If you are working with or care about hand hygiene compliance rates and patient safety, then this is a must read for you!

We all know that improving hand hygiene of healthcare workers is a crucial strategy to prevent hospital-acquired infections – the most common adverse event during medical care. Compliance rates are used to quantify the healthcare workers’ hand hygiene level. But can you trust these compliance rates?
Direct observations – time for a change?

Direct observation by human auditors is the most commonly used method of measurement. However, this method has some significant limitations, such as being labour intensive while only being able to obtain a small fraction of all hand hygiene opportunities. As a consequence, it provides a very limited picture of the true hygiene level at hospitals. Importantly, compliance rates reported using direct observation are inflated by the Hawthorne effect – but to what extent?   

Important new data to quantify the Hawthorne effect

I recently came across a very interesting study by McLaws et al. [1] who investigated the magnitude of the Hawthorne effect of hand hygiene compliance rates when comparing direct observation with automated surveillance.

Before digging into the data and the important results from this study, I want to briefly state that when talking about the Hawthorne effect, it is referring to a behaviour change due to awareness of being observed.

This is a problem in real life

Speaking from experience, this certainly does occur! During my career as a medical doctor, I have worked at several different hospitals. Whenever a hygiene auditor followed me around the wards it made me more aware of my hygiene behaviour. I am not perfect, and I admit that I have forgotten to sanitise my hands on occasion. However, when observed by the auditor, I always remembered to wash hands and use alcohol-gel hand disinfectants. I have therefore often questioned the “good” hand hygiene results that hospitals have published in reports.

Overestimating compliance by up to 300%

Now a study has quantified this problem and has shown how important it is to have automated hand hygiene monitoring instead of the manual direct observations. In a large hospital in Australia, an automated surveillance system collected data for six quarterly reporting periods and compared it with the data obtained from direct observations by human auditors from the same periods.

The study found that the results obtained from the direct observations were inflated up to 3.1 times compared with the automated rates. It means that if you are using direct observations at your hospital, you risk overestimating the healthcare workers’ hand hygiene compliance by 300%! Other studies have found similar results [2-4].

We are doing it for the patients

So why am I telling you this? Overestimating the compliance rates may not seem important at first glance but when you think about it, wrong compliance rates constitute a risk to patient safety. If you make strategic decisions regarding hygiene interventions or programmes and education based on flawed data, or worse, do not think there is a problem with hand hygiene performance - you put patients’ lives at risk. Data from CDC show that 10% of patients contracting a hospital-acquired infection will die as a result [5].

What you can do to increase patient safety

Together with colleagues from two Danish University hospitals we have developed an automated hand hygiene monitoring system, called the Sani nudgeTM system and a 5-step improvement tool. By using this, we have improved hand hygiene by 200% and decreased hospital-acquired infections by up to 64%.

Interested in knowing more?

If you would like to learn how the Sani nudgeTM system has helped hospitals to reduce HAIs by up to 64%, then click here. Or contact us so we can discuss your hospital’s specific needs.


[1] McLaws M-L, Kwok YLA. Hand hygiene compliance rates: Fact or fiction? Am J Infect Control. 2018;46(8):876–80.

[2] Hagel S, Reischke J, Kesselmeier M, Winning J, Gastmeier P, Brunkhorst FM, et al. Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring. Infect Control Hosp Epidemiol. 2015 Aug;36(8):957–62.

[3] Masroor N, Doll M, Stevens M, Bearman G. Approaches to hand hygiene monitoring: From low to high technology approaches. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2017 Dec;65:101–4.

[4] Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf. 2014 Dec;23(12):974–80.

[5] Data Portal | HAI | CDC [Internet]. 2019 [cited 2019 Jul 10]. Available from: https://www.cdc.gov/hai/data/portal/index.html