Table 4.

Methods to Measure Hand Hygiene

Method	Use	Strength	Weaknesses	Considerations
Direct overt observation 20,153	Gold standard for evaluation of technique Monitoring prevalence of hand conditions, adherence to facility or unit specific policies Inclusion in prevention bundle checklists can ensure appropriate hand hygiene prior to high-risk procedures (eg, central-line insertion)	Immediate feedback with correction of lapses Those completing prevention bundle checklists are empowered to speak up for patient safety. Can be used as a form of engagement among peers	High risk for bias due to the Hawthorne effect, should not be used to determine rates of adherence during routine care	As part of competency-based training a systematic approach may be used to ensure ongoing, regular assessments of knowledge and skill among all HCP.
Direct covert observation 14,16,17,19,25,47	Establishment of performance baseline Gauge progress towards facility established goals Evaluation of technique	Barriers and facilitators to hand hygiene can be identified	High risk for observation bias Observations potentially obstructed by physical barriers (eg, curtains) Time and labor intensive Those observed may be skeptical of data Feedback may be delayed or fail to penetrate to those observed Potential for patient harm if lapses not immediately corrected	Facilities should engage in strategies to reduce observer bias. Observers should have clear directions about how to address noncompliance.
Automated hand-hygiene monitoring systems (AHHMSs)	Supplements direct observation Establishment of performance baseline Gauge progress toward facility-established goals Provides trends in hand hygiene performance	More complete data regarding compliance due to continuous monitoring of all shifts and days of week HCP-specific adherence rates can be monitored using some systems Systems may provide real-time reminders to ensure adherence	Unable to evaluate technique Wearable devices may hinder HCP acceptance or completeness of analysis due to noncompliance with wearable use Recording errors may lead to HCP lack of confidence in data, variability in reliability of data between systems and in different physical settings Resource investment is significant and typically recurrent via annual client subscription	Rigorous evaluation is needed to ensure validity. Collaboration with and empowerment of HCP may lead to better acceptance. Will not eliminate need for observation or improvement campaigns but may allow for more targeted interventions
Remote video observation 30,37	Establishment of performance baseline Gauge progress toward facility-established goals Validate opportunities to determine denominators if not captured by an AHHMS Allows for review of unusual circumstances and validation of other monitoring systems	The absence of a human observer may reduce the Hawthorne effect. Potential for provision of immediate and end-of-shift feedback to individuals and unit managers	Visualization is restricted to camera views	Initial financial burden may be prohibitive. State and local laws and union expectations may complicate implementation. Patient privacy issues must be addressed in policies prior to implementation.
Patient-as-observer 38	May be appropriate in settings that are challenged with resources for observation such as outpatient settings (eg, emergency department)	Engages and empowers patients to remain aware of and comment on HCP hand hygiene behaviors. May improve patient satisfaction Cost effective	Information is limited to moments included in a single patient contact.	Useful for continuous quality improvement through sharing of patient feedback with HCP
Indirect measures	Event counts Product usage	Allows for assessment of effectively placed dispensers Volume usage may provide trends.	May not correlate with other measurement methods Does not differentiate between roles of HCP versus or healthcare facility visitors	Should not be used as the sole method of measurement
Audits of accessibility and functionality of supplies 43	Assure infrastructure that supports adherence	Provides assurance of functionality and availability of hand hygiene supplies	Infrastructure may not be amenable to change if restricted by administrative code (eg, building code)	Regular assessment can be performed during routine environment of care rounds.