Mental health settings are particularly vulnerable to outbreaks and transmission due to infectious pathogens like norovirus. This occurs since access to soap and water (sinks) is limited for safety reasons and alcohol hand rub is not available outside patient rooms because of concerns for ingestion and fire. Thus, novel hand hygiene improvement interventions are needed in mental health settings including new hand hygiene bundles tailored to VHA mental health settings and novel alcohol-free hand rubs that are safe for installation and use in mental health settings. Non-alcohol hand rub has been approved and is currently used in some VAs, but isn't currently a standard VA-wide practice. These products can expand access to hand hygiene in locations where alcohol-based products are not allowed.

The aim of this project is to develop tailored HH bundles (i.e., strategies) that will streamline the implementation process of antimicrobial stewardship by assessing and addressing challenges due to structural characteristics of the mental health facilities, its perceived compatibility, and the characteristics of the healthcare workers to facilitate HH compliance to combat Healthcare Acquired Infections (HAIs). The VA standard HH bundle includes -directive 1131 requires all VA's follow the following criteria:

(1) Implementing, at a minimum, categories IA, IB and IC of the most current CDC hand hygiene guidelines: in addition, consider current recommendations from the World Health Organization (WHO). Some VA medical facilities, based on the local risk assessment, may also choose to implement some CDC category II Recommendations (e.g., if moving from a contaminated body site to another body site during care of the same patient). 2) Periodically monitoring and recording adherence as the number of hand hygiene episodes performed by personnel relative to the number of hand hygiene opportunities, by ward or unit, and providing feedback to personnel regarding their performance. (3) Establishing goals for improving adherence with hand hygiene guidelines. (4) Assuring that hand hygiene products selected by the VA medical facility have been evaluated by the Infection Prevention and Control Program and approved by the Infection Prevention and Control Committee. Local bundles may also include HH signs, HH education, etc.

More than three million illnesses and 48,000 deaths are caused by antibiotic resistant bacteria each year, in the United States (US), with an annual economic impact of $35 billion in excess health care costs. In addition, the devastation caused by the COVID-19 pandemic has revealed the urgent needs and overwhelming limits of the US public health infrastructure to engage healthcare workers to rapidly adopt best-practices and assess emerging diseases. As a result, antimicrobial resistance and HAIs are considered by experts to be the current pandemic. This study will focus on hand hygiene of acute mental health facilities.

The goals of this study are to promote effective evidence-based strategies, promote adoption of healthcare workers participation, and ensure sustainability of continued use of HH bundles. Overall, these strategies will highlight and strengthen HH compliance which will help to train health care workers and combat the spread of infectious diseases in mental healthcare facilities. There is no randomization. The investigators are trying to improve standard practice, particularly allowing HH prep to be put on the ward that is alcohol free, and therefore expanding access to hand hygiene practices. No training interventions will be completed. The investigators will implement alcohol free hand rub in the tailored bundle. Staff may receive an update to their existing/routine standard training on hand hygiene practices.

Inclusion Criteria:

• VA mental health care workers on inpatient mental health units
• Quality improvement staff including infection control

Exclusion Criteria:

• Outpatient care settings