hand hygiene
By Paul Alper, BA
Direct Observation: A Robust Approach
for the WHO 5 Moments
I
was recently asked by the head of infection prevention
at a community hospital how to design a robust hand
hygiene direct observation program. Their objective was to
get the most accurate compliance data possible, as they got
ready for an upcoming Joint Commission visit.
I thought there might be others who would like to know
how to accomplish this given that direct observation is still
the most widespread method used for hand hygiene perfor-
mance measurement. This is in spite of the fact that direct
observation has been shown to have many shortcomings,
including lack of accuracy due to the Hawthorne Effect, 1 lack
of inter-rate reliability and bias on the part of the observers.
An Evidence-Based Approach
Drawing on the methodology of a landmark study 2 by
Steed, et al. that, for the first time, scientifically determined
the number of hand hygiene opportunities (HHOs) in
various settings using a disciplined approach to direct
observation-based on the WHO 5 Moments, I have created
a “best practices for direct observation” checklist.
Here is a summary and checklist for how facilities could
implement the approach used in the study and acquire
compliance data that is as accurate and reliable as we likely
can expect data from direct observation to be.
Checklist for a Robust Direct Observation Program
Note that apps to capture and compile direct observation
data for smart phones and tablets are available from your
App Store or provider. We will address the manual process
in Steps 3, 4 and 5 below but simply follow app instructions
if you are using one of them instead.
➊ Train observers. This should consist of the following
three steps:
a. Total familiarization with The WHO 5 Moments Poster.
b. Complete familiarization with the WHO Hand Hygiene
Training Films and Slides Accompanying the Training Films.
c. Practice doing observations with feedback from a lead
observer or infection prevention manager.
➋ Assess inter-rater reliability. Conduct this routinely to
ensure consistency of data collection.
a. In its simplest form, observers could conduct
direct observations together and compare results. A lead
observer could also accompany observers to reinforce
consistent results.
➌ Conduct Direct Observation. Observation of hand
hygiene behavior is accomplished using the WHO Data
Collection Tool or a modified version as such was the case in
the HOW2 Study. Johns Hopkins Medicine also has created
a Hopkins Medicine Monitoring Tool.
a. Complete the top part of the header before commenc-
ing observation (except end time and duration)
www.healthcarehygienemagazine.com • march 2020
b. A session should last no more than 20 minutes.
c. Record HHOs in the appropriate column and fill in the
square corresponding to the indications for hand hygiene
detected.
d. Record hand hygiene events or HHEs (or hand hygiene
actions) observed or missed for each indication.
e. Glove use may be recorded only when a hand hygiene
event is missed while the healthcare worker is wearing gloves.
f. At the end of the session, record end time and duration.
➍ Compile the data. Data from each Observation Form
should be entered into a master data base such as Excel.
Total hand hygiene events for a period are aggregated and
divided by the total number of HHOs to determine the
Compliance Rate for specific periods of time (week, month,
quarter, year) for specific units as well as aggregated for the
entire organization.
➎ Create graphs and reports. Performance graphs and
appropriate reports should be created and then shared with
unit and organization leadership.
➏ Give front-line staff feedback. Front line workers should
be provided with performance feedback as immediate as
possible after report creation.
➐ Create performance improvement action plans. Units
and departments should be responsible and accountable for
action plans to remove unit specific barriers and obstacles
to proper hand hygiene behavior.
While data from direct observation may be overstated,
if collected consistently, it should provide a sound tool for
measuring real improvement and the impact of initiatives de-
signed to drive sustainable growth in hand hygiene behavior.
Thanks to the HOW2 authors for the creative research
that inspired this column.
References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. (2014). Quantification
of the Hawthorne Effect in Hand Hygiene Compliance Monitoring Using
an Electronic Monitoring System: A Retrospective Cohort Study. BMJ Qual
Saf. 23, 974–80.
2. Steed C, Kelly JW, Blackhurst D, Boeker S, Diller T, Alper P and Larson E.
(2011). Hospital hand hygiene opportunities: Where and when (HOW2)? The
HOW2 Benchmark Study. Am J Infect Control. 39(1), 19–26. doi:10.1016/j.
ajic.2010.10.007
Paul Alper, BA, led the launch of PURELL®, invented the
first electronic hand hygiene monitoring system proven to
reduce infections while improving behavior and eliminating
costs and is now the VP Patient Safety Innovation for
Medline Industries, Inc. through an exclusive engagement
with his consulting practice, Next Level Strategies, LLC.
He can be reached for questions or comments at paul@
next-levelstrategies.com.
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