Improving hand hygiene compliance using the Sani 5-step tool


This paper shows how the Sani 5-step tool can be used by hospitals to significantly improve hand hygiene compliance among staff. The research was conducted at a Danish University Hospital over the course of a year and concludes that with multimodal approach using regular communication, clear goals, performance feedback and support from management, it is possible to significantly improve hand hygiene compliance in hospitals.

Improvement in technology creates new and clinically relevant opportunities

Electronic monitoring technology in the healthcare sector has long been a sought-after tool. From tracking patients, locating equipment and controlling hand hygiene, monitoring technology has quickly become an established status quo in many hospitals. With America being the front runner in the use of external monitoring systems in the private healthcare sector, Europe has now also begun the process.

Sani NudgeTM offers an automated hand hygiene monitoring system that goes above and beyond what is currently on the market. The system tracks staff’ hand hygiene compliance in all types of hospital rooms (medication rooms, patient rooms etc.) and by staff profession (nurses, physicians, physiotherapists etc.), thereby providing detailed information about the hygiene behavior.

Sani Nudge is the only system to measure patient contact. It creates a clean zone around the patient beds, measuring whether staff have been in contact with patients and whether they remembered to sanitize. This is possible due to specifically designed algorithms based on WHO’s “5 Moments for Hand Hygiene” guidelines (ref. 1).

Data from the system are correlated with the number of hospital-acquired infections in the departments which gives the hospitals a unique opportunity to measure the effect and impact of different educational initiatives.

A successful quality improvement project

This quality improvement study describes how a Danish University Hospital was able to more than double their hand hygiene compliance within a year using a data-driven stepwise process called the Sani 5-step tool. Importantly, such an increase has also been possible due to the dedication of the staff and infection control nurses who have been working closely with the system, taken ownership over the process and acted as true Sani Champions.

Step 1: Baseline

For the first eight weeks of the study, the hospital ward and staff received no feedback from the Sani Nudge system, and hygiene coordinators were told not to introduce any additional hand hygiene training. This period, known as the baseline (step 1, Figure 1), became the hospital’s starting point in the road to improving hand hygiene compliance.

Step 2: Nudging

During this step, a nudging feature of the system was switched on which improved the HHC. The nudging feature consisted of discrete visual nudges appearing on the Sani sensors which was placed on the alcohol-gel dispensers. The Sani sensor gave a “clue” whenever sanitation was needed followed by a positive reward after sanitation.

Step 3: Team reports

The objective of step 3 is to introduce the use of data to improve hand hygiene to the staff. This step gives the hygiene coordinators anonymized hand hygiene data to first show the total compliance level of the group, the proportion of high performers, low performers and those in the middle and finally to focus on specific situation the groups had to work on. The information is provided in detailed weekly reports that are printed out and posted on the noticeboard (visibility for all staff is key here). The staff, along with the head nurse, agree on compliance level goals to reach in each room type. This makes the staff feel included. By taking an active part in their goals, adds the element of group engagement to their hand hygiene improvement and initiates a culture change.

In the case of this Danish hospital, step 3 particularly helped the hand hygiene levels increase in room types that had previously received little attention, such as the storeroom. Other rooms with more significant increases included the medication rooms and staff toilets (Table 1). Feedback from the head nurse said this presentation of data really included all the staff in the ward to collaborate in making proper hand hygiene the standard of care.

Step 4: Individual reports

The objective of step 4 is to allow staff to see their individual hand hygiene levels in each room type compared with the average of their colleagues (anonymized). This step allows the staff to implement all elements of what they have learnt in previous steps and to work on self-improvement in areas that they felt they lacked in.

The staff saw the overall hand hygiene compliance in the ward increase and became more stable over the weeks as nurses that were performing poorly in some rooms were able to improve their hand hygiene behavior and thus the overall hygiene score of the hospital. Importantly, all rooms had increased significantly by the end of the program (Table 1).

Table 1. End results of the Sani 5-step tool

Room typeEnd results:
% increase in hand hygiene compliance
Medication room252%
Staff toilets178%
Patient rooms97%
Clean rinsing room91%
Dirty rinsing rooms70%

Step 5: Gamification

The objective of step 5 is to motivate the staff to continue improving their hand hygiene behavior and to keep their increased performance long-term by introducing game mechanics to the process. With gamification we continue building on the team relationship (from step 3) in the ward by introducing group challenges and competitiveness between the wards.

The challenges are designed in a way that educates the staff in which situations they need to improve, as well as what they need to do to improve. When completing a challenge, the ward is rewarded with a badge that prove that they have increased their compliance in that specific situation.

On strategically placed wall-mounted tablets, the staff can track how close they are to completing the challenges, as well as see how well they are performing compared to the other wards. This motivates the staff to complete more challenges, which allows the wards to reach their full potential in many more possible situations.


With the introduction of a stepwise approach of increasing hand hygiene using a multimodal approach, the Sani 5-step tool successfully helped the hospital improve the compliance level in all room types and situations. This in turn will reduce the number of hospital-acquired infections. Furthermore, with the reduction in infectious disease outbreaks within wards, the use of antibiotics can be reduced thus decreasing the growing antibiotic resistance.


1.WHO: (accessed on 06/11/2019)

Other references

Srifley J.A., et al. (2014) Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Quality and Safety Vol. 23, Is. 12, pp 974-980

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