Hand Hygiene

Publication ID: 2829235249
Published on: September 2023
Major Revision: May 24, 2024


Hospital staff hands are the single most common vehicle for the transmission of infectious pathogens in the hospital environment. In fact, hand hygiene compliance in most hospitals is less than 50%, which significantly contributes to the estimated 37,000 deaths each year in European countries and the nearly 99,000 deaths in the US linked to healthcare-associated infection (HAI). Adequate and thorough hand hygiene is the single most important, least costly, and most basic method for reducing HAIs in hospitals. HAI prevention efforts via hand hygiene are estimated to save nearly $35 billion annually. Healthcare organizations that successfully implement actionable steps to improve hand hygiene compliance, as outlined in this blueprint, can substantially reduce the risk of patient harm related to HAIs along with associated readmissions and longer hospital stays.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to increase hand hygiene adherence:

Contaminated hands of healthcare providers are a primary source of pathogenic spread. According to the CDC, hand hygiene is the single most important practice to reduce cross-transmission of microorganisms and healthcare-acquired infections.

According to WHO, hand hygiene should be performed:

  1. Before touching or encountering a patient
  2. Before performing a clean or aseptic procedure
  3. After an exposure risk to bodily fluids and after glove removal
  4. After contact with a patient and their immediate surroundings
  5. After touching an inanimate object in the patient’s immediate surroundings

To improve compliance with hand washing consider:

  1. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
  2. Use hand hygiene as a “pilot” trial for establishing a culture of safety and a culture of trust within the organization, because this is an area that “touches” everyone.
  3. Use the patient’s prompt to the clinician (“Have you washed your hands?”) as a test for clinicians’ responses and ultimately for the organizational culture.
  4. Ensure you have hand hygiene delivery systems at or near every point of care.

It is essential for frontline staff follow these procedures:

  1. Use alcohol-based hand sanitizers when hands are not visibly soiled. Apply 5 mLs to palms, rubbing vigorously to ensure all surfaces of both hands are covered, and allow 20 seconds for hands to dry.
  2. If hands are visibly soiled, wash hands with antimicrobial soap and water for at least 20 seconds with a vigorous motion to ensure all surfaces are clean and rinse under running water.
  3. Leave no part of hands or wrists untouched.
  4. Rinse off with running water and dry with clean towels or sterile paper towels.
  5. Do not touch the faucet or sink with your clean hands—either have automatic switch off or use the towel to switch off.
  6. Consider using chlorhexidine rather than soap and water for hands exposed to gram positive bacteria.
  7. Artificial nails and extensions contain pathogens and should not be used by healthcare professionals.
Unit Managers

This guide outlines the steps that managers can follow to increase hand hygiene adherence:

  1. Frontline Involvement and Competencies
    1. Ensure adequate training and documentation of competencies and skills.
    2. Create an organizationally consistent standard for proper hand washing and align competency checklists accordingly.
    3. Ensure new hires and floating staff are trained around the standard hand hygiene method.
    4. Model effective hand hygiene behaviors yourself.
    5. Involve volunteers and community members in hand hygiene education for patients and visitors.
    6. Ensure that hand hygiene protocols are embedded into clinical workflows, whether electronic or paper.
    7. Incentivize performance, whether financially (e.g., free meals), verbally (e.g., praise for performance), or professionally (e.g., employee evaluation).
    8. Hold staff accountable for providing the standard of care and reward success.
  1. Observation and Measurement
    1. Initiate a PI (performance improvement) project. Set a clear compliance target and a stretch goal. The target should be the minimum aim to show improvement from previous quarter or year. Uphold 100% compliance as a target goal.
    2. Measure and report hand hygiene rates monthly (total compliant actions/total opportunities x 100 = % adherence rate). Note trends in areas with low compliance but high HAI rates. Routinely reassess outcomes.
    3. Provide context for the clinical activities that align with the data reported. Train observers to remain vigilant around specific clinical activities in which hand hygiene is compromised to frame strengths.
    4. Emphasize the key role of observers in the data collection process and highlight the importance of their role as more than just a complement to their day-to-day duties. Provide recognition for their efforts and make this recognition known to the frontline staff members to highlight the observer role as legitimate and esteemed. Defer to observer expertise for owning the hand hygiene initiative.
    5. Ensure there are enough staff to effectively manage hand hygiene compliance. If full time observers are not indicated within the organizational budget, coordinate observations discreetly to mitigate improved performance upon knowledge of observation.
    6. Eliminate barriers to making rapid changes to documentation templates. Ensure documentation includes time and date of observations to assess for bias longitudinally.
    7. Coordinate a balance between observing and intervening/coaching in live time when hand hygiene is not performed.
    8. Identify the environmental and behavioral barriers associated with poor hand hygiene compliance. See “Performance Improvement Plan” section.
    9. Define key categories for hand hygiene noncompliance for data tracking.

Hand Hygiene Measurement 

Outcome Metrics

  1. Infection transmission
  2. diff or MRSA rates
  3. HAI rates
  4. Length of stay (LOS)
  5. Transfers to ICU/higher level of care

Process Metrics

  1. Environmental safety checklist use
  2. Use of PPE
  3. Traffic in and out of patient rooms
  4. Use of alcohol versus hand soap
  5. Post-discharge/post-service surveys with questions specific to hand hygiene (e.g., “Did you observe your provider washing their hands?”)
  6. Recognition of staff

Typical Gaps Identified in Hand Hygiene

Data collection

  1. Decreased trust in data quality due to the following, which causes a “not me” mentality:
    1. Little standardization for observation (e.g., timings, frequency, sample size) produces poor quality data that is not representative nor statistically significant.
    2. Individual interpretations of observation standards lead to variability in data, which compromises data quality and invalidates trends and longitudinal studies.
    3. Data collection timings are not spread out evenly throughout the day, week, and month, leading to biases.
    4. Professions are not broken down to individual roles, resulting in feedback that is too generic to drive ownership and change in behavior.
    5. General feedback of compliance rate lacks the granularity and context for individual staff to understand context or how they have contributed to the score and what can be done to improve.
  2. Lack of emphasis on key role of observers
    1. The rigorous skillset for quality data collection through observation is not emphasized as esteemed. Therefore, there is little interest in, and appreciation for, the observer role. Hand hygiene observation is seen as just another task on the to-do list without high regard for its importance. This perception is counterproductive to hand hygiene efforts and, ultimately, for creating a culture of safety.


  1. Complex work environment with many distractions
  2. Emergent patient needs
  3. Environmental cleaning
  4. Hands full


  1. Lack of incentives aligned with performance
  2. Lack of person-specific accountability
  3. Little recognition for champions (e.g., in monthly reports)
  4. Little organizational focus on hand hygiene
  5. Lack of leadership oversight and commitment
  6. Inconsistent communication
  7. Misperception of the need for hand hygiene when wearing gloves
  8. Lack of buy in from frontline about expectations
  9. Poor integration of expectations into existing frontline
  10. Little clear relevance via examples for each workflow (i.e., using general terms and not giving clear examples relevant to the person)


  1. Inconsistent education of new protocols
  2. New or visiting staff members
  3. Staffing needs
  4. Skin irritation/dryness
  5. Lack of assessment of patient barriers to performing hand hygiene (e.g., pain, mobility, etc.)


  1. Access to clean water, soap, hand sanitizer
  2. Plumbing for sink availability/convenience
  3. Wasted water and efficiency of water use
  4. Lack of adequate supplies

Performance Improvement Plan

  1. Gather the right project team.
  2. Form two teams:
    1. An oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
    2. The actual project team that consists of 5–7 representatives who are most impacted by the process.
    3. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization.
    4. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
  3. Understand what is currently happening and why.
    1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe.
    2. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
  4. Prioritize the gaps to be addressed and develop an action plan.
  5. Consider the cost effectiveness, time requirements, potential outcomes, and realistic possibilities of addressing each gap identified.
  6. Determine which are priorities of focus for the organization.
    1. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
  7. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
  8. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
  9. Measure both process and outcome metrics.
    1. Outcome metrics include the rates outlined above.
    2. Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow changes.
    3. Compare your outcomes against other related metrics your organization is tracking.
  10. Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is not.
  11. Identify barriers to completion of action plans and adjust the plan if necessary.
  12. Once you have the desired outcomes in the trial area, consider spreading to other areas.
  13. Be nimble and move quickly to keep team momentum going, and so that people can see the results of their labor. At the same time, don’t move so quickly that you don’t consider the larger, organizational ramifications of a change in your plan.
  14. Be sure to have a good understanding of the other, similar improvement projects that are taking place so that your efforts are not duplicated or inefficient.

The action plan should include the following steps:

  1. Assess the ability of the culture to change and adopt appropriate strategies.
  2. Revise policies and procedures.
  3. Redesign forms and electronic record pages.
  4. Clarify patient and family education sources and content.
  5. Create a plan for changing documentation forms and systems.
  6. Develop the communication plan.
  7. Design the education plan.
  8. Clarify how and when people will be held accountable.
Hospital Executives

This protocol outlines important information for executives regarding hand hygiene compliance: 

Executive Summary

  1. Routine Care
    1. Hand hygiene compliance in most hospitals is less than 50%, which significantly contributes to the annual healthcare associated infection (HAI) rates of 7.1% in Europe and 4.5% in the United States. This translates to 37,000 deaths in European countries and nearly 99,000 deaths in the US each year. Adequate and thorough hand hygiene is the single most important, least costly, and most basic method of reducing HAIs in hospitals. A 10% improvement in hand hygiene is associated with a 6% decrease in HAIs.
  2. The Cost
    1. According to WHO, HAIs are the most common adverse event in hospitalized patients globally and cost $28–$45 billion annually. The annual European financial loss due to HAIs is approximately 7 billion Euros with an estimated 16 million extra days in the hospital. In the US, that number is estimated to be $6.5 billion annually. It is estimated that every $1 spent on hand hygiene compliance improvement is associated with a $23.7 benefit for hospitals. Additionally, in 2008, Medicare opted for nonpayment to US hospitals in which patients acquired a predetermined set of eight HAIs. HAI prevention efforts via hand hygiene are estimated to save nearly $35 billion annually.
  1. The Solution
    1. Many healthcare organizations have successfully implemented and sustained improvements to increase hand hygiene compliance. The hand hygiene checklists for frontline staff and managers outline the actionable steps your organization should take to successfully improve hand hygiene compliance and summarize the available evidence-based practice protocols.
Patient & Families

This handbook outlines the steps that patients and their families can follow to ensure proper hand hygiene:

Patients and family members should understand that most HAIs (Healthcare-Acquired Infections) are preventable through proper hand hygiene. Patients and family members should expect their healthcare workers to communicate with them upon entry/admission to the facility and continuously throughout their stay/visit to ensure that they have performed proper hand hygiene and should continue to reinforce this behavior upon visitation.

  1. Inquire about barriers to patient hand hygiene performance (e.g., pain, mobility, etc.).
  2. Ensure that providers understand expectations about their hand hygiene.
  3. Ask about the proper method of hand washing from your providers if you are unsure about the proper steps.

Please consider printing this photo as a reminder to practice proper hand hygiene.

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AHRQ.  AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017. (2019)

Arefian, H., et al. Estimating extra length of stay due to healthcare-associated infections before and after implementation of a hospital-wide infection control program. (2019)

Bow J Eric., et al. Hand Hygiene Compliance at a Canadian provincial cancer centre – the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care. (2020)

Hand hygiene. European Centre for Disease Prevention and Control. (2020)

Hand Hygiene Fact Sheets. Healthcare Excellence Canada. (2023)

John’s Hopkins University. Hand Hygiene

Tartari, E., et al. Ten years of hand hygiene excellence: a summary of outcomes, and a comparison of indicators, from award-winning hospitals worldwide. (2024)

Toney-Butler TJ, et al. Hand Hygiene. (2023)