Direct Observation: the “Fool’s Gold” Standard

Direct Observation: the “Fool’s Gold” Standard

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fool’s gold (ˈfo͞olz ˌɡōld): something that you think will be very pleasant or successful but is not.

Direct observation is no longer the gold standard in hand hygiene performance monitoring. Direct observation is, rather, the “Fool’s Gold” standard.

You remember Fool’s Gold, or iron pyrite. It’s a mineral – not a metal – that’s shiny and gold-colored. It’s often confused for the real thing, but there is no value.  People wasted a lot of time trying to find this “gold,” only to have a false sense of its worth.

Direct observation is similar – it’s supposed to effectively measure hand hygiene performance, but it only appears to do so on the surface. In reality, all it provides hospitals are artificially inflated numbers that provide a false sense of security. Sure, it keeps the accreditation agencies off your back, but it is also killing your patients.

There has been a lot of work done to improve direct observation. With a lot of effort (and money) you can overcome some of the limitations such as low sample size, inability to see into rooms, inaccuracies, observer bias, and recall bias…but it is still has a fatal limitation – The Hawthorne Effect.

The Hawthorne Effect refers to a phenomenon that people will modify their behavior simply because they are being observed. When hospital clinicians spot the “secret shopper” that’s observing them, they are more likely to properly clean their hands. No matter how “secret” the observers are, the staff eventually figure it out, and this artificially inflates the numbers.

In every implementation of our electronic hand hygiene performance system, we have seen that the actual compliance rates recorded by our technology are a half to a third (or worse) of what the hospital has been reporting via direct observation. Two very elegant studies have demonstrated that hand hygiene increases by a similar 300% only when observers are present*.

This is simply human nature and there is nothing you can do to change this. What happens when you see blue lights on the highway? Everyone slows down. What happens when they go away? Everyone speeds back up.

The same thing happens with hand hygiene. As a result, direct observation makes you think that you are being successful but it is not….the exact definition of Fool’s Gold.


* 1. Srigley, J.A., et al., Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf, 2014. 23(12): p. 974-80.

2. Hagel, S., et al., Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring. Infect Control Hosp Epidemiol, 2015. 36(8): p. 957-62.

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