Clean Care is Safer Care

Hand hygiene monitoring and feedback

Evaluation and repeated monitoring of a range of indicators reflecting hand hygiene infrastructures and practices, as well as health-care workers’ and senior managers’ knowledge and perception of the problem of health care-associated infection and the importance of hand hygiene at the health-care facility, is a vital component of any successful hand hygiene campaign. On the right side of this page, you can directly access all the tools available for evaluation and feedback within the WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS). Data Entry and Analysis Tools using Epi Info™ are also available for each tool. Results can be summarized for feedback by using the Data Summary Report Framework.

WHO has also developed the Hand Hygiene Self-Assessment Framework, a tool to obtain a situation analysis and a score of hand hygiene promotion and practices within an individual health-care facility, according to a set of indicators reflecting the WHO MHHIS. Repeated use of the Framework will allow documentation of progress with time.

In particular, monitoring hand hygiene compliance is of crucial importance to:

  • assess baseline compliance by health-care workers (HCWs),
  • provide feedback to health-care workers about defective practices as well as improvement,
  • evaluate the impact of promotion interventions, and
  • investigate outbreaks.

Unobtrusive direct observation of hand hygiene practices by a trained observer is considered the gold standard for evaluating compliance. Detailed instructions on this method are included in the Hand Hygiene Technical Reference Manual. Observers can also be trained and validated by using the WHO Hand Hygiene Training Films and Slides Accompanying the Training Films. The WHO observation form exists for both hospitals and outpatient care settings. Web-based data collection and entry applications using touch screen and mobile devices have been developed and are being used in a number of countries. The Australian national hand hygiene campaign (Hand Hygiene Australia) has kindly agreed to make their online web-based application for hand hygiene compliance monitoring (HHCApp) freely available for use by other national campaigns or health-care facilities. To learn more about this opportunity, look at their web site. In the context of activities for 5 May 2013, WHO strongly encourages countries and individual health-care facilities to use the HHCApp and participate in the international data collection project launched by Hand Hygiene Australia.

Promising innovative electronic systems for the automatic monitoring of hand hygiene compliance are now available and can significantly facilitate data collection. They allow continuous monitoring over time and automatic data download and analysis. Importantly, the Hawthorne effect is significantly mitigated and required human resources are minimal. However, according to a recent WHO systematic review of the literature, limited evidence is available to validate their use compared to direct observation and their actual cost-effectiveness remains unknown. In most cases, these systems do not monitor standard hand hygiene indications and manufacturers should be strongly encouraged to integrate the 5 moments for hand hygiene concept into the design of these tools. The preliminary results of the literature review is now available (see the Resoursces section on the right side of this page). These new technologies present numerous advantages and may become the future approach to hand hygiene compliance monitoring when available resources permit, and provided that they can reflect the 5 moments for hand hygiene, but additional high quality research will be needed to support their adoption.

Consumption of hand hygiene products, in particular alcohol-based handrub, is another useful indicator. Data can be calculated easily and can be correlated with infection trends over time. However, to be helpful in inducing HCWs’ behavioural change, they should be used in parallel with hand hygiene compliance data.

In Part II.3 of the WHO Guide to Implementation, you can read more about how to undertake evaluation and feedback in the context of the WHO Multimodal Hand Hygiene Improvement Strategy.

Highlights on the best recent papers on hand hygiene evaluation and feedback:

  • Stewardson AJ, Allegranzi B, Perneger TV, Attar H, Pittet D. Testing the WHO Hand Hygiene Self-Assessment Framework for usability and reliability. J Hosp Infect 2013;83:30-5.
  • Marra AR, Edmond MB. Hand hygiene: state-of-the-art review with emphasis on new technologies and mechanisms of surveillance. Curr Infect Dis Rep 2012;14:585-91.
  • McGuckin M, Govednik J. Electronic hand hygiene compliance interventions: a descriptive guide for the infection prevention team. Am J Med Qual 2012;27:540-1.
  • Stewardson A, Pittet D. Quicker, easier, and cheaper? The promise of automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2011;32:1029-31.
  • Morgan DJ, Pineles L, Shardell M,et al. Automated hand hygiene count devices may better measure compliance than human observation. Am J Infect Control. 2012 Dec;40(10):955-9.
  • Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012 Jun 13;6:CD000259. doi: 10.1002/14651858.CD000259.pub3.
  • Costers M, Viseur N, Catry B, Simon A. Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene. Euro Surveill. 2012 May 3;17(18).
  • Monnet DL, Sprenger M. Hand hygiene practices in healthcare: measure and improve. Euro Surveill. 2012 May 3;17(18).
  • Behnke M, Gastmeier P, Geffers C, Mönch N, Reichardt C. Establishment of a national surveillance system for alcohol-based hand rub consumption and change in consumption over 4 years. Infect Control Hosp Epidemiol. 2012 Jun;33(6):618-20.
  • Allegranzi B, Stewardson A, Pittet D. Nationwide benchmarking of hand hygiene performance. Infect Control Hosp Epidemiol. 2012 Jun;33(6):621-3. doi: 10.1086/665720. Epub 2012 Apr 19.
  • Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32:1016-28.
  • Fuller C, Michie S, Savage J, McAteer J, Besser S, et al. The Feedback Intervention Trial (FIT) - Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial. PLoS ONE 2012;7(10): e41617.