Hand Hygiene Compliance Rates Aren’t as Important as You Think

By Clean Hands - Safe Hands

Want to decrease HAIs in your hospital or healthcare facility?

Stop focusing on hand hygiene compliance rates.

Yes, poor hand hygiene is strongly associated with healthcare-associated infections. That much has been known since the mid-1800s when Dr. Ignaz Semmelweis noted a strong link between hand sanitation and maternal mortality. Approximately 100 years later, the U.S. Centers for Disease Control and Prevention clearly identified hand hygiene as an important way to prevent the spread of infection; the first nationally endorsed hand hygiene guidelines soon followed.

Improving hand hygiene compliance continues to be a key focus of initiatives designed to reduce healthcare-associated infections (HAIs). In fact, the Joint Commission explicitly assesses hospitals’ progress toward National Patient Safety Goal #7, Reduce the Risk of Health Care–Associated Infections, in part by measuring how well they “set goals for improving compliance with hand hygiene guidelines” and “improve compliance with hand hygiene guidelines based on established goals.” 

But measuring and tracking hand hygiene compliance rates is not always the quickest or most effective way to reduce HAIs. To efficiently decrease the risk of infection, you must minimize missed opportunities for hand hygiene – and that metric may or may not correspond with hand hygiene compliance rates. 

Why “Missed Opportunities” Matter More than Hand Hygiene Compliance Rates

It’s simple math: a healthcare provider who has 1000 hand hygiene opportunities per week and a hand hygiene compliance rate of 80% misses 200 hand hygiene opportunities each week, on average. That’s 200 chances for pathogens to spread.

In contrast, a healthcare worker who has 100 hand hygiene opportunities weekly and a 50% hand hygiene compliance rate misses 50 hand hygiene opportunities per week. 

The first healthcare provider – the one with the 80% hand hygiene rate – is doing a far better job of hand sanitation than most healthcare providers, as hand hygiene compliance rates are often less than 50%. If you look only at hand hygiene compliance rates, you’d likely conclude that this worker is meeting expectations, and you’d be unlikely to offer them additional hand hygiene education, counseling, or assistance. 

Instead, you’d likely direct your attention to the worker with the 50% hand hygiene compliance rate. However, this employee missed far fewer hand hygiene opportunities, perhaps because this worker doesn’t have as many patient interactions. From an infection control standpoint, the worker with the 80% hand hygiene compliance rate is at greater risk of spreading infection than the employee with the 50% hand hygiene compliance rate.

To effectively decrease the risk of infection transmission, you must focus your efforts on decreasing opportunities for transmission. You can do so by measuring and tracking missed opportunities for hand hygiene

Uncovering Missed Opportunities for Hand Hygiene

Because healthcare is a dynamic environment, it can be difficult to measure hand hygiene opportunities. The World Health Organization (WHO) recommends that healthcare workers clean their hands at 5 essential moments

  1. Before touching a patient
  2. Before clean/aseptic procedures
  3. After body fluid exposure/risk
  4. After touching a patient
  5. After touching patient surroundings 

Busy clinicians encounter dozens, if not hundreds, of these moments each shift. An electronic hand hygiene system that captures and records individual data can help. The Clean Hands – Safe Hands systems uses Performance Bubble Plots to reflect both the hand hygiene performance and number of hand hygiene opportunities of individual providers. 

Each circle represents a badged individual. The size of the circle corresponds with the number of hand hygiene opportunities, with a large circle representing many opportunities and a smaller circle indicating fewer opportunities. The color of the circle represents hand hygiene compliance, with green signifying “good” and red indicating “needs improvement.” The tone of the color matters as well: Dark green is very good and dark red means there’s lots of room for improvement.

The visual representation of data makes it easy to spot outliers. A slightly deeper dive, though, is necessary to spot powerful opportunities to decrease the risk of infection transmission. Let’s take a look at this Performance Bubble Plot:

Vanessa missed quite a few hand hygiene opportunities and her hand hygiene rate is low. She had 339 opportunities, and her hand hygiene compliance rate is 16%, so she had 285 missed opportunities – 285 times when she should have sanitized her hands but did not.

In contrast, Hannah appears to be doing well. Her hand hygiene compliance rate is 50%, significantly higher than Vanessa’s. But because she had so many more hand hygiene opportunities – 629, to be exact – her absolute number of missed hand hygiene opportunities is 314. Her higher Activity Index means that she likely has more patient interactions. So, even though her compliance rate is greater than Vanessa’s, Hannah poses a significant risk of infection transmission.

Addressing Missed Opportunities Can Decrease HAIs

“There are a small number of people who make up a disproportionate amount of missed hand hygiene episodes,” says Chris Hermann, MD, PhD, founder of Clean Hands-Safe Hands. Identifying and tracking missed hand hygiene opportunities allows you to target your efforts so you can efficiently decrease HAIs. 


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