Hand Hygiene Compliance Industry Group Formed to Lead Change for Patient Safety

To create meaningful awareness of the patient safety risks and the economic burden to the U.S. healthcare system of outdated hand hygiene compliance measurement, eight U.S.-based hand-hygiene compliance solution providers have formed an alliance. The Electronic Hand-hygiene Compliance Organization (EHCO™) aims to lead and influence changes in hand-hygiene measurement policy and guidelines at accreditation organizations, government agencies, health insurers, and hospitals. EHCO’s focus is to improve hand hygiene compliance and, in turn, increase safety and reduce avoidable harm to patients and hospital staff. EHCO™ is a consortium of healthcare technology companies that provide SMART (Systems that Measure Accurately and in Real-Time) hand-hygiene compliance solutions. EHCO’s member companies are committed to lead and influence changes in policy and guidelines at accreditation organizations, government agencies, health insurers, and hospitals along with educating consumers on this important public health issue.  The intended outcome of their work is the reduction of avoidable harm.

Every year in the U.S., more than 700,000 hospital patients contract an avoidable infection known as an HAI, or healthcare-associated infection. Of those patients, approximately 75,000 will die.(1) While proper hand hygiene is critical to preventing the transmission of many infections, compliance with hand hygiene guidelines is less than 50 percent globally.(2) Until recently, the only way to measure how well healthcare workers performed hand hygiene was manual direct observation. With direct observation, individuals know they are being observed and adjust their behavior, a phenomenon known as the Hawthorne Effect, inflating a hospital’s true compliance rate. A hospital may think its hand hygiene compliance rate is 90 percent; but direct observation only accounts for 1.2 percent to 3.5 percent of all hand-hygiene events,(3) leaving more than 98 percent of hand hygiene events undocumented and compliance rates highly overstated.

“Patient health and lives are being put at risk by outdated compliance measurement methods which often inflate actual hand hygiene rates by up to 300 percent(4),” says Paul Alper, chairman of EHCO™ and vice president of patient safety strategy for DebMed. “Patients are subjected to extended lengths of stay and unnecessary suffering as a result of HAIs, many of which could be prevented with proper hand hygiene. That is why the members of EHCO are uniting to drive change in U.S. healthcare policy.”

Only within the past few years has evidence-based electronic measurement of hand hygiene become widely available to accurately and continuously measure hand hygiene compliance in real-time and enable meaningful feedback to healthcare workers. While capturing 100 percent of hand hygiene behavior electronically gives hospital leaders in quality, patient safety, and infection control visibility to accurate and reliable rates, no policy guidelines or mandates exist.  EHCO™ member companies believe that it is their responsibility to lead the change in the acceptable standard of care to improve public health and patient safety.

Connie Steed, director of infection prevention at the Greenville Health System in Greenville, S.C., has been working with one electronic hand hygiene company for the past six years to help them develop and perfect their system.

“We are excited to have electronic hand hygiene compliance measurement throughout our seven hospitals,” says Steed. “We now have a better understanding of the compliance rate for all of our hand hygiene behavior 24/7.  We switched away from direct observation, the most common monitoring methodology, because it only gave us data for a small snapshot in time and healthcare workers behave differently when being observed. Thus our rates with direct observation were much higher than our 24/7 reality. We have seen consistent double digit increases in hand hygiene compliance and reductions in healthcare-associated infections. These benefits have come with cost savings that can justify the cost of the system.”

The companies engaged in EHCO™ include Airista, BioVigil, CenTrak®, Clean Hands-Safe Hands, DebMed, Hill-Rom, Inc., SwipeSense, and Versus Technology.

“We have come together with a common goal, to lead the change in how hospitals measure this key performance indicator of patient safety and quality,” says Alper. “Just as every other area of healthcare is adopting advanced technologies for improved efficiencies and care, there is now innovative technology to help drive true improvement in hand hygiene compliance that is linked to the reduction of avoidable infections and their associated costs."

ICT spoke with Paul Alper further, to discuss the goals of EHCO.

ICT: Hospitals are most likely adhering to direct observation because they perceive it as being more cost-effective than automated systems. How will the consortium address this entrenched belief?

Paul Alper: The key word here is “perceived”. First, there are real costs to performing Direct Observation (DO). There is the labor to capture the data and administration time to process it, which when done right, can be very costly; however even then there is no guarantee that staff receives performance feedback in a timely manner.

Direct costs aside, the real issue with DO is that the data it produces is neither accurate nor reliable when it comes to measuring all of the hand hygiene behavior 24/7. At best, DO captures less than 3 percent of all events and the real number is probably much lower. That means there is no visibility to at least 97% of all hand hygiene events. To drive real improvement, reduce infections and their associated costs, hospitals need to capture 100 percent of hand hygiene behavior 24/7/365 and to give timely feedback to staff on their performance. Electronic monitoring allows hospitals to accomplish just that, and EHCO’s goal is to make this technology the future standard of care. EHCO members will present the scientific evidence to make the case to accreditation organizations, government agencies, health insurers and hospitals. When you further consider that the hospital associated conditions, or HAC penalty, in effect as of 2015, puts 1 percent of CMS revenue at risk for poor infection control performance (hospitals ranked in the bottom 25 percent will automatically be hit with the penalty), the timing is perfect to address how hand hygiene compliance is monitored as real improvement is essential to help avoid the penalty. 
ICT: For the hospitals that are still using direct observation, what have hospital administrators and infection preventionists expressed as concerns about transitioning to automated systems and how can the consortium help educate to these specific issues?

Paul Alper: Many hospital administrators and infection preventionists still believe that DO is the gold standard and are just beginning to become aware that evidence-based technology is available. Some are also concerned that when compliance is measured electronically, the rates will be lower. In fact, compliance does not go down but rather is no longer inflated due to the Hawthorne Effect and small sample size. This is why fact and evidence based communication on the subject are vital and EHCO views this as a real opportunity for sound education. We suggest that transitioning to an electronic solution can be transformational and readily achievable if these three criteria are met: First, the transition is done with leadership support; second, done in a way that does not criticize the DO work of the past but rather embraces the emergence of evidence based technology that is the future; and lastly is framed as a way to eliminate the risk of avoidable infections and suffering which in the end is the aim of all in healthcare - to first do no harm. Just as every other area of healthcare is adopting advanced technologies for improved efficiencies and safer care, there is now innovative technology to help drive true improvement in hand hygiene compliance that is linked to the reduction of avoidable infections and their associated costs.
ICT: What are the immediate goals of the consortium? How will it begin to reach out to hospitals to promote its mission and achieve its goals? How will it benchmark its success?

Paul Alper: One of EHCO’s immediate goals is to make the evidence-based case to accreditation organizations, government agencies and health insurers to mandate that hand hygiene compliance measurement is brought up to the technological standard of the rest of healthcare. We will begin outreach over the next few months to begin the process with the goal of bringing about changes in policy, guidelines, regulations and incentives for how this key performance indicator of patient safety and healthcare quality is measured.

It’s almost as though hand hygiene is oversimplified in the minds of healthcare’s leaders. It’s easy to assume that people are cleaning their hands at the right time. But they are not; and if a monitoring method is providing inaccurate reporting and bad data, it puts patients at risk.  EHCO’s work will be done when DO alone is no longer considered an acceptable way to measure hand hygiene compliance as it is an antiquated method. Sophisticated technology is now available to do the work, and EHCO will lead the change for this technology to become the new standard of safe care.

ICT: There seem to be some big names missing from the list of consortium members – were the present manufacturers selected for a certain reason? Are other companies going to be approached about joining? How easy/challenging is it to bring so many players with diverse systems to the same table to achieve consensus?

Paul Alper: As part of the process in creating EHCO, the major players in the hand hygiene monitoring technology category were invited to join the consortium and focus on this considerable patient safety and public health issue. All of those who joined EHCO embrace the philosophy of rising above commercial and competitive interests and believe in working collaboratively for the public good. EHCO members have three things in common: all have technology that is capable of capturing 100 percent of hand hygiene events; does not require product conversion which can create a barrier to adoption; and all members have agreed to put improved patient safety and outcomes ahead of their commercial interests. EHCO invites all like-minded organizations interested in joining to reach out to us at EHCOhealth@gmail.com/

The EHCO website will be live on Feb.  2, 2016.


1. "Healthcare-associated Infections (HAIs)." Centers for Disease Control and Prevention, 15 Oct. 2015. Web. Available at http://www.cdc.gov/HAI/surveillance/#survey.
2. McGuckin M. Waterman R. Govednik J. “Hand hygiene compliance rates in the United States - a one-year multicenter collaboration using product/volume usage measurement and feedback.” School of Population Health Faculty Papers. March 2009 24(3): 205-213.
3. Fries SL, Tolentino G, Thomas T, et al. Monitoring hand hygiene via human observers: how should we be sampling? Presented at 21st Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; Dallas, TX: 2011. Abstract 50. Available at https://compepi.cs.uiowa.edu/index.php/Publications/Shea11c
4. Srigley JA, et al. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Qual Saf, 974-80. doi:10.1136/bmjqs-2014-003080. Available at http://www.ncbi.nlm.nih.gov/pubmed/?term=srigley+quantification.