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Improving Hand Hygiene Requires a Multi-Modal Approach

By Megan J. DiGiorgio & Lori Moore

As hospitals reopen services, patients are seeking assurances the facility has made their well-being a priority from the moment they walk in the door.

Studies show patients feel safer knowing that their healthcare providers’ hand hygiene is being monitored.1 Hand Hygiene (HH) is a simple task performed in a complex environment. It is one of the most foundational aspects of patient safety that spans across all hierarchies and disciplines and there is much room for improvement in virtually every healthcare organization. The gold standard metric for measuring compliance has been direct observation (DO). However, less than 1% of all HH opportunities are captured.

Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Recognizing that unit leadership and frontline healthcare workers (HCW) are closest to the patient – who better to speak up and provide the immediate reminders when hand hygiene opportunities are missed? To this end, many hospitals also have their infection preventionists or other hand hygiene team members serve as coaches, or just-in-time (JIT) coaches, who stop HCW when they observe a missed opportunity and have a conversation about contributing factors for noncompliance and provide education on hand hygiene protocols. While extremely valuable, this coaching occurs sporadically and often exclusively during dayshift, not on off-shifts and weekends. Considering the many opportunities for hand hygiene, the current system simply isn’t providing HCW with what they need to make hand hygiene a ritual, automatic behavior-– consistent immediate feedback.

Unit-led-just-in-time-coaching may very well be the key to providing consistent (24/7), nonpunitive, on-the-spot feedback when hand hygiene noncompliance is observed. Real-time identification of hand hygiene misses along with direct individual accountability have been shown to improve compliance.2,3 As hospitals seek to maximize resources, it is critical to find efficiencies that save time and reduce waste without detracting from patient care. Electronic compliance monitoring (ECM) systems provide the resources to track, monitor, and develop data-driven solutions. ECMs track soap and sanitizer dispenser activations (events) and room entries and exits (opportunities) to provide real-time performance metrics on staff, patients and visitors and captures data 24/7. The purpose of any ECM is to collect data about hand hygiene events and provide feedback to staff so that they can use it to change and improve their practices. Understanding how the ECM system works and having trust in the validity of the data generated is critical for staff buy-in and behavior change.

Good metrics drive strategy, direction and performance. When ECM systems are combined with performance improvement strategies, HH rates can be increased and sustained leading to an increased culture of safety.

Today’s leaders of healthcare facilities are faced with difficult challenges.  Organizations that want to prosper must respond to these challenges and change strategies to continue creating value.  There is undisputed evidence that adherence to HH reduces cross-transmission of harmful organisms.  With so much at stake, there should be no stone left unturned in the pursuit of gaining a better understanding of the current state of HH behavior.

Megan J. DiGiorgio MSN, RN, CIC, FAPIC
GOJO Industries, Inc.


  1. 2018 Houston Methodist follow-up patient survey, GOJO AMS pilot results survey.
  2. Linam MW, Honeycutt MD, Gilliam CH, Wisdom CM, Deshpande JK. Impact of a successful speaking up program on health-care worker hand hygiene behavior. Pediatr Qual Saf. 2017;2:e035
  3. White CM, Statile AM, Conway PH, Schoettker PJ, Solan LG, Unaka NI, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129:e1042-e1050.