Patient Safety Tip of the Week


January 5, 2010              How’s Your Hand Hygiene?




Hand hygiene remains problematic at almost every healthcare facility we visit. Nationally we are still only seeing less than 50% compliance rates for hand hygiene (rates for physicians historically always lagging behind those for nurses). It remains enigmatic that an intervention that costs so little in terms of time and money yet is so remarkably effective in reducing nosocomial infection rates would be so poorly utilized in all our healthcare settings. But the good news is that there are a whole host of promising interventions that may improve compliance rates with hand hygiene.


The Joint Commission, through their recently created Center for Transforming Healthcare has had a multi-hospital project on hand hygiene for about a year now. Those hospitals measured their baseline rates of compliance, then looked at the causes of and barriers to hand hygiene at their respective facilities. They are now in the process of targeting each of those causes/barriers and are expected to report the success of their solutions by mid-2010. Their goal is to get more than 90% compliance.


Their list of causes for failure to clean hands includes the following:

  • Ineffective placement of dispensers or sinks
  • Hand hygiene compliance data not collected or reported accurately or frequently
  • Lack of accountability
  • Lack of just-in-time coaching
  • Safety culture does not stress hand hygiene
  • Ineffective or inefficient education
  • Hands full and no place to put things down
  • Wearing gloves interferes with the process
  • Perception that hand hygiene is not needed if wearing gloves
  • Simply forgetting
  • Distractions


For each of the causes listed above the organizations are developing potential solutions, piloting them, and measuring impact.


There is still considerable debate about the best way to determine compliance with hand hygiene. Most hospitals measure by direct observation. A group of Maryland hospitals is implementing a “secret shopper” methodology. But even the “secret shopper” method has its shortcomings. Virtually all the facilities in the Joint Commission project that use secret shoppers found biases. They also found that, contrary to many of our data collection sampling methods, random observation of hand hygiene is not reliable. There are new technology solutions (such as use of RFID technology) being investigated as potential better ways to collect compliance data. Some facilities also use consumption of cleaning solutions as a proxy for handwashing, though this method would also pick up wasted/leaked solutions and use by non-healthcare personnel (though we’d argue the latter are just as important an issue).


Patients (and their families) need to get more involved as well. Unfortunately, too many patients are not willing to speak up. They are worried about offending their hospital care providers, especially physicians. Enter a great project just completed jointly by CDC, Catholic Healthcare Partners, and the Premier healthcare alliance. They investigated use of the CDC video “Hand Hygiene Saves Lives” at 17 CHP facilities. Patient who were shown the video were twice as likely to report asking their nurses to wash their hands. And doctors reported that they were twice as likely to be asked by their patients to wash their hands. Moreover, the doctors and nurses were generally comfortable with patients asking them to wash their hands.


Because patients may be reluctant to potentially offend their physician, be creative and have a little fun developing a campaign that is humorous and might help patients feel more comfortable “challenging” their physician. Here’s one we’d like to see: use “Wanted…Armed and Dangerous!” posters in patient rooms, putting a picture of their attending physician on an old-west style wanted poster with a subcaption “If you see this individual, beware and make sure he/she washes his/her hands!”. (Before you try that one, make sure your attending physicians have a sense of humor!)


A novel approach, called “positive deviance” (Marra et al 2010) has also been shown to yield a significant improvement in hand hygiene and a corresponding decrease in healthcare-associated infections (HAI’s). Positive deviants (Yes! That’s what they call them! Think you’ll offend your attending physicians by the “wanted posters” mentioned above? Wait til you begin referring to them as “positive deviants”!) are “individuals or groups whose uncommon behaviors and strategies allow them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges.” They applied the experience from Albert Einstein Medical Center in Philadelphia at reducing MRSA infections to step-down units in their own hospital, using a comparable step-down unit as a control and later applying the same approach to both step-down units. They demonstrated the intervention roughly doubled the number of hand hygiene episodes and substantially reduced the number of HAI’s.


Another innovative approach used an “On the Spot” campaign (Phillion 2009) with special cards with a Dalmation icon and the “you’ve been spotted” theme to provide both positive and negative feedback to healthcare workers. Workers who were “spotted” doing correct hand hygiene were given cards that were congratulatory and contained a reward such as a small cash amount to be used in the cafeteria or gift shop. Those workers who were noted to be non-compliant with hand hygiene got an identical card that said on the inside “We’re putting you on the spot for not using hand hygiene”. The fact that the cards are identical on the outside avoids publicly confronting offenders and positively rewards compliers. However, to produce sustained improvement they eventually had to post names (both the “good” and the “bad”) but did it in a fashion that positively rewarded the desired behavior. They were able to approach a target of 90% compliance. Goes to show you can have fun at the same time you are improving your patient care.


There are two primary sources for hand hygiene guidelines: the CDC Guideline for Hand Hygiene in Healthcare Settings and the WHO Guidelines on Hand Hygiene in Health Care . The WHO Guidelines now come with a summary document that contains a nice table outlining all the successful strategies for improving hand hygiene compliance. WHO also has an implementation guide that emphasizes the need for a multimodal approach to improving hand hygiene compliance.


The “5 Moments of Hand Hygiene” in the WHO guideline are:

  1. Before touching a patient
  2. Before clean/aseptic procedures
  3. After body fluid exposure risk
  4. After touching a patient
  5. After touching patient’s surroundings


The WHO implementation guide nicely outlines the tools and steps needed in a strong campaign to improve your organization’s hand hygiene performance and, ultimately, your patient outcomes. We strongly recommend you make good use of this invaluable resource.






Joint Commission Center for Transforming Healthcare. Hand Hygiene Project.



Clark C. Secret Shopper Program Checks Hospitals' Hand Hygiene. HealthLeaders Media, November 13, 2009



Beaver M. New Joint Commission Project Tackles Handwashing Missteps.

Infection Control Today. 12/16/2009



Premier - Catholic Health Partners - CDC
Hand Hygiene Research Project


download the video free from CDC website



Marra AR, Guastelli LR, Pereira de Araújo CM et al. Positive Deviance: A New Strategy for Improving Hand Hygiene Compliance. Infect Control Hosp Epidemiol 2010; 31: 12–20



Matt Phillion, for HealthLeaders Media, Health Leaders News November 6, 2009

Hand-hygiene Rates Improved Through Variety of Reinforcement Styles



WHO Guidelines on Hand Hygiene in Health Care. WHO 2009.


WHO Guidelines on Hand Hygiene in Health Care. WHO 2009.

(summary document)


WHO. Save Lives. Clean Your Hands. Guide to Implementation



CDC. Guideline for Hand Hygiene in Healthcare Settings - 2002














Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive