Hand Hygiene Compliance in a Non-Compliant World

Author: Holly Montejano, MS, CIC, CPHQ, VA-BC

Categories: Hand Hygiene April 28, 2019

We all know that hand hygiene is a cornerstone of infection prevention and the “wash your hands” slogan is synonymous with infection prevention campaigns. We also know that it’s often a missed opportunity in healthcare. Why is compliance such an issue when the potential harm to patients can be so severe?

In honor of World Health Organization (WHO) Hand Hygiene Day, let’s look at why measuring compliance is not always an exact science, and look at some microorganisms invading the healthcare space, making compliance a critical priority to infection prevention and patient safety.

Hand Hygiene Protocol(s):

There are many variables which need to be considered before building a program around hand hygiene. The Joint Commission’s Hand Hygiene Monograph is a comprehensive guide that considers all aspects of hand hygiene compliance, including compliance monitoring tools (both human and electronic), hand hygiene products, consistency of monitoring for accurate interpretation of results, leadership support required for hand hygiene compliance, and the subsequent need for sustainability with a culture of safety within the facility1. Product placement is also a large part of compliance. Often sinks are sporadically placed throughout a hospital unit creating a barrier to hand hygiene. Alcohol-based hand sanitizers can be strategically placed within the patient zone to increase convenience and help compliance1. Building a robust hand hygiene program is a resource intensive endeavor- but we know that the results from this effort can have positive impacts to infection prevention and healthcare-associated infection (HAI) reduction.

Some challenges to measuring compliance mentioned in the Monograph include variations in the:

  • Patient and environmental contact locations within a facility
  • Opportunities (to perform hand hygiene) are 24 hours a day and 7 days a week all year long and involve clinical and non-clinical staff
  • Frequency of hand hygiene varies by type of care being provided on a unit, capturing observations is resource intensive and can vary given the observer, and observer bias (Hawthorne effect) can be difficult to eliminate1. (Hawthorne effect is the alteration of behavior by the subjects of a study due to their awareness of being observe).

Despite clear education programs for both hand hygiene itself, and the opportunities where it is warranted, healthcare facilities still struggle with low compliance. Data collection is so important; if shared within a facility it could help drive improvement.


Let’s review some great resources available online to help educate healthcare facilities on hand hygiene opportunities, complete with audit tools to measure compliance so improvements can be made.

The World Health Organization (WHO) provides robust online resources for facilities to bolster hand hygiene compliance. The 5 Moments for Hand Hygiene is a pragmatic and effective model highlighting the appropriate moments for hand hygiene while providing patient care. The “5 Moments of Hand Hygiene” are2:

  1. before touching a patient,
  2. before clean/aseptic procedures,
  3. after body fluid exposure/risk,
  4. after touching a patient, and
  5. after touching patient surroundings.

The Centers for Disease Control and Prevention (CDC) offers some additional moments for hand hygiene including before and after glove removal, before eating and after using the restroom3.

Both the WHO and the CDC provide downloadable educational resources highlighting the steps of both hand washing (with soap and water, when hands are visibly soiled; when dealing with a spore forming bacteria or norovirus) and hand rubs with an alcohol-based hand sanitizer (for all other hand hygiene opportunities). The WHO provides a downloadable audit tool to measure hand hygiene compliance within your facility in their hand hygiene starter kit online4.

Hand Hygiene starts with you!

Hand hygiene is not only an important practice for healthcare workers, it is also an important activity for the patient to keep themselves free of infection. Research recently published in Clinical Infectious Diseases showcases the transmission potential of multi-drug resistant organisms (MDROs), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and resistant gram-negative bacilli (RGNB) from the patient’s hands to their surrounding environment5. Patients admitted to two different Michigan hospitals were recruited to the study upon admission as an inpatient and cultured on admission, days three and seven, and weekly until they were discharged. Sites of cultures included patient nares, dominant hand and six high touch environmental surfaces within the patient room. Patients with MDROs found on their hands were also found to have environmental surfaces contaminated with MDROs5. This study serves to highlight the importance of patient hand hygiene to reduce the environmental surface contamination in their immediate environment. The importance of environmental disinfection should also be noted where patient hand hygiene is not a guaranteed event.

An emerging MDRO, garnering the media spotlight in recent months, has been Candida auris. This fungus typically impacts patients who are already immune-suppressed and will cause death in one in 3 patients with invasive infection6. As you’re probably aware, those aren’t great odds for/of survival. Once a patient becomes infected, it can be very difficult to treat; some infections have been resistant to all three types of antifungal medications. Candida auris can live on surfaces for several weeks so surface disinfection of the patient environment is critical (Check out EPA’s LIST K for recommended disinfectants which includes our Sani-Cloth® Bleach Germicidal Disposable Wipes) as well as appropriate hand hygiene with either hand sanitizer or soap and water. Education of the patient, staff and visitors regarding hand hygiene and appropriate use of personal protective equipment (PPE), such as gown and gloves, is pivotal to preventing the spread of this very difficult-to-treat bug.

Hand hygiene has always been a pillar of infection prevention:

In the age of MDROs and other newly emerging pathogens, now more than ever, it is vitally important for all staff and visitors to be compliant with appropriate hand hygiene to thwart transmission of these organisms within a facility. Hand hygiene programs need to be supported from the top down, built into the patient care framework to encompass all levels and scopes of care, and include education for both patients and visitors. At the end of the day, patients should feel empowered to remind their healthcare worker(s) to perform hand hygiene, and to be his/her own safety advocate! These organisms are everywhere, so one missed opportunity can impact a life. This Hand Hygiene Day (and beyond), please remember to…WASH YOUR HANDS!

  1. Joint Commission. “Measuring hand hygiene adherence: overcoming the challenges.”Oakbrook Terrace, IL: The Joint Commission(2009).
  2. World Health Organization: https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/, accessed April 19, 2019.
  3. Centers for Disease Control and Prevention: https://www.cdc.gov/handhygiene/providers/index.html, accessed April 19, 2019.
  4. Lona Mody, Laraine L Washer, Keith S Kaye, Kristen Gibson, Sanjay Saint, Katherine Reyes, Marco Cassone, Julia Mantey, Jie Cao, Sarah Altamimi, Mary Perri, Hugo Sax, Vineet Chopra, Marcus Zervos, Multidrug-resistant Organisms in Hospitals: What Is on Patient Hands and in Their Rooms?,Clinical Infectious Diseases, , ciz092,https://doi.org/10.1093/cid/ciz092
  5. Centers for Disease Control and Prevention: https://www.cdc.gov/fungal/diseases/candidiasis/pdf/Candida_auris_508.pdf, accessed April 23, 2019.


Holly Montejano MS, CIC, CPHQ, VA-BC
holly Clinical Science Liaison, PDI Gulf Coast


Holly’s passion for infectious disease epidemiology developed during her undergraduate studies at University of Connecticut, where she studied biology and anthropology – and the profound impact of disease on people, public health and within healthcare systems.

Learn more about Holly here.


Phone: 321.439.7923

Email: Holly.Montejano@pdihc.com

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