Cameras + feedback = 88% HH compliance

"Big Brother is Watching You."
George Orwell, 1984

A novel solution to the historic problem of hand hygiene (HH) compliance suggests "Big Brother" and all its ominous connotations may be not such an unwelcome presence after all. The use of video cameras and real-time feedback dramatically improved and sustained HH compliance rates on a 17-bed unit at North Shore University Hospital in Manhasset, NY.

"We initially thought that some of the staff may [be concerned] `that someone is constantly watching us,'" says Donna Armellino, RN, DNP, CIC director of epidemiology at North Shore. "Once we discussed it with the staff and saw their enthusiasm it became less of an issue. Those concerns disappeared very quickly."

The investigators evaluated healthcare worker HH with the use of remote video auditing with and without feedback. The study was conducted in a 17-bed intensive care unit from June 2008 through June 2010. Cameras were placed with views of every sink and hand sanitizer dispenser to record HH of workers. Sensors in doorways identified when individuals entered and exited. When video auditors observed a worker performing HH upon entering and exiting, they assigned a "pass." If not, a "fail" was assigned. HH was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail.

Bruce Farber"I think people's behavior changes when they know they are being observed and they know the purpose of the observation," says Bruce Farber, MD, hospital epidemiologist at North Shore. "The whole culture changes. That's clear in virtually every field that has studied direct feedback, whether it's traffic lights or the food service industry. "

During the 16-week pre-feedback period, HH rates were less than 10% and in the 16-week post-feedback period increased to 81%. The increase was maintained through 75 weeks at an aggregate rate of 88%.

In a surprising finding, the presence of cameras alone did not make the difference — it was the feedback of compliance rates that sealed the culture change. To repeat, the aforementioned 10% adherence rate was stunningly low even after the cameras alone were introduced.

"They knew they were there, but they really didn't clearly know what their purpose was," Farber says. "At the same time we had on-site people saying that our rates were 60%. And the definition we used [in video observations] was much tougher."

The definition of appropriate HH at the hospital requires workers to perform HH both before and after all patient room entries and exits. They must also disinfect hands after touching objects in the patient's environment and after removing gloves.

Despite ongoing training, many clinicians mistakenly thought that hand washing or using an alcohol-based hand sanitizer either prior to or after having patient contact is sufficient, while others assumed the use of disposable gloves can take the place of HH.

"They all were in favor of doing it, but [lagged] in terms of knowing the order to pass, to have to do it before and after [seeing patients] and within 10 seconds," Farber says. However, once education was reinforced and the cameras were complemented by an aggregate feedback system, compliance rates began to rise dramatically.

In another unusual feature, the compliance auditing is conducted by remote third-party human auditors. They use a web-based workflow software program to visualize and assess HH compliance by clinical staff with the use of video cameras and doorway motion sensors. As performance data are collected, feedback metrics are automatically tabulated by a central server database and delivered back to the hospital staff through electronic "LED" boards, electronic mail summaries and comprehensive weekly performance reports. The electronic boards can also be used for positive feedback, sending a message like "Good Shift!" if compliance is coming in very high.

Sustaining the gain

"We have had this for three years and there has been no decrease in compliance rates," Farber says.

The ability to sustain the gain — the common downfall to many an infection prevention initiative — makes a huge difference for Armellino.

"When we put in the cameras the hope was to achieve sustainability," she says. "Through my experience in the past there have been a lot of short-lived campaigns and initiatives to temporarily improve HH. Because of the inability to continuously monitor and give feedback there is always a drop — the rates don't stay up. You have manpower when you focus on the issue, but then other issues come up so you have to redeploy staff. "

In contrast, the way the North Shore program is set up, Armellino receives compliance updates twice a day, allowing her to intervene as needed.

"I know how well they are doing and I know when I need to encourage the leadership there to change some of the behaviors because we see the rates dropping — I'm talking about an 80% range, she explains. "They have had a wonderful run close to 90% and even higher in the unit over the past couple of weeks. But when I see an 85% I get concerned."

While the direct relationship between HH and infection rate reduction has been studied in one form or another since Semmelweis in the 19th century, small scale interventions like the one at North Shore can find it challenging to achieve the numbers needed for statistical significance.

"We have seen a decrease in our transmission rate of MRSA, but this is a 17-bed unit and a second unit that [has been added since the study] has no more than 18 beds," she says. "When you look at infections they are relatively low, so it's very hard to say, 'Because we did this our rates went down.' There are a lot of other variables that come into play to change infection rates, but we did see a drop in MRSA transmission rates. "

Then again, Armellino notes, "We don't need any more studies to know that hand washing is a good idea."

Video monitoring requires a significant financial investment, and that can be daunting for hospitals in challenging economic times. North Shore received a $50,000 grant from the New York state health department to install the system. Monitoring costs $3,000 for an initial unit and $1,000 a month for each additional unit. The monitoring is actually conducted by an outsourcing firm in India, with additional monitoring and quality assurance auditing by workers in Huntsville, AL.

On the other hand, hospitals that can achieve and verify such high compliance rates will almost certainly be preventing costly healthcare associated infections by sharply reducing the likelihood of cross transmission between patients. When thousands of dollars of subsequent care are eliminated in the act of preventing a single infection, one could argue that such surveillance and feedback systems are well worth the considerable investment they require. The cost may also be justified in areas in which patients are at highest risk for infection. It is likely that the frequency of the audits could be reduced without compromising the result to reduce the cost, Farber says.

"They are monitored very frequently now; we probably need a lot less monitoring to accomplish the same result," he says. "But in the study they were monitored thousands of times per day."

The technology may have other applications in quality auditing, with examples including compliance with proper technique during resuscitation, rapid responses, central line catheter placement, select nursing care (such as turning and positioning to prevent decubiti), as well as patient interactions. In addition, compliance with patient isolation measures could be recorded and audited to ensure barriers like gloves, gowns and masks are donned and worn appropriately.

And what about Big Brother?

Lauris C. KaldjianThe increasing invasiveness of high tech surveillance of health care worker behavior has the potential to lead to unethical situations and systems, warns Lauris C. Kaldjian, MD, PhD, Director of Bioethics in the Department of Internal Medicine University of Iowa Carver College of Medicine.

Asked to review the study for HIC, Kaldjian says North Shore set up the program with a wise commitment to full transparency from the onset.

"I am impressed by the transparency and candor with which they designed this intervention," he says. "Healthcare workers were aware that HH was a condition of employment, signed an annual HH contract, and were informed that cameras were being installed to monitor HH to generate aggregate data only. One of the key elements in these sort of interventions has to be a straight forwardness so that care workers know what's going on and they know why it's going on."

Using the LED displays to give direct feedback to staff is both equitable and fair as long as all parties agree on the definitions of the observed behavior, he adds.

"If there is no dispute there, this kind of approach seems to be a very impressive attempt to try and reflect what is actually happening and show that to the people who are the actors on the stage," he says. [They are using] this as not only an incentive to try harder but also congratulate them for doing well."

Of course, extending such surveillance into other areas potentially involving patients would open up a new set of ethical and disclosure questions. However, in the current study one could certainly argue that it is better to know cameras are monitoring you than a lurking "secret shopper" of the human variety.

"Nobody felt like they were being [observed] unfairly," Farber says. "It was all up front and was not secret."

While aggregate data is presented, Farber conceded that individuals could be identified from the tapes and their compliance assessed.

"Yes, no question, we have video of everybody going in and out," he says. "We just have to call up the time and day and I could get it — I have gotten it — but we purposely have not gone after specific individuals."

As such programs and the high tech devices to conduct them continue to evolve, health care workers could eventually be fed back individual HH compliance rates like surgeons being told their rates of surgical site infections.


  1. Armellino 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 Published online on November 21, 2011.

Camera use common in other industries

Hospitals leary of adopting

In an era where all manner of privacy is disappearing, health care lags well behind other industries in using cameras for monitoring behavior.

Adam Aronson, chief executive officer of Arrowsight in Mount Kisco, NY, began by monitoring food safety, animal welfare and productivity in the meat industry.

At a ham plant in Council Bluff, IA, Arrowsight placed cameras in a hallway outside the bathroom. Workers were supposed to squirt alcohol-based gel on their hands after leaving the bathroom.

"What we found was that the workers basically ignored the protocol despite the fact that there was a sign," he says. "Within two weeks of providing feedback, the number was 95%."

Aronson shared the information with his father, vice chair of quality at Beth Israel Deaconness Medical Center in Boston, who urged him to tailor the technology for hospitals. Aronson tried, but the hospitals he approached weren't interested. "We hired some consultants and met with 10 hospitals, none of whom would even trial it for free," he says.

Then Aronson had a personal experience that pushed him to do more. Both his mother and sister acquired serious infections during hospital stays. Aronson decided to try again. He was able to use the technology in an outpatient surgery center in Macon, GA, and show its value.