Industry Roundtable: Hand Hygiene Compliance

In February, a new industry consortium, EHCO™ -- the Electronic Hand-hygiene Compliance Organization – was formed by eight U.S.-based hand-hygiene compliance solution providers. This month, we further exploring the status of the hand hygiene market and the obstacles to bringing this sector up to the electronic status of the rest of healthcare. In a healthcare world of value-based care, where data is key, patient engagement is growing every day, and speed of access to information is saving lives, why are we still using pen and paper to record hand hygiene? The members of EHCO answer eight questions to shed some light on this topic.

Q: In today’s electronic age, why are hospitals adhering to direct observation? Do they perceive it as being more cost-effective than electronic systems? If so, how will EHCO address this? 
A: Changing long-standing standards in healthcare is difficult no matter the topic. People and hospitals in particular are resistant to change. It is also difficult for leaders to call the current standard inaccurate when for decades they have been led to believe otherwise. An electronic system of any kind that captures and reports on all hand hygiene behavior and that makes people more accountable is likely to face organizational and cultural barriers when it comes to acceptance as the new standard. Some argue that these systems have not yet proven themselves to be cost-effective. The question they never ask, however, is “cost-effective as compared to what.” Healthcare-associated infection (HAI) and hand hygiene compliance statistics in the U.S. have not materially changed for decades, despite countless resources being dedicated to the problem. EHCO is bringing all the collective evidence together in a united effort to prove just how effective various electronic hand hygiene compliance monitoring systems really are when it comes to avoiding unnecessary costs associated with preventable infections. ECHO maintains that we should not use a monitoring method that produces inaccurate results. If direct observation could fix the problem of hand hygiene compliance, it would have done so long ago. Electronic hand hygiene systems solve the age-old compliance measurement gap problem and, in return, significantly lower HAI risks to patients. This is a powerful and good thing for patients, their families and all healthcare system stakeholders.
-- Brent D. Nibarger, chief client officer, BioVigil

Q: For the hospitals that are still using direct observation, what have hospital administrators and infection preventionists expressed as the top concerns about adopting electronic systems? Why is an issue as seemingly simple as hand hygiene not so simple?  
A: Hospitals are apprehensive to migrate to electronic monitoring in part due to direct observation being the monitoring standard for many years. Change is difficult but the main issue is the rising hospital-acquired infections that are affecting patients, increasing costs, lengthening patient stay and so on. Hospitals are busier than ever and staff to patient ratios are forever decreased. One way to solve for this epidemic is to improve handwashing by investing in electronic monitoring that will give hospitals the tools to drive behavior change. Nurses, want to have a safe environment and we can help. There is an overarching concern from hospitals that electronic monitoring will make staff feel as if they are being watched constantly and will potentially be punished for their poor compliance. The reality is that electronic monitoring enables caregivers to change engrained behavior and provide proof of their good hand hygiene scores through reports that ultimately protects caregivers and their patients. In my experience, the caregivers who were hesitant to adopt electronic monitoring initially were incredibly pleased over time with the capabilities delivered by electronic monitoring. Further, while infection preventionists and administrators may realize direct observation is neither accurate nor reliable, they may not know enough about the accuracy of electronic monitoring and available solutions. It’s imperative that hospitals learn more about what is available, the benefits of each, and invest in the solution that is right for them. Hand hygiene compliance can, in fact, be simple, with the right electronic monitoring solution in place to aid in changing engrained behavior, assist with driving sustained improvement in compliance, and help them protect patients and their caregivers.
--Trey Cook, vice president and general manager of clinical workflow solutions, Hill-Rom, Inc.

Q: What are the immediate/short term goals of the consortium?
A: EHCO members have come together to explore avenues of mutual interest and cooperation in order to drive improvement for hand hygiene compliance in healthcare through electronic monitoring systems. That improvement will increase patient safety through reduction of HAIs, strengthen hospitals’ financial situation by reducing the potential of CMS penalties, and enhance the reputation of hospitals that adopt the technology. EHCO is actively acquiring data on how these systems perform and is reaching out to accreditation organizations, government agencies, health plans and thought leaders to present them with compelling evidence that electronic monitoring should become the future standard of care. We also look to educate organizations about compliance monitoring solutions available now to establish and enforce formal infection control mechanisms.
 -- Sy Sajjad, chief executive officer, AiRISTA

Q: How will EHCO begin to reach out to hospitals and organizations to promote its purpose and achieve its goals? What defines success? 
A: EHCO does not promote any specific company or technology platform. Instead, the Consortium will be reaching out to the senior leaders at accreditation organizations, government agencies, health insurers, infection prevention and disease prevention organizations along with hospitals and patient safety advocacy groups to educate them on the most recent evidence that makes the case for adoption of electronic monitoring systems over direct observation as the acceptable standard of care. We will conduct high level meetings (some of which are already scheduled) at which we will share the compelling case for why measuring hand hygiene, a critical element of patient safety and healthcare quality, needs to be done 24/7/365 with an electronic system capable of capturing and reporting on 100 percent of hand hygiene events, not an insignificant and biased sample size as is captured using direct observation with pen and paper or an iPhone app. We will succeed when regulations, guidelines, recommendations change in favor of adopting highly reliable electronic systems over inaccurate and flawed methods that rely on human direct observation. As we enter the digital age of quality and performance improvement, the change will take place, just as alcohol replaced soap and water as the primary method of hand hygiene back in the 1980s and 1990s.
-- Paul Alper, vice president, patient safety strategy, DebMed

Q: What are the challenges and shortcomings of direct observation? What are some of the studies that support these disadvantages?
A: Direct observation has been found to be flawed due to multiple factors. The main issue is that the caregivers behave differently when they know they are being watched, and as a result they modify their behavior to what they think it should be - this is known as the Hawthorne Effect.  
A recent 2014 study by Srigley, et al. (2014) proved that hand hygiene compliance was overstated by 300% when caregivers were within the line of sight of the observer. (See: 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: The second problem with direct observation is that because it is a costly endeavor to have staff monitoring others, the sample size and the amount of data gathered is insignificant. If facilities want to paint an objective, accurate and reliable picture of their hand hygiene practices, they cannot continue to monitor using traditional methods with small sample sizes.  The most well-known study that outlines these shortcomings was published in Infection Control and Hospital Epidemiology in 2010 ( The published study compares multiple methods of collecting hand hygiene data and concludes that direct observation cannot be considered the gold standard for assessing hand hygiene.
-- Brett McGreaham, senior product manager, healthcare innovations, Versus Technology, Inc.

Q: How can electronic monitoring systems improve hand hygiene rates?
A: Electronic monitoring systems present innovative, automatic, and efficient monitoring alternatives to direct observation to help drive true improvement in hand hygiene compliance. Evidence-based electronic measurement of hand hygiene has become widely available to accurately and continuously monitor hand hygiene compliance and enable meaningful feedback to healthcare workers.
By using electronic systems to measure 100 percent of hand hygiene behavior, hospitals can audit hand hygiene processes, set new benchmarks to improve hand hygiene compliance rates, reduce the spread of unnecessary infections, improve patient outcomes, and lower healthcare costs.
-- Adam R. Peck, senior director, marketing, CenTrak

Q: How can electronic monitoring systems make the life of the infection preventionist easier? What can IPs do to support and promote EHCO?
A: Infection preventionists (IPs) today are incredibly frustrated by the lack of accountability inherent with pen and paper based monitoring. Electronic monitoring provides real data, and that enables changing behavior and habits around hand hygiene. This makes life easier for not just IPs, but all healthcare workers across the hospital. However, this revolution needs to start in the infection control department and then IPs need to become informed and passionate advocates for change with senior leadership where the decisions get made. They are the ones that can say no to paper reporting, no to countless hours of observation, no to ineffective methods of behavior change. IPs need to be talking about this in their local APIC meetings, bringing up the concept in committees and becoming champions for this transformation happening in healthcare. Ultimately, the perceived standard of pen and paper based monitoring needs to change from "best attempt" to "sub-par" in the world of infection prevention. This new standard is the best support an IP can provide to promote EHCO.
-- Mert Iseri, chief executive officer, SwipeSense

Q: EHCO is comprised of eight different companies and technologies. What if anything, do all the technologies have in common?
A: The common theme among all of the EHCO member companies and technologies is that they accurately monitor and capture 100 percent of all hand hygiene events. Currently, almost every hospital monitors hand hygiene through direct observation, which drastically undersamples the number of hand hygiene events. The data is then further compromised in many hospitals due to either observation bias and/or the Hawthorne Effect. Combining these factors results in hospitals making decisions around hand hygiene data that is simply not accurate. The EHCO companies all have developed and tested technologies that allow hospitals to collect accurate data on 100 percent of the hand hygiene behavior in their facilities 24/7/365. While the approaches to collecting and reporting on this data are different, all of the systems provide hospitals with data that can be used to manage the performance of their staff and improve patient safety.
-- Chris Hermann, PhD, chief executive officer, Clean Hands Safe Hands