Hand Hygiene:

Education, Monitoring and

Feedback

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 Presenter
Laraine Washer, MD
Associate Professor
Hospital Epidemiologist
University of Michigan Health System

Contributions by
Heather M. Gilmartin, NP, PhD, CIC
Denver VA Medical Center
University of Colorado

Russ Olmstead, MPH, CIC

Trinity Health, Livonia, MI

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 Learning Objectives
• Calculate hand hygiene adherence rates based
upon hand hygiene events and opportunities

• Compare and contrast different hand hygiene

adherence monitoring methods

• List components of a hand hygiene data

collection tool

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 Multi-Modal Approach to
Improve Adherence

• Education

• Monitoring

• Feedback of data

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 Education to Improve Adherence
• Educate personnel on the importance of improving
hand hygiene adherence
• Train all healthcare personnel on hand hygiene at
hire, when job functions change and at least annually
• Personnel should:
– Display knowledge of the indications or “moments” to
perform hand hygiene
– Demonstrate appropriate hand hygiene technique

(Ellingson K, Infect Control Hosp Epidemiol, 2014)

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 Hand Hygiene Adherence Monitoring
• Why is your healthcare facility measuring hand
hygiene adherence?
• What is your hand hygiene adherence goal?
• What hand hygiene opportunities will you measure?
• How will measurements by performed? By whom?
• How will data be shared?
• Who is accountable for the data?

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Why Measure Hand Hygiene Adherence?

Reasons for measuring hand hygiene adherence

• Reduce healthcare-associated infection rates
• Regulatory requirements
• Determine if performance requires improvement
• Compare performance to other organizations
• Inform improvement efforts

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 Hand Hygiene Adherence Monitoring
• Adherence = (Actions/Opportunities) x 100%
• Define opportunities you will
audit
– Before room entry or patient
contact
– Between clean and dirty tasks
(difficult to audit)
– After patient contact or upon
room exit
(Image from WHO Guidelines on Hand Hygiene in Health Care, WHO, 2009)

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 Hand Hygiene Adherence Monitoring
Method Pros Cons
Direct observation of hand • Educational moment • Does not measure adherence during
hygiene technique patient care
• Captures information on product, • Time and resource intensive
technique • Can influence performance
Direct observation of hand
• Data summarized by personnel
hygiene adherence
type, shift, unit
• Educational moment
Indirect measurement of • Easy to track consistently • Consumption may not correlate with
volume of alcohol-based hand appropriate use
rub or soap used • Biased by purchasing patterns
Self-report of hand hygiene • Captures perceptions and barriers • Unreliable
adherence • Rates often inflated
• Option in areas where direct • Unclear correlation
Patient satisfaction survey observation difficult (e.g.,
ambulatory setting)

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 Direct Measurement Methods of
Observation for Hand Hygiene
• Covert observation, “secret shoppers”
– Training and standardized tools are necessary
– Inter-relator reliability
– Mobile handheld device for data collection

• Overt observation
– Coaching component
– Observation + intervention = measurevention

• Technology assisted
– Video monitoring later reviewed by trained auditors
– Automated systems with wearable devices
– Eliminates selection and observer bias
– Can provide just-in-time reminders

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 Specifics of Monitoring
• No accepted standard for number of observations

• Many hospitals use 30 or more observations per month per

unit

• Can include data separated by role type

• Can include data by shifts

• May include documentation of contributing factors for failure

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Hand Hygiene Data Collection Tools

CDC. ICAR Tools.https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html

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 Data Sharing
• Set targets for improvement
– Be realistic. Will be influenced by baseline data
– Align with rewards and recognition

• How often will hand hygiene adherence data be shared?

• How will it be displayed?

– Website, quality boards, emails etc.

• Who needs to see the data?

– Hospital leadership
– Unit leadership
– Individual healthcare personnel
– Patients

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Report Overall Unit Specific Data

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Report Before and After Adherence

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Report Role Specific Data

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 Hand Hygiene Technique
Using Hand Cultures

GOOD TECHNIQUE

NOT-SO-GOOD
TECHNIQUE
(Images from Mody L, JAMA Intern Med, 2015)
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 Hand Hygiene Technique
Using Pathogen Simulation

(Images courtesy of Lona Mody, MD at the University of Michigan)

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 To Impact Change
Everyone Needs to Know Their Role

(Image from the University of Michigan Health System Infection Prevention and Epidemiology)
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 Accountability
Vanderbilt Center for Patient and Professional Advocacy

(Image from Pyramid for Promoting Reliability and Professional Accountability, Vanderbilt
Center for Patient and Professional Advocacy, 2016)

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 References
• Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee: HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices
Advisory Committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Am J Infection Control 2002; 30(8):S1-S46.

• Consensus measurement in hand hygiene project. Joint Commission Center for Transforming Health Care. 2009.

• Ellingson K, Haas J, Aiello A, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control
Hosp Epidemiol. 2014; 35(8):937-60.

• Hand Hygiene: Why, How and When? World Health Organization. 2009, 1-7. Available at
http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf
• Mody L, Krein SL, Saint S, et al. A targeted infection prevention intervention in nursing home residents with indwelling
devices: A randomized clinical trial. JAMA Intern Med. 2015; 175(5):714-23.

• Pittet D, Allegranzi B, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core
Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus
recommendations. Infect Control Hosp Epidemiol. 2009; 30(7):611-622.

• Pyramid for Promoting Reliability and Professional Accountability. Vanderbilt Center for Patient and Professional Advocacy.
2016. Available at https://ww2.mc.vanderbilt.edu/cppa/45627

• WHO Guidelines on Hand Hygiene in Health Care. World Health Organization (WHO). Published 2009. Available at
http://www.who.int/gpsc/5may/tools/9789241597906/en/

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THANK YOU!

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Speaker Notes

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 Speaker Notes: Slide 1
Welcome to part two of Hand Hygiene course titled “Hand
Hygiene: Education, Monitoring and Feedback.”

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 Speaker Notes: Slide 2
The content for this module was developed by Laraine Washer,
an infectious diseases physician and hospital epidemiologist at
the University of Michigan Health System, with support from a
multidisciplinary team of physicians, nurses and infection
preventionists devoted to improving patient safety and infection
prevention efforts. In particular, we would like to thank and
acknowledge Dr. Heather Gilmartin, Russ Olmstead and the
STRIVE national project team for their contributions and review
of this module.

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 Speaker Notes: Slide 3
This module will outline how to calculate hand hygiene
adherence rates based upon hand hygiene events and
opportunities, compare and contrast different hand hygiene
adherence monitoring methods and list components to include
on a hand hygiene data collection tool.

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 Speaker Notes: Slide 4
This webinar is focused on using several strategies as part of a
multi-modal approach to improve hand hygiene adherence.
These practices include education, monitoring and providing
feedback on adherence to hand hygiene in the healthcare
setting. Your facility is likely having ongoing discussions about
hand hygiene. The word cloud on the right visually represents
words and phrases collected from frontline healthcare personnel
in conversations about improving hand hygiene with the most
commonly heard words represented as the largest.

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 Speaker Notes: Slide 5
Let’s first talk about training staff. Educating healthcare
personnel is an important component of improving hand hygiene
adherence. Organizations should provide hand hygiene training
to all staff at hire, whenever their job functions change, and at
least annually. As part of this training, healthcare personnel
should be able to describe the indications or “moments” for
hand hygiene and be able to demonstrate correct hand hygiene
technique as described in Module 1 of this hand hygiene
webinar series. For more information about competency-based
training for hand hygiene and other infection prevention issues,
please refer to the foundational module on “Competency-based
training, Audit and Feedback.”

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 Speaker Notes: Slide 6
Once expectations and vital behaviors of hand hygiene are clear
to all personnel at your facility, then a monitoring program to
assess adherence is recommended.
This webinar will address several questions that should be
answered when developing or revamping a hand hygiene
program.

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 Speaker Notes: Slide 6 Continued
For example:
– Why is your healthcare facility measuring hand hygiene
adherence?
– What is your adherence goal? This may require
understanding your baseline in order to set a realistic goal.
– What hand hygiene opportunities will you measure?
– How will measurements be performed? And by whom?
– How will hand hygiene adherence data be shared?
– What is your accountability structure?

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 Speaker Notes: Slide 7
Facilities should clearly understand their specific reasons for
measuring hand hygiene adherence. This may be different for
individual facilities. Facilities may have more than one reason
including regulatory requirements to determine baseline rates
and whether hand hygiene should be a priority for improvement.
Other facilities may wish to compare performance to other
organizations or use data to inform improvement efforts. All
facilities should be interested in achieving high hand hygiene
adherence to reduce healthcare-associated infection rates.

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 Speaker Notes: Slide 8
To measure hand hygiene adherence, the opportunities for hand
hygiene must be clearly defined in ways that are possible to
measure.
You may recall that in the first module of this hand hygiene
course, we discussed the World Health Organization’s five
moments of hand hygiene. Facilities should educate all
healthcare personnel on all opportunities or moments for hand
hygiene.

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 Speaker Notes: Slide 8 Continued
As a reminder, these opportunities are:
– Before touching a patient
– Before performing a clean or aseptic procedure or
manipulating an invasive device
– After touching body fluids
– After touching a patient
– After touching patients surroundings (contaminated items
or surfaces) or removing gloves

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 Speaker Notes: Slide 8 Continued
While it is ideal to track and audit all hand hygiene opportunities,
facilities may choose to audit only adherence to specific
opportunities. Many facilities choose to audit before and after
patient contact or room entry and exit because this is
operationally the most simple method. Auditing opportunities
before clean and after dirty tasks is operationally difficult. There
is some evidence that measuring adherence on room entry and
exit may be an acceptable stand-in for other opportunities within
the patient encounter. If a facility chooses to primarily monitor
“wash in” and “wash out”, then they should include intermittent
assessments of opportunities before clean procedures and after
body fluid exposure to identify and correct gaps.

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 Speaker Notes: Slide 9
The difficulty in establishing an adherence monitoring program is
that there are no national standards for measurement.
Additionally, there are several potential methods that can be
useful for monitoring, but each has its own pros and cons.
Direct observation of technique is a popular method for
assessing competency and providing education about hand
hygiene – the problem, though, is watching someone wash their
hands or apply alcohol rub correctly does not guarantee that he
or she will adhere to those best practices during a busy work day.
Therefore, direct observation of technique by itself may not be
adequate to really know that personnel are doing hand hygiene
appropriately.
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 Speaker Notes: Slide 9 Continued
Direct observation of hand hygiene adherence on hospital units,
either by a designated hand hygiene monitor or by using a secret
shopper, is the best way to capture the most information. It tells
you what products personnel are using and information about
technique—for example, how well people coat their hands with
hand rub or how long they stand at the sink. You can also see
who is performing hand hygiene appropriately at the bedside
and collect role specific data including nursing staff, physicians,
physical therapists, social workers or dietary staff. The challenge
with this methodology is it's very time and resource intensive
and may be difficult to get data from all shifts.

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 Speaker Notes: Slide 9 Continued
Measuring the volume of hand hygiene product being used is
one way to track trends in consumption of alcohol-based hand
rub or hand soap in a consistent way with minimal effort and can
be compared to other like units or industry averages. However,
product volume measurement may be unreliable if products are
bought in bulk and stored for later use.
You can also survey personnel to self-report hand hygiene
adherence. This method has limited utility because we often
self-report that we're doing a better job than we actually are.
But what we can do with these surveys is understand personnel
perceptions of barriers and challenges to doing hand hygiene.

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 Speaker Notes: Slide 9 continued
That can actually give you some insights into what your
personnel might be finding as obstacles to performing hand
hygiene.
Some facilities incorporate questions about healthcare personnel
hand hygiene into patient satisfaction surveys. This approach
may be a good option in areas where direct hand hygiene
observation is difficult such as the ambulatory environment.
However, there are no data on whether this methodology is
correlated with overall adherence.

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 Speaker Notes: Slide 10
Now, let’s focus on different types of direct hand hygiene
observation – successful hand hygiene programs may have one
or a combination of these approaches. One approach is to utilize
covert observers-sometimes known as “secret shoppers.” These
individuals should undergo training and use a standard data
collection tool. Covert observers should have their observations
validated initially after training. Optimally programs should
perform inter-relator reliability testing at intervals to assure
accuracy.

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 Speaker Notes: Slide 10 continued
Another approach is to use overt observation, where the
observer is known to be observing hand hygiene adherence. The
observations may be biased by the Hawthorne effect, but the
observer can act to provide “just-in-time coaching,” making the
observation part of the intervention (i.e. “measurevention”).
There are also many methods of technology assisted direct
observation. These include the use of in-person data collection
programs using hand held devices with commercial or self-
developed data collection tools. Video monitoring aimed at sinks
or alcohol-based hand rub dispensers record opportunities for
hand hygiene that is later reviewed by trained auditors.

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 Speaker Notes: Slide 10 continued
There are also devices that can be worn by healthcare personnel
and sense when they enter into a patient room, detect when
hand hygiene is performed and if hand hygiene is not performed
remind the healthcare personnel to do so. These devices have
the potential to eliminate selection and observer bias and can
provide just-in-time reminders. However, there are currently
only a few studies that show successful widespread use of these
systems in real-world settings.

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 Speaker Notes: Slide 11
There is no standard for the number and distribution of hand
hygiene observations that should be performed. However, poor
hand hygiene is likely to be observed with even a few
observations. Many hospitals target 30 or more observations per
month per unit. Depending upon the resources dedicated to
hand hygiene data, the data can be collected to allow separation
of performance by role type, which can include nurses,
physicians, students, environmental services, food tray
deliverers, volunteers and others. Data can also be divided by
shifts.

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 Speaker Notes: Slide 11 Continued
These specific measurements can help target training and
interventions. When there is difficulty meeting performance
targets, data may also include documentation of likely
contributing factors for failure. Some examples could include not
performing hand hygiene when part of a rounding group or
when carrying supplies, or prior to putting on gloves. This
information can be used to direct the next steps in improvement
activities.

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 Speaker Notes: Slide 12
Regardless of what monitoring method you choose to use to
monitor hand hygiene adherence, your hand hygiene program
should use a standardized data collection tool.
The World Health Organization tool pictured here on the left is
one example of such a tool. It is organized to collect data across
all five moments of hand hygiene. Additionally, the Center for
Disease Control and Prevention provides checklists for hand
hygiene in the Infection Control Assessment Tools by setting
located here: website
https://www.cdc.gov/hai/prevent/infection-control-assessment-
tools.html.

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 Speaker Notes: Slide 12 Continued
Many facilities choose to use a customized data collection form.
Some facilities do collection on paper forms and others use
handheld computer tablets or other electronic devices. Here, on
the right, you can see a modified version of the WHO data
collection form utilized by trained covert hand hygiene observers
at an academic healthcare center. Key information collected
includes the unit, month, time of day, observation type-before or
after room entry, adherence and occupational role type.

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 Speaker Notes: Slide 13
Once you have collected your hand hygiene data, it should be
shared and coupled with expectations. It is important that the
health system or unit set defined targets for improvement. These
targets should depend upon baseline performance and the
frequency of measurement. The facility may set a goal of
improvement for example; – 10 percent per month or quarter, or
90 percent in the next fiscal year. The hand hygiene program may
choose to align release of data with rewards and recognition
programs for staff.

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 Speaker Notes: Slide 13 Continued
The program should decide how often data will be shared. This
may vary based upon role. For example, monthly or quarterly
data may be appropriate for hospital leadership, but more
frequent data may be needed for unit-level leadership. The
program should also determine the best way to communicate
and display data-incorporating into other health system data
sharing practices, but also consider highlighting data in a
different way to make it stand out. The program should
determine who needs to see the data and in what detail-and
should include all levels of hospital leadership as well as frontline
healthcare personnel. The program should decide if the data will
be visible to patients and visitors.

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 Speaker Notes: Slide 14
Providing feedback on hand hygiene adherence to frontline
personnel and leadership is key to raising awareness and
maintaining high adherence rates.
Hand hygiene data can be displayed in a variety of ways. The
graph on the left shows total facility hand hygiene rates with
improvement over time. This particular graph represents at least
30 observations in each hospital unit per month. Some hospitals
may choose to display the number of observations on the graph.
The graph on the right shows a unit-specific performance graph
and includes the unit goal of greater than 90 percent adherence
by a specific date. Consider opportunities for “just-in-time”
education when incorrect practices are observed.

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 Speaker Notes: Slide 15
Data can also be displayed with separation for different hand
hygiene opportunities. This bar chart displays adherence with
hand hygiene before room entry and after room exit. Adherence
is routinely higher after room exit than before room entry. This
trend can highlight opportunities for improvement in the hand
hygiene program. Other contributing factors can be collected as
well and can identify targeted areas for education or
improvement efforts.

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 Speaker Notes: Slide 16
Data can also be separated by different role types. The graph on
the left shows adherence for providers including physicians,
nurse practitioners and physician assistants. This graph shows
some improvement, but there is a recent leveling off in hand
hygiene.. Role-specific data can be powerful motivation for
professional groups. The graph on the right shows hand hygiene
adherence for environmental service employees. This graph
displays initial poor adherence with a remarkable improvement
and continued increase towards the hospital’s adherence goal.
Displaying and recognizing improvement can support and
promote continued adherence efforts.

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 Speaker Notes: Slide 16 Continued
And remember, that while the data are used to provide a
quantitative measure for improvement, it is important to not just
rely on the data -institutional leaders, unit managers, and
infection preventionists should “go and see” the initiative in
action. Go to the units and observe the practice. Does it seem to
match up with the data? Use in-person assessments to provide
coaching and feedback about barriers and achievements. This is
particularly important if the hand hygiene observer is someone
who is known to the unit. By periodically validating the data with
your own eyes and encouraging staff to speak up when they see
a missed hand hygiene opportunity, you will continue to build
the foundations for a sustainable culture of safety.

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 Speaker Notes: Slide 17
Some programs may want to focus not just on “are you doing
it?” but “are you doing it well?” Interactive activities are always a
great way to engage personnel and visual interactions can be
exceptionally powerful. Researchers at the University of
Michigan conducted hand hygiene culture demonstrations
where they showed healthcare personnel what they carried on
their hands before and after hand hygiene with alcohol-based
hand rub. The photograph on the left shows that the healthcare
personnel did a pretty good job with hand hygiene and cleared
most of the organisms, where as the picture on the right shows
no difference between the pre- and post-cultures, suggesting a
need for this staff person to improve their technique.

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 Speaker Notes: Slide 18

Adequacy of hand hygiene technique can be

demonstrated using a lotion product that simulates
bacteria or virus contamination of the hands. The lotion
can only be visualized under ultraviolet light. The
product is rubbed on the hands, which are then washed
with soap and water. The hands will appear clean under
standard lighting, like the photo on the left. However, if
the hands are placed under ultraviolet light, like the
image on the right, lotion residue is still visible,
demonstrating inadequate hand hygiene technique.

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 Speaker Notes: Slide 19
Data collection and sharing is most powerful when each
healthcare personnel clearly understands expectations and owns
their part in data collection and improvement efforts.
This picture demonstrates the hand hygiene responsibilities
outlined for healthcare personnel at the University of Michigan
Health System. The patient is at the pinnacle of the pyramid and
has the least responsibility.

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 Speaker Notes: Slide 19 Continued
Direct patient care providers, or frontline personnel, are
expected to know and practice three University of Michigan
Health System Vital Behaviors related to hand hygiene. They are
Clean, Remind and Thank:
• Clean Hands: Before room entry and patient care, between
dirty and clean tasks and after room exit or patient care;
• Remind others if they forgot to perform hand hygiene; and
• Thank others if they remind you when you forgot to perform
hand hygiene.

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 Speaker Notes: Slide 19 Continued
Supervisors, managers and directors have additional roles of
modeling best behaviors, providing positive feedback and
performing disciplinary action when needed. These roles need to
also ensure adequate resources, develop appropriate safety
culture and include hand hygiene in department goals and
priorities.
System-level quality leadership has the added expectations of
directing strategic goals related to hand hygiene and ensuring
that hand hygiene is clearly voiced as an institutional imperative.

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 Speaker Notes: Slide 20
Lastly, when individuals clearly know expectations and roles and
objective data on hand hygiene is provided, healthcare
personnel should be accountable for appropriate hand hygiene
behaviors. The Vanderbilt Center for Promoting Reliability and
Professional Accountability outlines an accountability pyramid
that can be applied to hand hygiene and other professional
behaviors. This is part of a safety culture that promotes
professionalism as the foundation of safe quality health care.
This pyramid shows that most healthcare personnel are
accountable to expectations around patient safety and
professionalism.

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 Speaker Notes: Slide 21
No Notes.

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 Speaker Notes: Slide 22

No notes.

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