform hand
hygiene. This potentially nurse-driven intervention
would need to account for suboptimal communication
within the hierarchy of health professionals. Previous
efforts to improve interprofessional collaboration have
highlighted the importance of senior doctors and nurses
setting an example for more junior healthcare workers,
and encourage the development of shared mental
]. This could be fostered through
increasing collaborative practice, interprofessional patient
rounds, or implementing a communication skills
training . Increasing open communication between
nurses and physicians is crucial for patient safety, and
interventions based on shared accountability models
have had favorable impacts on hand hygiene adherence
and rates of HAIs [
Our study had several limitations. It was conducted at
a single, private hospital that is considered one of the
pioneers of infection control in Manila. Private hospitals
comprise 60% of the roughly 1800 hospitals in the
Philippines, and generally serve patients who can afford
fee-for-service payments [
]. Thus, our findings may
not be generalizable to smaller, community hospitals
located in more rural areas of the country or to
institutions that lack organizational support for infection
control policies. In our institution, for example, the rate
of ESBL Klebsiella pneumoniae based on a hospital
antibiogram in 2016 for non-ICU and ICU patients was
between 16 and 19% (n = 125), compared to a much
higher rate of 40% (n = 8861) among 24 surveillance
sites all across the Philippines. Similarly, the rate of
carbapenem resistant Acinetobacter baumanni, though very
high at 27–34% (n = 116), was still lower than the 52.1%
(n = 3967) found in these surveillance hospitals [
The study population was limited to a small size and
selected based on convenience sampling. While we
sought to include participants representing a wide range
of clinical experiences, our results may not reflect
hospital-wide opinions regarding infection control.
Other key stakeholders, such as patients, hospital
management, and environmental cleaning staff may have
additional perceptions and should be included in future
These limitations notwithstanding, our study findings
have implications for infection preventionists, hospital
epidemiologists, and clinicians in resource-constrained
settings. For example, the emphasis on and interest in
hand hygiene compliance monitoring at our study site
suggests that interventions to optimize hand hygiene
might be a high priority, even in low-resource settings.
Moreover, our systems approach may serve as an
exemplar for other facilities seeking to prioritize infection
Previously studied infection control interventions in
the Philippines have either demonstrated minimal
impact, or have examined only a single disease outcome
(catheter-associated urinary tract infection) [
These studies suggest that infection control
interventions in this country have the potential for success, but
are also faced with the inherent difficulties of
resourcelimited settings. The perceived availability of resources is
another challenging aspect of intervention
implementation; even if resources do exist within a healthcare
facility, they will not be useful if clinicians are unaware of
them or do not believe they are readily available . In
recognition of these concerns, we incorporated the
perceptions held by key stakeholders in order to prioritize
areas for future intervention.
Discussions with healthcare providers revealed that
infection control practices in a resource-limited setting
were perceived positively by most. Primary facilitators in
this institution included a well-established infection
control unit with support from the rest of the healthcare
team and hospital organization. There are several viable
opportunities for future intervention to overcome the
existing barriers. These include real-time feedback of
hand hygiene surveillance data, provision of medical
trolleys and portable alcohol-based hand rub dispensers,
improvement of retention packages for nursing staff, and
advancement of interprofessional communication. These
measures may provide important tools for reducing
HAIs in this type of resource-limited healthcare facility.
CCTV: Closed circuit television; HAI: Hospital-acquired infection;
HICEC: Hospital Infection Control Executive Committee; ICU: Intensive care
unit; MDRO: Multi-drug resistant organism; RFID: Radio-frequency
identification; SEIPS: Systems Engineering Initiative for Patient Safety
AB was supported by a pre-doctoral NIH traineeship, TL1TR000429,
administered by the University of Wisconsin Madison, Institute for
Clinical and Translational Research, funded by NIH award UL1TR000427.
Availability of data and materials
De-identified interview transcripts collected and analyzed during the current
study are available from the corresponding author on reasonable request.
KM drafted and critically edited the manuscript and contributed to data
analysis. AB contributed to study design, data collection, data analysis, and
critical manuscript editing. CA and NS contributed to study design and
critical manuscript editing. All authors read and approved the final
Ethics approval and consent to participate
This study received expedited review and approval from the Institutional
Review Board at The Medical City. The Institutional Review Board at the
University of Wisconsin-Madison granted this study exempt from review.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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