Five ways to measure hand hygiene compliance

The Institute of Healthcare Improvement's (IHI) How-to Guide: Improving Hand Hygiene, was developed in conjunction with the Centers for Disease Control and Prevention, the Society of Healthcare Epidemiology of America, and the Association for Professionals in Infection Control and Epidemiology. It includes monitoring checklists. To monitor hand hygiene compliance, IHI suggests the following measures:

1. The percentage of caregivers who answer all five questions correctly on a standardized hand hygiene knowledge assessment survey.

Consider selecting a random sample of 10 clinical providers from diverse disciplines each month (or at other intervals specified by the hospital) to answer a five-question survey along with a competency check (Measure #2). (Specific questions can be designated by the hospital and/or selected from a IHI sample survey at http://www.shea-online.org/Assets/files/IHI_Hand_Hygiene.pdf). An alternative strategy is to assess knowledge using an intranet-based system. Hospitals could require employees to take an annual online test for or could conduct more frequent sampling.

An alternative strategy is to assess knowledge by using an intranet-based system. Hospitals could require employees to take an annual online test for or could conduct more frequent sampling.

2. The percentage of caregivers who perform all three key hand hygiene procedures correctly.

Randomly select a sample of 10 clinical providers from diverse disciplines each month (or at other intervals specified by the hospital) and observe them to determine if they perform the three key hand hygiene procedures correctly: hand washing, alcohol-based hand rub, and gloves. This method has the strength of direct evaluation and feedback, but is time consuming. It also provides an opportunity to ensure that providers are not wearing artificial nails or nail extenders and have their nails trimmed to less than ¼ inch.

Alternatively, competence can be assessed by monitoring hand hygiene practices during actual work. This has the advantage of being unobtrusive and integrated with other monitoring activities, but precludes direct feedback and adds complexity to the monitoring process.

  • Hand washing: Wash hands with soap and water, including contact with soap for at least 15 seconds, covering all surfaces (palm, back of hand, fingers, fingertips, and fingernails); rub with friction. Turn off water without recontaminating hands: If the faucet is hand-operated, use paper towel to turn off the faucet; if the faucet is automatic, credit for compliance is given for correct performance. Dry hands with fresh paper towel.
  • Alcohol-based hand hygiene product (rub, gel, or foam): Use enough to cover all surfaces (palm, back of hand, fingers, fingertips, and fingernails); rub until dry (at least 15 seconds), which ensures sufficient volume has been applied.
  • Remove gloves using correct technique (so as not to contaminate the hands with a contaminated glove surface).

3. The percentage of bed spaces at which there are clean gloves in appropriate sizes and dispensers (wall-mounted or free-standing bottles) for alcohol-based hand rub/gel/foam that contain product, are functional, and dispense an appropriate volume of product.

Make direct observations monthly (or at other intervals specified by the hospital) on the same nursing units where Measures 1 and 2 are monitored. Alternatively, availability can be assessed periodically as part of routine multidisciplinary rounds.

  • Dispenser of alcohol-based product must be present, readily accessible at the point of care, not empty, functional, and capable of delivering the appropriate volume of product. If hand/pocket bottles are used, an adequate supply must be readily available and accessible on the ward.
  • At least two sizes of gloves should be available and readily accessible at the point of care.

4. The percentage of patient encounters in which there is compliance by health care workers with all components of appropriate hand hygiene and glove practices.

Compliance is monitored 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. (This independent monitoring can be reinforced with monitoring by the care team during routine multidisciplinary rounds, which permits immediate assessment and feedback.) Observation periods should be 20-30 minutes (repeated if necessary) so that approximately 25-30 patient encounters are observed.

The emphasis should be on observing complete encounters so that the proper measure of complete compliance with all components of the hand hygiene and glove intervention package can be calculated. Divide the number of encounters in which all components were performed correctly by the number of encounters observed and multiply by 100 to calculate the percentage compliance rate.

"Complete compliance" is defined by the adherence with the hand hygiene techniques and use of gloves as outlined in the table on p. 56. Gloves should be worn for all types of contact if the patient is on isolation precautions that require the use of gloves for contact with the patient and the environment, or if there is a unit-based procedure for universal gloving (wearing gloves for contact with all patients and their immediate environment).

Additional monitoring: The following additional measure also can be used, but it does not replace direct observation of health care worker compliance during patient encounters:

  • Volume of alcohol-based hand hygiene product consumed per week (or per month) divided by the number of patient days in the corresponding time period.
  • Self-reporting by personnel or patients is not a reliable measure of compliance.

(Editor's note: A copy of the guide and tools is available at www.shea-online.org/Assets/files/IHI_ Hand_Hygiene.pdf.)