Hand hygiene compliance: we’re kidding ourselves

I’d like to direct your attention to a flurry of fairly recent correspondence in the Journal of Hospital Infection around whether the high levels of hand hygiene compliance commonly reported in England are realistic and useful.1-5

On the one hand, we know that actual hand hygiene compliance with the WHO 5 moments for hand hygiene is seldom more than 40%.6 In fact, if you count the number of typical opportunities and the time it takes to wash your hands (properly), then 100% compliance probably isn’t possible, even in theory.1, 2, 4, 5 Therefore, an expectation to report a high level of hand hygiene compliance (north of 95%) is neither realistic nor useful as a performance indicator.

On the other hand, how can we possibly justify not achieving a high level of hand hygiene compliance (in excess of 95%)? Semmelweis’ data should be enough to convince everybody of the importance of this simple, low-cost, high-impact intervention. So, if our hand hygiene compliance isn’t already >95% then it jolly-well should be!3

When I first joined the NHS, I spent some time on a ward doing some covert auditing. I dressed in my doctor’s uniform (light blue shirt rolled up to just below the elbow, sand coloured chinos, and shinyish shoes) and pretended to take notes. I can tell you that hand hygiene compliance was nowhere near 95%. In fact, it was nowhere near 50%. And I would say that this is fairly typical!

So, for me, we need a useful performance indicator of hand hygiene compliance. It doesn’t really matter to me whether the bar is set at 10% or 90%. But it needs to be a performance indicator that can identify areas of poor performance and drive focussed genuine improvement initiatives.


[1]        Mahida N, Boswell T, Vaughan N. Re: In defence of high hand-hygiene compliance rates. J Hosp Infect 2017; 97: 32-3.

[2]        Mahida N. Hand hygiene compliance: are we kidding ourselves? J Hosp Infect 2016; 92: 307-8.

[3]        Oliver C, Thompson A, Cooke RPD. In defence of high hand-hygiene compliance rates. J Hosp Infect 2017; 97: 31-2.

[4]        Bradley CW, Holden E, Garvey MI. Hand hygiene compliance targets: what are we actually targeting? J Hosp Infect 2017; 95: 359-60.

[5]        Jones S, Reay S, Bull D, Gray J. Hand hygiene compliance monitoring: we need to stop kidding ourselves. J Hosp Infect 2017; 97: 33-4.

Image: Wikipedia.


One thought on “Hand hygiene compliance: we’re kidding ourselves

  1. Dear Jon,
    Sir Humphrey would say you are very courageous. An Emperor’s New Clothes moment.
    When we did studies on doctors’ practices years ago the compliance with hand hygiene opportunities
    (though “opportunities” had not been invented then) was about 50% but if you looked at efficacy of the
    process in terms of covering all areas of the hand it was about 50%, even with overt observation and a n instruction chart over the sink. So the real compliance was 50% of 50%.
    I also suspect that all the enormous effort put into auditing has had a minimal effect except for creating a lot of stress in dedicated staff. Now that you have officially pointed this out one could lose the will to live altogether! What is your answer? Despite the sound and fury, all the extra effort has mainly been exhorting the troops to try harder with less resources. The sort of technology to automatically measure performance
    referred to in the JHI papers would help and demonstrate real commitment from management.
    Doctors do respond to seeing the results of hand cultures and the efficacy of their decontaminating procedure
    on colonisation but the teaching of microbiology to medical students has been diminished rather than up-regulated.
    I hope you have stimulated some real thought on what we should do.

    David McGechie
    Consultant Microbiologist.
    Fiona Stanley Hospital
    Western Australia.


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