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Monitoring staff hand hygiene compliance

Healthcare-associated infections are not accidents and could be prevented by means of implementing a “safety culture” within hospitals

Prof Fernando Bellissimo-Rodrigues MD PhD

Prof Didier Pittet MD MS CBE 

Hôpitaux Universitaires de Genève (HUG) et Faculté de Médecine

World Health Organization (WHO) Collaborating Centre on Patient Safety 

Like the Greek philosopher Pythagoras, we dream about a world where people will, whether alone or in public, always do the best they can. In this world, there will be no place for monitoring anyone’s attitude.1 Unfortunately, we are very far from that dream picture, and monitoring some key professional activities is necessary to ensure human and environmental safety.

The term “safety culture” started to be used after the 1986 Chernobyl nuclear accident,2 which highlighted that many of the events we call incidents or accidents do not really deserve that label, in the sense that they are direct consequences of human acts. Deep analysis of past nuclear events, airplane disasters, railway crashes, and ships sinking, reveals that the vast majority of them could be prevented if every step of the related workflow process was conducted within a safety culture perspective.

It is the same with healthcare-associated infections, since it has now been widely demonstrated that most of its episodes are not “accidents” and could be prevented by means of delivering safer care within the healthcare setting.3,4

 But unlike those major catastrophes, healthcare-associated infections don’t draw too much public attention and thus do not elicit a sufficient responding attitude from healthcare settings.5,6 It is mainly for that reason that it continues to “silently” kill hundreds of millions of people worldwide each year, affecting every healthcare facility in every country and health system.7 

Promoting hand hygiene procedures within the healthcare setting is considered the most effective measure to prevent healthcare-associated infections and enhance patient safety.8–10

World Health Organization (WHO) recommendations

Looking at the proposal of the WHO multimodal strategy for hand hygiene improvement,9 there are five elements that are considered essential requirements for achieving best practice in healthcare settings:

(1) Providing alcohol-based hand rub at the point of patient care and continuous access to hand hygiene agents and related items;

(2) Assuring continuous healthcare workers education on hand hygiene;

(3) Performing observation of hand hygiene practices and providing timely performance feedback;

(4) Displaying reminders in the workplace (Figure 1);

(5) Creating a safety culture in the whole institution.

When considering healthcare settings in Europe, most institutions have already implemented recommendations one, two, and four.11 Now it is time to move on and amplify the implementation of monitoring staff compliance with hand hygiene, which will certainly contribute to the amplification of an institutional safety climate.

Monitoring compliance with hand hygiene

The easiest and cheapest way to estimate hand hygiene compliance is to regularly measure alcohol-based hand rub and soap consumption within each ward or unit. Although simple to implement, this will only provide a general assessment of the picture, with no further details on individual compliance for specific indications. Of course, this is better than not monitoring anything, but, in our view this should only be used as a single strategy in low-resource settings, or in low-risk facilities, such as those providing ambulatory care.9

Several approaches have been proposed in literature for hand hygiene compliance monitoring. At the Hôpitaux Universitaires de Genève (HUG), we developed a peer-based, direct observation method 20 years ago, which is still considered the gold standard by WHO today.9,12 Besides having a strong conceptual foundation, this method identifies all the opportunities for hand hygiene (Figure 2) that are clinically relevant for both patient and healthcare worker health, and has been validated and used in a wide range of facilities in different countries, continents and cultures.9,10,13 Beyond that, it provides both an opportunity for the infection control practitioners to identify local obstacles for hand hygiene, and to give immediate customised feedback to the healthcare worker.

More recently, automated monitoring of hand hygiene practices have been proposed as an alternative to the direct observation, claiming to consume less human resources and to provide larger and more representative data sets, subjected to less observation bias and Hawthorne effect.14,15

Proposed automated systems to date are based on bottle counters, radiofrequency, ultrasound, real-time location systems, or detectors of alcohol vapours. They aim to monitor compliance with hand hygiene based on surrogate markers of the “Five Moments” approach. Such surrogates include healthcare workers entering or exiting a patient’s room, or approaching or leaving a patient’s bed. This would account for monitoring compliance with moment number one (before touching a patient), four (after touching a patient) and five (after touching patients surroundings), while missing moments number two (before clean/aseptic procedure) and three (after bodily fluid exposure), which are also extremely relevant from the patients and the healthcare workers perspectives, respectively.14,15

Although promising, to date no automated monitoring system has proved to be able to monitor and improve hand hygiene compliance with all the five moments, nor has been proven effective in preventing healthcare-associated infections. Implementation cost is another matter of concern with automated systems.14,15

Performance feedback

Independently of the method of monitoring hand hygiene compliance, adequate feedback should be provided to healthcare workers in a timely manner, otherwise monitoring would be useless. Usually they want to know what their compliance rates are and even to compare their own rate with colleagues’ rates.9

Besides individual feedback, it is important to provide feedback at team (or group) level and eventually on a public level. Group-level feedback and compliance rate comparisons provide internal benchmarking and promote a safety culture within the institution.9

Although it is still a matter of debate, we believe that external benchmarking of hand hygiene practices will become increasingly common in the near future, and may even become mandatory for healthcare facilities.9

In conclusion, while Pythagoras’ dream has not come true, every hospital must drive efforts to continuously monitor its own hand hygiene practices, and deliver appropriate feedback to its healthcare workers. Although these efforts are great, the benefits to patient and healthcare worker safety are remarkable.


  1. Schur E. Pythagoras and the Delphic Mysteries: A Biography of Pythagoras. Forgotten Books, 2007.
  2. INSAG (International Nuclear Safety Advisory Group) of the International Atomic Energy Agency. The Chernobyl accident: updating of INSAG-1. Safety Series no 75-INSAG-7, 1992.
  3. Pittet D et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641–52.
  4. Pittet D et al., Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356(9238):1307–12.
  5. Pittet D et al. Hand hygiene: still not sufficiently recognized in European hospitals. Hospital Health Care 2006/2007.
  6. Bellissimo-Rodrigues F et al. Selfishness among healthcare workers and nosocomial infections: a causal relationship? Rev Soc Bras Med Trop 2014;47(4):407–8.
  7. Allegranzi, B. and Pittet D, Healthcare-associated infection in developing countries: simple solutions to meet complex challenges. Infect Control Hosp Epidemiol 2007;28(12):1323–7.
  8. Allegranzi B, Storra J, Dziekana G. The First Global Patient Safety Challenge “Clean Care is Safer Care”: from launch to current progress and achievements. Journal of Hospital Infection 2007;65(S2):115–23.
  9. WHO. Guide to Implementation: A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy, 2009.
  10. Allegranzi B et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013 ;10:843–51. 
  11. Latham JR et al. The role and utilisation of public health evaluations in Europe: a case study of national hand hygiene campaigns. BMC Public Health 2014;14:131.
  12. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130(2):126–30.
  13. Sax H et al. My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection 2007;67:9–21.
  14. Edmond MB, Marra AR. New technologies to monitor healthcare worker hand hygiene. Clinical Microbioly and Infection 2014;20:29–33.
  15. Ward MA et al. Automated and electronically assisted hand hygiene monitoring systems: a systematic review. Am J Inf Control 2014;42:472–78.