During the testing phase of the WHO Multimodal Hand Hygiene Improvement Strategy, over 350 health-care facilities from all around the world volunteered to implement the strategy using the Implementation Tool Package. These were called "complementary test sites" (CTS) and included individual health-care facilities and some hospital networks in Italy (190 hospitals), Switzerland (116 hospitals), Malaysia (15 hospitals), Spain/Catalunya (6 hospitals), Brazil (5 hospitals) and Mongolia (3 hospitals).
Following web registration, the sites had access to the entire range of tools included in the package through a web-based platform. The tools were available in English, French Spanish, and Italian. A discussion forum was also integrated into the platform for technical interaction between coordinators of the sites; similar discussion platforms were also hosted at the websites of some of the CTS networks.
All hand hygiene promotion activities were conducted autonomously in these sites without direct monitoring or support by the First Challenge team. However, many sites interacted with the First Challenge team and provided feedback on implementation. An evaluation process took place to assess the use of the strategy and tools and their usefulness and importance for hand hygiene improvement and impact on hand hygiene practices in these facilities. Important and useful feedback on several aspects of the implementation including the local adaptation was obtained.