The Joint Commission Update for Infection Control

Achilles heel of hand hygiene: Monitoring HCW compliance

Joint Commission seeks best practices on difficult issue

The Joint Commission is trying to solve the Achilles heel of hand hygiene: monitoring compliance by health care workers. As part of its increasing emphasis on infection control, the The Joint Commission is seeking innovative and cost-effective methods to address adherence to hand hygiene guidelines.

"The [Joint Commission is] trying to prepare a monograph of best practices for measuring hand hygiene adherence," says leading hand washing expert Elaine Larson, RN, PhD, FAAN, CIC, a principal in the project and a professor of pharmaceutical and therapeutic nursing at Columbia University in New York City. "People around the country are having a horrible time trying to figure out how to monitor it. It is so expensive. You can't pay somebody to observe all the time. Nobody really knows the best way to do it."

The Joint Commission continues to make hand hygiene a national patient safety goal, requiring compliance with the evidence-based recommendations in the hand hygiene guidelines issued by the Centers for Disease Control and Prevention (CDC) in 2002. The problem many infection control professionals are having, however, is meeting this 1A recommendation in the CDC guidelines: "Monitor health care workers' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance."1

To improve the situation, The Joint Commission is looking for proven methods and strategies for monitoring hand hygiene compliance. "They try to use CDC guidelines for their standards, and CDC recommends having some kind of a monitoring plan," Larson says. "People are just at a loss at how to do it in a sustainable, cost-effective way."

The results of the project will be published in a free, educational monograph that recommends promising practices for measuring hand hygiene compliance. The monograph, planned for publication in early 2008, will be the culmination of an 18-month project by the Joint Commission, the Association for Professionals in Infection Control and Epidemiology (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO), World Alliance for Patient Safety, the Institute for Healthcare Improvement (IHI), and the National Foundation for Infectious Diseases (NFID). Submissions will be confidentially reviewed by an expert panel under Larson's direction.

Gold standard not so golden

In general, the gold standard for hand hygiene adherence is considered to be direct observation and charting of compliance by an ICP or other health care worker. Organizations such as the Hand Hygiene Resource Center have created well- designed monitoring tools for this approach.2 (See form.) The Institute for Healthcare Improvement also recommends monitoring with direct observation by a trained observer using a standardized procedure and form. Independent observers are strongly recommended, preferably individuals who routinely are on the ward for other purposes and are not part of the care team, the IHI recommends.3 Independent monitoring can be reinforced with monitoring by the care team during routine multidisciplinary rounds, which permits immediate assessment and feedback, the IHI suggests. Observation periods should be 20 to 30 minutes, with the emphasis on observing complete encounters so that the proper measure of compliance can be obtained.

Emphasizing that self-reporting by personnel or patients is not a reliable measure of compliance, the IHI does note that adjunct measures to monitor adherence include tracking the volume of alcohol-based hand hygiene product used for a given time period. That is considered a less accurate strategy than direct observation, which is problematic in its own right. Problems include the expense of such labor-intensive monitoring and the influence of the well-known Hawthorne effect, which means essentially that observation tends to change behavior. Measuring compliance with hand hygiene practices during the delivery of care has long been complicated because of the resources needed to monitor the practices of many different care providers in numerous locations for meaningful periods of time. The absence of standardized approaches to measuring hand hygiene performance makes it impossible to determine whether overall performance is improving, deteriorating or staying unchanged as new strategic interventions are introduced. "Obviously, the gold standard is observation, but that changes behavior and it is very expensive," Larson says. "So the gold standard isn't even very good. There have been a number of proposals, including electronic monitoring devices. So the Joint Commission is sending out this invitation across the country for people who have found a good way to monitor hand hygiene to submit it as a best practice."

Must be applicable to soap, alcohol

The compliance tools will need to be applicable to both traditional hand washing practice and the use of alcohol hand rubs, which have become more predominant in health care since they were strongly emphasized in the CDC guidelines. While the alcohol hand hygiene dispensers are ubiquitous in heath care settings, Larson is doubtful compliance has really increased. The historical view is that health care workers comply with hand washing only about 50% of the time.

"There are some studies coming out that indicate the alcohol [hand rubs] are taking off and they are starting to improve practice," she says. "People are using the alcohols more, but my sense is that they are not necessarily performing hand hygiene more often. They are just using the alcohol instead of soap. I'm not sure that it has really increased the bottom line rate of adherence. But the alcohol products are certainly being widely adopted across the country."

If the expert panel determines that a submitted example has potential value to other health care facilities, the organization will be contacted for additional information and permission to include it in the monograph. Examples of promising practices for measuring compliance with hand hygiene guidelines are being sought from across a variety of settings, including hospitals, ambulatory care, home care, long-term care, and behavioral health. Organizations submitting examples are asked to include supporting documentation, such as published studies or summaries of results regarding the use of the method, as well as a sample of data in the manner it is displayed (i.e., charts or graphs).

(Editor's note: For more information on this initiative, contact Linda Kusek, project coordinator, Consensus Measurement in Hand Hygiene Project, the Joint Commission, at


  1. Centers for Disease Control and Prevention. 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. MMWR 2002; 51(RR16):1-44.
  2. The Hand Hygiene Resource Center at
  3. Institute for Healthcare Improvement. How-to Guide: Improving Hand Hygiene A Guide for Improving Practices among Health Care Workers On the web at: