Direct observation is the go-to method for most hospitals for measuring hand hygiene compliance among healthcare workers. Despite its limitations, this practice continues to be promoted. But what does science say when it comes to the efficacy of this audit method?

Regular hand hygiene compliance is recommended to achieve and sustain high compliance rates [1]. Direct observation is the standard practice, but this method is scientifically debated, and many hospitals are therefore starting to use modern approaches to asses hand hygiene compliance.

What does the science say?

A recent systematic review investigated potential biases in hand hygiene compliance monitoring by direct observation [2]. Seventy-one publications were assessed for the presence and type of methodological bias and found the following:

  • None of the studies were free of bias.
  • Selection bias was present in all studies because they did not collect data on the weekends (86%) and at night (65%).
  • Half of the studies only investigated hand hygiene compliance in single-specialty settings (critical care units).
  • There was inconsistency of terminology, tools and description of data collection, and only 37% of the studies investigated the level of agreement between observers (inter-rater reliability).
  • In 13% of the studies, observers had previously received training, and the method of training was specified clearly in only 32% of them.
  • In 25% of the studies, observation was less than 1 hour which provides limited power to the studies.

Multiple sources of bias were detected in all studies in which hand hygiene compliance was monitored by direct observation. This reduces the validity of the results from the 71 studies and challenging the current opinion that direct observation of hand hygiene compliance is the gold standard approach.

What does the future bring?

Robust, credible data are required to measure performance and promote and sustain evidence-based practice and quality improvement, but there are threats to the validity of data collected by human observation. Regular hand hygiene compliance monitoring by direct observation continues to be promoted and used despite the recognition of the potential to produce inaccurate and unrepresentative data.

Automated options are available which are able to replace human errors. However, this method is not able to assess hand hygiene techniques. Therefore, the future of hand hygiene monitoring might be a combination of the best of the two worlds. Things are not always “Either-Or”. Sometimes you get the best results when you are able to leverage on the strength of both methods. And sometimes you cannot always see clearly, but with glasses – you might.


[1] Last_April_versionHH_Guidelines[3].pdf [Internet]. [cited 2019 Sep 3]. Available from: https://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5B3%5D.pdf

[2] Jeanes A, Coen PG, Gould DJ, Drey NS. Validity of hand hygiene compliance measurement by observation: A systematic review. Am J Infect Control. 2019 Mar 1;47(3):313–22.