Simple methods improve hand-washing compliance

One idea: Change location of hand-wash stations

It’s no secret that compliance with hand hygiene is a key element in reducing the rate of hospital-acquired infections. Yet changing physician behavior often is easier said than done.

"Just posting signs or sending letters from the chief of staff or infection control officer will not cause much change in physician behavior or change the culture, even though all recognize the need," says Frederick P. Meyerhoefer, MD, principal of the Canton, OH-based Meyerhoefer Organization, a consulting firm that specializes in compliance with Joint Commission on Accreditation of Healthcare Organizations standards.

Even if your organization’s infection control officer makes regular presentations to physicians about nosocomial infections and hand washing, you still have the problem of how to monitor compliance, he says. "Because of the multiple areas where hand washing should occur, it is very difficult to objectively monitor a process where compliance is subjectively decided by the individual."

A recent study suggests that physicians don’t wash their hands enough between patient encounters. Researchers placed identical liquid soap dispensers next to sinks in a primary care surgical unit in the United Kingdom, and recorded the levels of soap the clinicians used at the end of the year. Nurses were found to wash their hands significantly more often than physicians.1

To increase physician compliance, try these effective strategies:

Change the location of hand-wash stations.

Often, the physical setup for hand washing is badly arranged, according to Meyerhoefer, who adds that sinks and other supplies may be inconveniently located in relation to patient rooms.

"The new CDC [Centers for Disease Control and Prevention] hand hygiene recommendations addressing alcohol-based hand rubs now allow hand-wash stations to be placed nearer the need," he adds.

Sinks are no longer required because the hand rub takes the place of soap and water, Meyerhoefer explains. Still, there are regulations stating how and where stations can be placed and the amount of hand rub that can be stored on a unit.

"The regulations still apply, primarily because of the slight potential for explosion," he explains. "Any hospital has to check into that before doing any installation."

When physicians fail to wash their hands, it isn’t always deliberate — they may be pressured by time constraints or forget because of poorly located sinks, he underscores. "The process has to be structured to easily facilitate physician compliance."

Educate patients.

Include information about hand washing in patient education materials, with the goal of making patients aware of that expectation for all physicians, health care workers, and others who come into contact with the patient, Meyerhoefer recommends. "If physicians and others realize that their actions will be noted by patients, this will also serve as a goad for individual compliance," he says.

Patients can be strong advocates for this type of change, says Meyerhoefer. "Patients are sensitized to infections, with concerns about new viruses and antibiotic-resistant organisms being trumpeted in the press," he says. "Note all the cleaning products in the supermarkets touting their antibacterial prowess." He gives the example of one elderly woman attaching a sticker saying, "Have you washed your hands?" to her patient gown.

To develop patient handouts, Meyerhoefer suggests using the CDC hand hygiene recommendations and the revised JCAHO infection control standards, which become effective January 2005.

Armed with this knowledge, patients will realize that they have the right to ask their physicians whether they have washed their hands before performing an examination, adds Meyerhoefer.

"What argument can any health care professional make that hand washing is not the correct and necessary thing to do?" he asks. "More and more, this type of information will be available to the public as part of the increasing release of a hospital’s quality data."

Allow patients to see hand washing.

Consider placing sinks or hand washing stations at the entrance to each patient room to allow patients to observe hand washing, suggests Meyerhoefer.

At Swedish Medical Center in Seattle, dispensers are placed directly in patient rooms, reports Nancy J. Auer, MD, FACEP, the facility’s vice president for medical affairs. "We make it easy for them, by making bottles and dispensers of alcohol gel readily available for their use," she says. "Patients do like to see physicians wash their hands when they come into a room. It gives them extra comfort that the physician is concerned about their health."

Ask peers to observe physicians with poor compliance.

Physicians are strongly influenced by their peers, and you should use this as leverage to ensure compliance, advises Linda L. Dickey, RN, MPH, CIC, infection control practitioner at University of California — Irvine Medical Center in Orange. "When a physician is noted by a staff member not to have good hand hygiene compliance, we confidentially ask a respected peer or superior to observe and provide direct feedback."

Staff are encouraged to remind other health care workers about hand hygiene if a breach in infection control practice is noted. "This is a cultural norm we reinforce when we talk informally to staff or physicians, provide inservices, or present data," she says. "We emphasize this should not be viewed as a correction of behavior as much as a helpful reminder — a reminder that not only helps keep the patient safer, but also the health care worker."

If blatant or repetitive breaches in infection control practices are noted, staff are encouraged to notify infection control so corrective action can be taken. "If an individual calls us with a report of a lack of hand hygiene compliance, their report is kept confidential," Dickey notes.

Health care workers should be able to freely express concerns peer-to-peer, she stresses.

"We must get over the idea of blame in health care if we speak to each other about a behavior that isn’t up to par. We must keep in mind two things: Infection control practice protects both the patient and the health care worker, and we need to treat patients as we would want to be treated," Dickey adds

[For more information, contact:

  • Nancy J. Auer, MD, FACEP, Vice President for Medical Affairs, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Phone: (206) 386-6071. Fax: (206) 386-2277. E-mail:
  • Linda L. Dickey, RN, MPH, CIC, Infection Control Practitioner, University of California Irvine Medical Center, 101 The City Drive, Orange, CA 92868. Phone: (714) 456-5360. Fax: (714) 456-5367. E-mail:
  • Frederick P. Meyerhoefer, MD, The Meyerhoefer Organization, 1261 White Stone Circle N.E., Canton, OH 44721. Phone: (330) 966-6717. E-mail:]


  1. Stone A. Audit of soap usage by a primary care team. BMJ 2003; 327:1,453-1,454.
  2. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in HealthCare Settings. MMWR 2002; 151(RR16); 1-44.