Ensuring hand-washing when no one’s watching

Tips for encouraging staff compliance

It is this dirty little secret: Everyone thinks health care providers of all people wash their hands all the time. But it is not so. Indeed, if you are counting “washing” as “washing correctly when you should for the right length of time,” then the numbers shrink to sometimes embarrassing levels.

At Northshore Hospital in Manhasset, NY, the vice president of infection prevention, Donna Armellino, RN, DNP, CIC, says hand-washing is a challenge — not just to make sure it is done, but to measure how often it is actually happening. “You can do human observation, but the subjects can see you observing and it modifies their behavior,” she says. “Once the observer leaves, that person’s hand-washing may return to what it was before anyone was watching.”

During observational studies, hand-washing frequency was near 100%. But what was it really? There was a way to find out: to use cameras to capture what happened and when after a provider entered a patient’s room.

Using a video monitoring program, Northshore put the cameras in the medical intensive care unit rooms. They were motion-activated to turn on whenever someone walked in the door, and were pointed so as to avoid catching patients.

Remote auditors looked at the video feeds, noting whether a clinical staff member washed his or her hands upon entrance and before exit.

Implementing the program took about a year from the idea to actual filming — there were privacy considerations to think about related to HIPAA compliance, as well as research into the only other facility to make use of the remote auditing program: a surgi-center in Macon, GA, which saw hand-washing rates rise from a dismal 30% to 90% in three weeks.

Once they started the project, they audited 100-150 instances per day. The data are tabulated and sent to a scoreboard in the unit, which includes data from the last 5-30 minutes. If rates fall below a certain level, Armellino gets an email alert. She can check on the per room, per provider, and per unit rates. There are also daily and weekly summary reports.

Staff had some initial concerns, such as whether the information would be used to discuss personal behaviors, or just the aggregate behavior on the unit. “They were worried about being disciplined, but our plan was just to use this for positive reinforcement and aggregate numbers. And once we alleviated their fears about the potential for discipline, they were okay,” Armellino says.

Expanding the program

The cameras ran with no feedback for a couple months in June 2008. The rates were less than 15% — largely because the rule was that once providers entered the room, they had to wash their hands within 10 seconds.

Feedback began in October, and when staff understood the 10-second rule, rates climbed. They have been over 85% since October 2008. When a particular room hits 90% or above, there is a messaging system to give positive reinforcement.

The hospital expanded the taping to the surgical ICU in 2010, with baseline readings at about 30% initially. Rates quickly rose to the 90s and have stayed there since.

Armellino says there are 20 cameras in the medical ICU, and 18 in the surgical unit. They cost about $50,000 to buy and install. The hospital pays a monthly monitoring fee of “less than $4,000” per month. “It is worth it because hand hygiene is up and maintained, and if we can’t relate that directly to a reduction in hospital-acquired infection because our cohort is so small, I can say we have seen a decrease in C. difficile and MRSA. It is hard to say if it is related, though, or significant since our rates are low to begin with.”

Other uses for cameras

The hospital thinks there are other potential uses for the cameras, but there will never be one for each of the 800 or so beds. That would be intrusive to many and probably just too expensive. Among the issues that might benefit from monitoring are using bedrails and turning and positioning patients — although that would require patient permission. More likely to happen first is a protocol in the operating rooms for end of day and cleaning between cases.

The hospital’s experience was documented in a study published in 20121. That led to other hospitals opting into the video system, including the University of California San Francisco Medical Center, which is doing its own study on hand-washing. Other facilities are working on projects that use videotaping to see how providers comply with protective clothing and hand-washing requirements with patients in isolation units.

For more information on this topic contact Donna Armellino, RN, DNP, CIC, Vice President, Infection Prevention, North Shore Health System, Manhasset, NY. Email: darmelli@nshs.edu.


  1. Amellino D, Hussain E, Schilling ME et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012 Jan 1;54(1):1-7