Accurate Data Is Key in Raising Hand Hygiene Compliance and Improving Patient Safety

The Joint Commission considers hand hygiene the most important intervention for preventing healthcare-associated infections, which are responsible for 75,000 deaths annually.

The Joint Commission considers hand hygiene the most important intervention for preventing healthcare-associated infections (HAIs),1 which are responsible for 75,000 deaths annually.2 Direct observation (DO) has long been considered the gold standard for measuring hand hygiene compliance, which is why infection preventionists (IPs), nurses, volunteers and medical students in hospitals across the country spend hours walking around with clipboards, documenting if clinicians washed or sanitized their hands as often as they should.

Time and resources spent on observing, reporting and calculating results manually might have been worth it if DO produced accurate data 24/7. Yet, the vastly overstated 90-100% compliance rates reported by many hospitals do not present a true picture. IPs are usually the first ones to realize the discrepancy because there is no direct correlation between the near-perfect compliance rates and HAIs in a hospital.

Reasons for data inaccuracy include intrinsic limitations of DO, where observers can see only a fraction of all hand hygiene behavior, well below a sample size that would be statistically significant. Typically, observers can only monitor “in and out” hand hygiene behavior, which means upon staff entry and exit from the patient room, missing key opportunities inside the room. The well-documented Hawthorne effect3 resulted in healthcare workers behaving differently — performing hand hygiene – when they know they are being observed. Generally speaking, the true compliance rates in hospitals hover around 40%.4

If hospitals use DO as the primary compliance measurement tool and believe the near-perfect results, they typically are complacent and have no sense of urgency to drive improvement in staff hand hygiene behavior. No change means patients will continue acquiring HAIs and suffer the harm as a result, and hospitals will continue paying to treat them, as well as paying Centers for Medicare & Medicaid Services’ Hospital-Acquired Condition (HAC) penalties. Since October 2014, hospitals ranking in the bottom 25% with respect to HACs are being charged an automatic 1% of their yearly Medicare payments. MRSA and C.Diff infections were added as part of the HAC penalties this year — two infections that are notoriously linked to hand hygiene. This is why hospitals are beginning to explore and adopt electronic hand hygiene compliance technology to gather data that is accurate, reliable and unbiased.5

Evidence-based electronic systems that are supported by peer-reviewed research can capture 100% of hand hygiene events automatically, 24/7, and not only upon room entry and exit, but also based on the World Health Organization’s (WHO) Five Moments for Hand Hygiene,6 which is considered a higher clinical standard because it is more protective for the patient. Five Moments calls for healthcare workers to wash their hands before contact with a patient, before an aseptic task, after body fluid exposure risk, after contact with a patient, and after contact with a patient’s surroundings.

While some electronic systems track individual performance via badges and allow for personal feedback, others capture hand hygiene events on the unit or department level to foster the culture of teamwork with peer-to-peer feedback.

Knowing true compliance numbers is a starting point for organizational transformation. Accurate performance measures are the key to any performance and quality improvement initiative. Accurate data establishes a true baseline, and from thereon, IPs, nurses, physicians and hospital leadership can use that data to drive change.

A good example of results hospitals can achieve with such technology is outlined in a recent study, published in the American Journal of Infection Control.7 In this study, Greenville Health System (GHS) investigated how using data from the compliance system based on WHO’s Five Moments for Hand Hygiene can impact compliance and hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) infections. Over 33 months of the study, compliance rates at GHS increased by 25.5%; MRSA HAI rates decreased by 42%; and the hospital saved approximately $434,000 in MRSA-related care costs in the 12 months post implementation of the technology.

As more hospitals begin implementing electronic hand hygiene compliance technology, putting data to work and achieving results, certain best practices have emerged.5 They include the following:

  • Educate staff on how the technology works and its benefits versus DO to secure their buy-in before the technology is implemented.
  • Ensure leadership is 100% engaged and behind the initiative, and communicates the importance of the Five Moments for Hand Hygiene compliance measurement.
  • Transition from measuring hand hygiene compliance based on the “in and out” method to the Five Moments for Hand Hygiene guidelines.
  • Educate and train staff on the unit level and allow units to set their own hand hygiene compliance goals.
  • Integrate hand hygiene compliance as part of criteria for a manager’s evaluations.
  • Designate hand hygiene champions for each unit for peer-to-peer feedback— and make peer-to-peer feedback a psychologically safe thing to do.
  • Communicate compliance numbers in real-time in daily huddles.
  • Celebrate improvements in hand hygiene compliance and achievement of the goals.

Implementation of electronic hand hygiene compliance technology requires organization-wide support, but when properly enculturated, the accurate data it provides allows hospitals to initiate a sustainable change for the better. This technology can be used to inform and alert direct observers, who can then follow-up on a unit that needs improvement, education, or to gain further insights. As quality in patient care comes sharper into focus in the value-based system, it behooves us to remember the simple truth: proper hand hygiene improves safety and health outcomes of your patients.


1. Hand hygiene information. The Joint Commission website. Accessed September 19, 2016.

2. HAI data and statistics. CDC website. Updated March 2, 2016. Accessed September 19, 2016.

3. Haessler S. The Hawthorne effect in measurements of hand hygiene compliance: a definite problem, but also an opportunity. BMJ Qual Saf. 2014;23(12):965-967. doi:10.1136/bmjqs-2014-003507.

4. Evidence for hand hygiene guidelines. WHO website. Accessed September 19, 2016.

5. Start with real hand hygiene data to improve clinical outcomes. DebMed website. Published June 23, 2016. Accessed October 4, 2016.

6. WHO. Five moments for hand hygiene. WHO website. Accessed September 19, 2016.

7. William Kelly JW, Blackhurst D, McAtee W, Steed C. Electronic hand hygiene monitoring as a tool for reducing health care—associated methicillin-resistant Staphylococcus aureus infection. Am J Infect Control. 2016;44(8):956—957.