All hands on deck when it comes to hand hygiene improvement

At Hamilton Health Sciences (HHS), grassroots hand hygiene improvement initiatives in partnership with infection control practitioners have been successful in increasing compliance rates and staff engagement

Improving hand hygiene compliance among healthcare workers is a constant endeavor for health care organizations. Since 2009, hospitals in Ontario have been required to report compliance rates to the Ministry of Health and Long-Term Care, and the results are publicly available online. Several other provinces have subsequently implemented similar policies. Although this policy has brought attention to the importance of hand hygiene in preventing healthcare-associated infections, there have been questions about the accuracy of the reported rates.

Most hospitals measure hand hygiene using direct observation, in which a human auditor monitors healthcare workers as they perform their clinical duties. There are limitations to direct observation, one of which is the fact that people may change their behaviour when they are aware of being observed – a phenomenon known as the Hawthorne effect. Although it has long been assumed that the Hawthorne effect increases the compliance rates as measured by direct observation, until recently there have been limited data on the size of this effect.


Recently, I had the opportunity to work on a study addressing this issue with colleagues from the University Health Network, the Institute of Health Policy, Management and Evaluation at the University of Toronto, and Infonaut Inc., based on research conducted at the University Health Network in Toronto. The study was recently published online in the journal BMJ Quality & Safety. In the study,  a real-time location system was installed on two multi-organ transplant units for eight months in order to track the movement of people and to measure each time a soap or hand sanitizer dispenser was used. We were able to determine how often hand hygiene was being done in areas that were visible to an auditor, compared that to different times and locations when there was no auditor within eyesight. Results showed that hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible.

“The magnitude of what we found calls into question the accuracy of directly observed hand hygiene rates and the usefulness of measuring and reporting them,” said senior author Dr. Michael Gardam of University Health Network in a press release. “That said, human auditing of hand hygiene has been helpful to draw attention to this important preventative measure—we just can’t stop focusing on it because our posted rates are not nearly as high as we think they are.”


Despite the limitations in measurement of hand hygiene, it is essential to continue quality improvement activities. One approach known as “frontline ownership” has been championed by Dr. Gardam and has shown promise in improving hand hygiene as well as addressing other complex problems in health care. This strategy involves engaging frontline healthcare workers and empowering them to develop local solutions that work best for them, rather than imposing a “one size fits all” program on the entire organization.

At Hamilton Health Sciences (HHS), this type of frontline ownership approach has been applied to our hand hygiene program. A hand hygiene toolkit is available to all staff and provides resources for the development of unit-based hand hygiene programs. Infection control practitioners help each unit to develop individualized hand hygiene solutions.

Staff in the pediatric critical care unit at HHS’ McMaster Children’s Hospital were the first to develop their own hand hygiene campaign in 2012. Staff, with support from the infection prevention and control (IPAC) team, designed colourful, eye-catching posters featuring pictures of children of staff members and the message to “Please wash your hands”. The posters are included in patient admission packages and posted by each child’s hospital bed/crib. Family members are educated about the importance of hand hygiene and are encouraged to remind staff members and physicians to clean their hands. “The staff came up with the idea, took the ball and rolled with it,” says Cindy O’Neill, manager, infection prevention and control, HHS. “It was unique to the individual and what motivates them. As a result, we are seeing a cultural shift with improved teamwork where everyone is excited about the program.”


The Burn Trauma Unit at HHS’ Hamilton General Hospital (HGH) followed suit, posting pictures on the wall of staff members cleaning their hands. In the intensive care units at HGH, staff “champions” adopted that idea and have led a hand hygiene improvement program since December 2012. In addition to posting pictures, the group has designed t-shirts with the slogan “It’s in our hands” to promote hand hygiene. Many nursing and medical staff members have participated in hand hygiene audits with IPAC staff, and some have now been trained as auditors in order to provide ongoing monitoring and feedback to their colleagues. Several staff members on the unit also developed an in-service in which they acted out scenarios to illustrate common hand hygiene challenges in their units.

Hand hygiene work has begun more recently on other units across HHS, including a project led by a frontline nurse on the hematology oncology unit at HHS’ Juravinski Hospital, in collaboration with IPAC. The staff member gave presentations to her colleagues and posted “fact or fiction” scenarios related to hand hygiene on the unit, with prizes given out for correct answers.

On the medicine units at HGH, a hand hygiene display has been installed and staff have been invited to join IPAC staff on audits in order to better understand the process. All frontline staff are being included in the initiatives, including nursing, allied health, environmental assistants, physicians, residents, and medical students. The focus is on changing the culture and having a positive emphasis. “We have really noticed a change in the staff,” says Gail Fisher, infection control practitioner, HHS. “They are more welcoming now and don’t feel so much like we are the hand hygiene police.”

Although measurement and public reporting of hand hygiene compliance rates continues to be mandated in Ontario and other provinces, successful ‘grassroots’ initiatives such as those shared above demonstrate that the focus should be on engaging frontline staff to bring about hand hygiene improvement in order to achieve the real goal of preventing healthcare-associated infections and providing safer care for patients.