A Helping Hand: Innovative Approaches to Expanding Hand Hygiene Programs in Acute Care Settings

Washing hands at a sink

(Adobe Stock 1298928756)

Hand hygiene is the cornerstone of infec­tion prevention in the hospital setting. Health care workers’ hands are recog­nized as vectors of harmful pathogens, yet adherence to hand hygiene protocols often falls short of expectations.¹ Not only does hand hygiene performance serve as a metric that impacts local and national hospital rankings,² but comprehensive hand hygiene monitoring programs are required for hospital compliance with Centers for Medicare & Medicaid Services standards.³ Despite public health, financial, and reputational incen­tives, capturing hand hygiene observa­tions to assess and improve adherence remains an opportunity for hospitals.

Background

To address challenges with hand hygiene adherence and staff engagement, the infection prevention department of a 493-bed academic hospital sought to improve its hand hygiene program. From July 2023 through June 2024 (fiscal year [FY]23), 3 innovative approaches were implemented to increase hand hygiene observations, improve hand hygiene performance, and foster sustained engagement in the hospital’s hand hygiene program. These approaches included establishing a dedicated workforce to focus on hand hygiene at institutional and unit levels, providing hands-on training and education to multi­disciplinary staff, and communicating directly with leadership regarding unit-level hand hygiene performance.

Coordinator engaging with nurses and unit clerks. May 2024.

(Photograph courtesy of Kerri Simone, MPH, CIC; Alexander O’Flaherty Linehan; and Will Zacamy)

A Dedicated Workforce

Although all health care workers are responsible for performing hand hygiene, monitoring has historically been the responsibility of a facility’s infection prevention program. The scope of infection preventionists (IPs) spans far beyond the duties of hand hygiene moni­toring, including infection surveillance and control, outbreak response, compli­ance with state and national reporting and regulatory requirements, main­taining environment of care, granting construction permits, and more. With a national median of 1 IP per 121 acute care patient beds,⁴ dedicating certified IPs to operate a robust hand hygiene program may not always be practical.

To address this need, the depart­ment’s administrative coordinator was assigned to prioritize and spearhead the growth of the hand hygiene monitoring program. The coordinator became the administrator of the facility’s electronic hand hygiene monitoring platform designed to capture moments of hand hygiene when entering or exiting a patient’s room. The coordinator ensured staff in clinical and nonclin­ical areas had access to the platform and completed training on the mobile-based monitoring application. Users were educated on accurately discerning between performed and missed hand hygiene opportunities.

To bolster the number of observations across the hospital, the infection prevention department onboarded an undergraduate student volunteer. An IP and the coordinator trained the volunteer to ensure they understood infection prevention principles, including hand hygiene and the electronic monitoring system. The volunteer was granted a security-issued identification badge and access to hospital-laundered scrub attire to enable observations to be conducted throughout the facility.

Figure 1. Number of Hand Hygiene Observations and Active Observers Enrolled in Hand Hygiene Program by Fiscal Year Quarter

(Courtesy of authors)

To maximize efficiency, the volunteer was dispatched to units and departments with low observation rates and to areas with exceptionally high performance rates to validate the data. The volunteer’s general anonymity also offered a way to discount the Hawthorne effect of exemplifying better hand hygiene practices while being monitored.

Hands-On Training With Frontline Staff

Before these interventions, the hand hygiene program relied on clinical nurses as observers and hand hygiene champions for their units. However, given that a nurse’s primary responsibility is direct patient care, submitting hand hygiene observations on their cell phones was not always practical in their workflow. To increase observations across all inpatient units, nursing leadership officially appointed (by job description) unit clerks to complete a minimum number of hand hygiene observations per shift. To ensure success, the coordinator partnered with the nursing education department to educate unit clerks on recognizing and electronically documenting hand hygiene observations.

Additionally, the coordinator provided education on observation and data collection to clinical support roles such as pharmacists, dietary aides, and environmental service personnel who travel throughout the hospital and see a wider range of employees. As a result of these strategic interventions, the coordinator saw a 100% increase in active, trained observers using the application (Figure 1).

For direct engagement with clinical staff, the coordinator created a hand hygiene cart to conduct live education sessions during rounds on clinical units.

The cart was equipped with a UV light and UV lotion (a proxy for alcohol-based hand sanitizer) to effectively demonstrate how well the staff applied the product. During these traveling direct observation education sessions, the coordinator provided pamphlets to staff to reinforce proper hand hygiene practices. Those who partici­pated received incentivizing samples of candy and hand sanitizer.

In addition to the overall improvement in hand hygiene performance (Figure 2), direct engagement with clinical staff was also achieved, which built a greater rapport between departments and served as a fun reminder to always wash your hands.

Figure 2. Rate of Hand Hygiene Adherence by Fiscal Year Quarter

(Courtesy of authors)

Engagement With Hospital Leadership

Although efforts to engage with frontline staff had always been in place, clinical and nonclinical leaders were largely unaware of their department’s hand hygiene performance. To improve trans­parency and promote leader engagement, the coordinator began sharing with leaders a weekly report of their depart­ment’s total number of observations and compliance rate by job role to highlight areas of opportunity. This direct and transparent communication was instru­mental in securing support from lead­ership at all levels for engagement with the hand hygiene program. The inter­ventions implemented in FY23 increased the number of active, trained observers performing hand hygiene observations.

Next Steps

During this period of sustained program growth, many observations were collected. This enabled the coordinator and IP team to focus educational efforts tailored to specific roles often docu­mented as nonadherent in hand hygiene.

Lending a Hand to Other Hospital Hand Hygiene Programs

Innovative approaches to hand hygiene programs can help increase hand hygiene observations and improve performance in the hospital setting. Even without an automatic or elec­tronic monitoring program, collecting observations and tracking adherence can benefit from expanding a hand hygiene workforce beyond the infection prevention team. This expansion fosters interactive learning and transparent communication with leaders. Although led by infection prevention departments, hand hygiene programs are further strengthened and sustained by innova­tion and multidisciplinary engagement in improving patient safety.

References

1. Glowicz JB, Landon E, Sickbert-Bennett EE, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update. Infection Control & Hospital Epidemiology. 2023;44(3):355-376. doi:10.1017/ice.2022.304
2. Handwashing. Hospital and Surgery Center Ratings | Leapfrog Group. (n.d.). https://ratings.leapfroggroup.org/measure/hospital/2024/handwashing
3. The Joint Commission. https://www.jointcommission.org/standards/standard-faqs/home-care/national-patient-safety-goals-npsg/000002354/. Accessed 13 March 2025
4. Bartles R, Reese S, Gumbar A. Closing the gap on infection prevention staffing recommendations: Results from the beta version of the APIC staffing calculator, American Journal of Infection Control. 2024; 52(12): 1345-1350. doi.org:10.1016/j.ajic.2024.09.004.