There is ongoing debate on the most effective
way to monitor hand hygiene compliance across
the continuum of healthcare (acute-care hospitals,
ambulatory-care settings, long-term care, home
care, etc.). There are a variety of methods currently
used to monitor hand hygiene practices: direct
observation, secret shoppers, product usage,
patient reporting and electronic monitor systems.
Since there is no consensus on the best way to
monitor hand hygiene compliance, a facility may
choose to use more than one method for a better
picture of hand hygiene compliance. The Joint
Commission offers a monograph on hand hygiene
monitoring compliance methodology. It predom-
inantly reports on the creative ways that facilities
have instituted observational monitoring.
Patients may be asked to complete a survey
card about their observations about hand hygiene
practice or via an interview. This method has
been used both in ambulatory-care settings and
in some acute-care hospitals.
Direct observation continues to be used
by many facilities. Some institutions reward
staff for doing so many direct observations per
month. Others assign the responsibility to specific
staff that has been trained to conduct direct
observations using a common form for data
collection. They may conduct the observations
during their normal work assignments or monitor
separate from regular work assignments. Others
may act as secret shoppers by visiting units and
observing care practices. Challenges of direct
observation include: time and human resource
usage; the Hawthorne Effect if staff recognize
that they are being observed for hand hygiene
practices; and the ability or non-ability to view
all aspects of care that require hand hygiene,
especially in private patient rooms; and training
observers to assure consistent data collection. As
direct observation monitoring has evolved, many
facilities have developed programs for phones or
tablets to be able to directly record data, which
helps to decrease the time to enter and analyze
data previously collect on forms.
There are products that have dispensers that
can measure how often someone accesses the
product. There are also programs that have
determined the number of expected hand hygiene
events that occur in patient care unit or in an
ICU. The volume of the product that is used for
each event and a usage index can be calculated
to determine if the expected number of uses
have occurred. This method does not require as
many human resource hours to observe hand
hygiene. The volume of use can be trended to
show if usage is consistent and ongoing versus
a lower volume that expected would require an
investigation to determine the cause.
Innovative technology has been developed to
electronically monitor hand hygiene compliance.
www.healthcarehygienemagazine.com • may 2020
Some measure compliance on entry and exit of
the room, others monitor compliance within the
patient care zone or a combination of electronic
data. By installing an electronic monitoring
system, a facility can monitor hand hygiene
practice throughout the day and produce data
that shows on-going compliance.
Some challenges exist with electronic
monitoring:
➊ Identification badges worn by staff to record
the persons activity can be heavy to wear, need
batteries or recharging, and must be coded to
identify the person who is using it, which can be
difficult if the badge is shared by personnel on
different shifts. The cost of the badge for some
systems can prohibit a facility having a monitor for
each healthcare provider. Each system is working
on improving this process and the facility must
evaluate what will work best for them.
➋ Installation of electronic monitoring compo-
nents in each room on a unit and connecting the
data to a common database varies with system
and must be done in a way not to interfere with
other patient care electronics. Facilities mainte-
nance staff should be involved in the installation
of the system to avoid problems.
➌ Cost of the system can be challenging
especially if installation in all patient rooms is
done. Some facilities have elected to rotate the
units where they monitor to decrease overall
cost. Many vendors are working to improve their
systems and to decrease overall costs to allow for
wider use of their electronic monitoring system.
➍ Validation of the data recorded by the
electronic monitoring system should be done
to make sure that the system is collecting data
as designed. Validation should include direct
observation as well as evaluation of the generated
reports. Preventive maintenance should also be
done to ensure that it is functioning.
As direct
observation
monitoring has
evolved, many
facilities have
developed
programs for
phones or
tablets to be
able to directly
record data
which helps to
decrease the
time to enter
and analyze
data previously
collect on
forms.
Electronic hand hygiene compliance monitor-
ing continues to evolve, making it easier to use
with better data being available. Meanwhile,
facilities may want to use several monitoring
techniques to evaluate hand hygiene as a main
infection prevention strategy until the “gold
standard” is established. They should continue
to evaluate the various systems and determine
which one will be helpful to provide a broader
look at hand hygiene compliance.
Self-reporting of hand hygiene compliance
has been shown not to be accurate and provides
an over-estimate an individual’s actual hand
hygiene practices. Therefore, it is essential for
the hand hygiene compliance data be generated
and shared to encourage change in practices.
Accurate reporting of hand hygiene compliance
in a format that is easy to understand and can
illustrate compliance trends should be the goal of
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