Hand Hygiene Compliance Auditing Does Not Work



In 2009 the World Health Organization began marketing compliance auditing of the “Five Moments for Hand Hygiene” in an effort to improve the hand washing rates among healthcare workers to reduce hospital-acquired infections. The authors of this article describe this campaign as a tragic public health misstep, due to invalid conceptualization and measurement, consuming scarce public health resources that could be devoted to developing a real understanding of hand hygiene behaviour.

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Hand hygiene is crucial, there can be no doubt. Ignaz Semmelweis demonstrated this fact in Vienna in the 1840s, when he discovered that dirty hands were responsible for so many post-partum deaths in hospital maternity wards.[1]  At the time, it was surely a discovery worthy of a Nobel Prize. Today it is merely common sense, and authoritative hospital hand hygiene guidelines have now existed for decades.[2]

However, the advent of advanced antibiotics since the 1960s appears to have relegated infection control to a quieter channel of medical scholarship. Methicillin-resistant Staphylococcus aureus (MRSA) was first observed in 1960, only one year after the introduction of methicillin itself.[3]  However, only within the last several years have virulent bacteria in hospital environments evolved and become highly prevalent, developing alarming resistance to many and sometimes all available antibiotics.[4]  The spectre of being defenceless against hospital-acquired infections has catapulted hand hygiene into the foreground of the patient safety discourse.

In 2007 the World Health Organization introduced its “Five Moments for Hand Hygiene” framework, which outlined five key moments in healthcare when personnel should be washing their hands: before patient contact; before an aseptic task; after body fluid exposure risk; after patient contact; and after contact with patient surroundings.[5]  The subsequent WHO campaign, since 2009, to recruit hospitals and healthcare facilities around the world to participate now stands at 18,365 registered healthcare facilities in 174 countries.[6]

The Five Moments are alluring because they appear to be actionable and measurable: they can be benchmarked, targeted for intervention, and they offer a seemingly objective yardstick to measure improvement in the otherwise nebulous notion of patient safety.  Most hand hygiene auditing programs have been aligned to the Five Moments, and are designed to enforce the Five Moments as well as to provide feedback to healthcare workers.[7]

there is little valid evidence of any relationship between interventions that improve compliance

However, those involved in conducting hospital hand hygiene compliance auditing, and the frontline healthcare workers being audited, share an open secret:  there are serious validity problems with the way data are collected, interpreted, and reported.[8]  Those who have studied the hand hygiene compliance research literature know that there is little valid evidence of any relationship between interventions that improve compliance with the Five Moments and hospital infection rates.[9],[10]

The Problem

The problem with the WHO’s Five Moments for Hand Hygiene is actually twofold:

  1. Compliance rules attempt to reduce an extremely complex behaviour into simple rules

Self-health-related behaviour is notoriously difficult to change in individuals.[11]  This is evident in the epidemiology of obesity, cardiovascular disease, diabetes, smoking, alcohol, and so forth. As a result, expecting substantial behaviour change by fiat is naïve.

For example, imagine setting rules at precise moments in time for someone to quit smoking: no smoking at meals, no smoking in bed, no smoking inside bars, and so forth. These rules comprise a very logical strategy for reducing smoking, but they will not be effective because they are not addressing the complex mental and physiological underpinnings of this behaviour.[12]  The result is to displace smoking to other times and places, along with cycles of regression to usual habits.

Weight loss provides a second example of self-health-related behaviour change rules: a maximum number of calories at each meal, no dessert after dinner, no French fries with lunch, no bagels at breakfast, no alcohol on weeknights, and so forth.  Such rules should work perfectly, but they usually do not:[13] people will find other ways to indulge the complex interplay of mental and physical triggers, such as snacking between meals, eating larger portions, and so forth.

Hand hygiene behaviour among healthcare workers can also be seen as a self-health-related behaviour that stubbornly resists intervention for improvement.[14]  The psychology of personal hand hygiene has not been well studied, but it deserves serious consideration.  For example, the therapeutic approach known as motivational interviewing appears effective for smoking cessation,[15] and could be used to develop novel interventions to target the cause of hand hygiene behaviour, rather than simply insisting that rates improve.

  1. Conceptualizing hand hygiene quality with a few narrow and subjective measures is not valid.

There are a lot of hands in a hospital environment, belonging to clinicians, patients, and their visitors.  Pathogenic bacteria do not differentiate between people’s roles, but hand hygiene compliance measurement does.  Some of the worst infections, such as C. difficile, vancomycin-resistant enterococcus (VRE), and carbapenem-resistent enterobacteriacae (CRE), are known to spread via the fecal-oral route, meaning that they enter the patient’s body through the mouth.[16]  This would suggest that patients’ own hands should be cause for concern, but the WHO is silent on patient hand hygiene.  Rather, the focus is on a tiny sampling of clinician hands, and only at the Five Moments.  Restaurant kitchens typically have signs admonishing staff to wash their hands when they use the bathroom, but no such signs appear in hospitals.

As for the effect of auditors on compliance behaviour, there is an undeniable ‘gaming’ of this measurement system. A recent study using pervasive electronic surveillance of hospital staff behaviour before, during and after hand hygiene audits consistently revealed a 300% increase in hand hygiene behaviour when in the line of sight of an auditor.8  Another study found that observation-based assessment on the same hospital ward varied between 44% and 94% compliance, depending on how well the observer knew the staff, not on hand hygiene performance.[17]

In light of the arbitrary and poorly measured conceptualization of hand hygiene, finding no relationship between reported compliance and infection rates is hardly surprising: what is being measured and reported seems to have little to do with preventing the spread of bacteria.


The ultimate measure of hand hygiene success lies in producing a sustained drop in infection rates.  Using this standard, the WHO Five Moments scheme has failed hospitals and their patients for nearly a decade.  However, the problem here is worse than simple failure.  The Five Moments amount to a tragic misstep in public health because this ubiquitous program has sucked up vast public health measurement and management resources across the globe, but without contributing meaningfully to the reduction of hospital-acquired infections. Because of the myopic focus on the Five Moments, no resources are directed to other critical facets of hand hygiene, such as patient hands, staff bathrooms, and the behaviour of visitors.

The Five Moments need not be abandoned, because they represent an excellent training framework for a minimum handwashing standard for clinicians during the course of patient contact.  Nursing schools would do well to drill the Five Moments during patient care simulations.  There is also some value in using unobtrusive, electronic monitoring of one or two of the Moments, such as when clinicians enter and exit patient care areas.  There are many such systems on the market today.[18]

However, hospitals can and should move far beyond the Five Moments, to better understand hand hygiene dynamics. For example, the pervasive measurement afforded by electronic monitoring could also provide data to help managers understand where and when hand hygiene is happening or not happening. Specifically, better electronic monitoring could provide information on:

  1. Areas (rather than people) where compliance is typically bad (or good), which may suggest environmental design changes to improve behaviour
  2. Times and places staff are cleaning their hands more or less may help design interventions that are precisely targeted where they are needed
  3. Rates of bathroom hand hygiene among visitors as well as staff can be used to estimate what might be one of the most dangerous sources of bacterial proliferation
  4. The effectiveness of interventions to promote hand hygiene awareness outside of the Five Moments perspective on direct staff-patient contact

Another way to connect hand hygiene behaviour with infection rates might be to measure the amount of hand hygiene that happens around patients, regardless of who is doing the hand cleaning.   In contrast to the Five Moments, such a conceptualization might well reveal a correlation with infection rates, providing a valid measurement to test interventions for improvement.

None of these alternate ways to measure hand hygiene quality pose any particular technical or policy problems.  The problem is, this work is not happening because there appears to be no appetite for it: neither the WHO nor the CDC has made any meaningful statement about the importance of hand hygiene beyond the restrictive Five Moments.  As a result, there is what could be called a “cult of hand hygiene”: a slavish adherence by hospital infection control departments to the Five Moments.  This cult embraces a myopic and arbitrary framework without valid measurement and without any capacity to see anything beyond its confines, including such obvious targets as bathrooms.  The result has been the entrenchment of a dysfunctional, false complacency that something is being done.

It is this complacency that prevents the kind of research, experimentation, and adoption of automated measurement tools that would promote the understanding hand hygiene holistically, as a complex behaviour.  Armed with that understanding, hand hygiene interventions might be designed to reduce infection rates, something that the Five Moments have not been able to do.


[1] Young TK. (2005). Population Health (2nd Ed). London: Oxford Press

[2] Garner JS, Favero MS. (1986). CDC guideline for handwashing and hospital environmental control, 1985.” Infection Control 7, 231–43.

[3] Jevons MP, Parker MT. (1963). Methicillin resistance in staphylococci. Lancet 281, 904-907.

[4] Plotkin MJ, Shnayerson M. (2003). The Killers Within: The Deadly Rise of Drug-Resistant Bacteria. Boston : Little, Brown and Company.

[5] Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D, et al. (2007) ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection 67(1): 9–21. Retrieved December 23, 2015: http://www.who.int/gpsc/5may/background/5moments/en/

[6] World Health Organization (2015). Registration Update – Countries or Areas. Retrieved December 23, 2015: http://www.who.int/gpsc/5may/registration_update/en/

[7] Joint Commission (2009). Measuring Hand Hygiene Adherence: Overcoming the Challenges.  Retrieved December 24 from: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf

[8] Srigley JA, Furness CD, Baker R, Gardam M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Quality and Safety 23(12). Retrieved December 23, 2015: http://qualitysafety.bmj.com/content/early/2014/07/07/bmjqs-2014-003080.full

[9] DiDiodato, G (2013, June). Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. Infection Control and Hospital Epidemiology 34(6):605-10.

[10] Gould DJ, Moralejo D, Drey N, Chudleigh JH. (2010). Interventions to improve hand hygiene compliance in patient Care. The Cochrane Library, Issue 9.

[11] Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People to Change. 2nd ed. NY: Guilford Press.

[12] DiClemente CC, Procaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. (1991). The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology 59(2), 295-304.

[13] Jeffery RW, Epstein LH, Wilson GT, Drewnowski A, Stunkard AJ, Wing RR. (2000). Long-term maintenance of weight loss: Current status.  Health Psychology 19(1, Suppl), 5-16.

[14] Whitby M, McLaws M-L, Ross MW. (2006). Why healthcare workers don’t wash their hands: a behavioral explanation. Infection Control and Hospital Epidemiology 27(5), 484-492.

[15] Heckman, C. J., Egleston, B. L., & Hofmann, M. T. (2010). Efficacy of Motivational Interviewing for Smoking Cessation: A Systematic Review and Meta-Analysis. Tobacco Control, 19(5), 410–416.

[16] Chin J. (2000). Control of Communicable Diseases Manual. 17th ed. Washington: American Public Health Association.

[17] Pan SC, Tien KL, Hung IC, Lin YJ, Sheng WH, Wang MJ, Chang SC, Kunin CM, Chen YC. (2013). Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PLoS One 8(1).

[18] Ward MA, Schweizer ML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. (2014). Automated and electronically assisted hand hygiene monitoring systems: a systematic review. American Journal of Infection Control 42(5), 472-478.

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Colin Furness BSc MISt PhD MPH
Colin has twin backgrounds as a hospital infection control epidemiologist and information systems designer. He is an adjunct professor at the University of Toronto’s Institute for Health Policy, Management, and Evaluation, and he is an assistant professor (status) at U of T’s Faculty of Information. Colin also maintains a small private practice in information systems evaluation and design, and he consults in his role as Chief Scientist for Infonaut, a privately held company focused on information systems to support hospital infection surveillance.
Niall Wallace
Niall Wallace is a co-founder and the Chief Innovation Officer of Infonaut Inc. Infonaut is a privately held Canadian company with Canadian locations in Toronto, and Hamilton Ontario, with US offices in Buffalo New York. Born out of Ontario’s SARS crisis, Infonaut solves the global challenge of deadly hospital infection through their proprietary real-time surveillance, analytics and behavior improvement platform. Niall has used his background in population health, public health, data-warehousing and privacy to develop deep expertise in innovative platforms that use the power of location technology, and B.I. systems for disease and infection surveillance.