Hand hygiene compliance at your hospital is not 90% and it's probably not even 80%

A few weeks ago, we got a review back on a manuscript (fortunately accepted with minor revision) but one of the reviewer's comments was an example of truthiness invading infection prevention.  The comment was one we hear often and since you can't typically communicate with a blinded-reviewer, I thought I'd mention the comment and what my response would be here.

Reviewer: "...only 63% of HCWs performed hand hygiene on exiting the room...in the year 2012, compliance rates of 50-63% is just plain depressing..." This comment and the other comments by the same reviewer seem to suggest that the four hospitals in our study were outside the norm and that we should clearly have hand hygiene compliance above 90%.

My (theoretical) reply: Hand hygiene compliance rates are not as high as reported.  Many things can explain this from the Hawthorne effect to only collecting data during 9-5 business hours. Fortunately, we have data from The Joint Commission Center for Transforming Healthcare.  In 2009 they began a hand-hygiene project.  Dr. Mark Chassin, President of The Joint Commission, described the project in a 2010 interview:

"We are collecting data from all Center hospitals. We are continuing to do so even for the eight hospitals that participated in the hand hygiene project, past its formal closure. In April 2009, at the beginning of the project, performance was collectively at 48% and has now stabilized at around 82%. It’s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%. So getting reliable measures was understandably a big issue at the start of the project."

When we do hand hygiene studies we use a uniform extraction sheet and collect data from all hours. We also collect 1000's of hours of data. From our experience, it is likely that hand hygiene in most hospitals is closer to the 50% reported in the 2009 Joint Commission study and not near the claimed 90% that everyone likes to see.

Final note:  If we think compliance is 90% we will do nothing, but if we accept the fact that it is 50% or 63%, we can address that with further interventions or initiatives. Acknowledging this is a necessary first step in making our hospitals safer.

Source: An Interview with Mark Chassin, The Joint Commission on Quality and Patient Safety, October 2010.