Fool’s gold: 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. Instead it is, rather, the “Fool’s Gold” standard.

Fool’s Gold, or iron pyrite is a mineral – not a metal –with a superficial resemblance to gold.. It’s often confused for the real thing, but there is no value. Martin Frobisher returned to England from a voyage to find the North West Passage in 1576 with a cargo of this supposed 'gold mineral', but as you can guess it had absolutely no value.

Direct observation is similar – hospitals have for many years used it to measure  hand hygiene performance with the intend to know exactly how good healthcare workers are at complying to hand hygiene guidelines. But it only appears to do so on the surface. In reality, all it provides hospitals are a false sense of security.  Of cause, it keeps the accreditation agencies happy, 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. European Hand Hygiene Excellence Award look at how good hospitals are at performing direct observations and hospitals performing many observations are more likely to be nominated. But besides the inability to see into rooms, inaccuracies, observer bias, and recall bia there is still a fatal limitation – The Hawthorne Effect.

The Hawthorne Effect is the phenomenon that people will improve their behavior because they are being observed. When hospital clinicians spot the “secret shopper” that’s observing them, they are more likely to follow hand hygiene guidelines. No matter how “hidden” the observers are, the staff always know they are there, and this artificially improves their results.

Every time we talk with a hospital they refer to their high hand hygiene compliance scores. They don't have a problem with hand hygiene because for the last five years their direct observations "prove" that they are compliant 90% of the time. But when we install our objective hand hygiene monitoring system we see that the actual compliance rates recorded are more than half of what the hospitals has been reporting via direct observation. Two extensive studies have demonstrated that hand hygiene increases by a similar 300% only when observers are present*. Think about it, how good do you really think your hospital is right now?

This is simply human nature and there is nothing you can do to change this. What happens when you spot the speed camera on the highway? Everyone slows down. What happens when you pass? 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.