Identifying Barriers to Hand Hygiene Audit and Feedback

This is a guest post by Daniel Livorsi MD and Heather Schacht Reisinger PhD from the University of Iowa Carver College of Medicine and the Iowa City VA Health Care System

Our research group recently published a qualitative investigation of hand hygiene in JAMA Network Open. The study describes real-life barriers encountered by 8 VA hospitals in their use of audit-and-feedback to improve hand hygiene compliance. For anyone involved in hand hygiene monitoring and improvement, the barriers we describe will probably not come as a surprise. In brief, we found that auditing hand hygiene compliance by direct observation was perceived to collect inaccurate data and created tension with frontline staff; the feedback process did not encourage positive change.

Although the importance of hand hygiene is widely acknowledged, our field’s understanding of how to improve hand hygiene compliance is still relatively primitive. All of the hospitals we visited had implemented audit-and-feedback, which was the focus of the study, but many were also using other strategies, such as environmental engineering and education. Despite these well-intentioned efforts, hand hygiene compliance rates at the participating sites were 49.8% (n = 9791) at room entry and 63.9% (n = 10 135) at room exit. It seems safe to assume that such poor compliance rates are common across all of healthcare. To meet regulatory standards (e.g. the Joint Commission), hospitals need to keep going through the motions of auditing, but wouldn’t it be great if all this effort could be directed towards interventions that actually work?

An accompanying editorial argues that all of these audit-and-feedback programs were missing one key component: immediate personalized feedback coupled to individualized action planning. In general, feedback is more effective if it is provided in real-time and is individualized, so this strategy is appealing. However, at the hospitals we describe, giving personalized feedback would likely face some logistical challenges, including limited personnel to perform these separate individualized audits and potential pushback from labor unions on the collection of individualized performance data. In addition, collecting individualized data still does not address larger questions about the accuracy of direct observations.

Like many processes in healthcare, improving hand hygiene will require both technical interventions and socio-adaptive changes. Clearly, compliance rates are not where they need to be, and the current strategies are not effective. I don’t pretend to know the answers, but as a field, let’s not give up on trying to find some solutions.

image credit: honoring University of Iowa Veterans


  1. Perhaps we need to stop trying to get "real data" with no Hawthorne effect, but instead leverage the Hawthorne Effect! Have lots of prominently placed, explicitly identified, not secret Hand Hygiene observers - then hand hygiene really would come closer to 90% wherever the active and visible observers are! Probably cheaper than electronic monitoring...

  2. Would be interesting to see - they did something like that with infection control police during the NIH KPC outbreak years ago with good effect and likely cheaper than automated systems.

    We will have several more papers coming out on this topic - one in press at ICHE that shows that if we do rapid observations we can reduce the Hawthorne effect and get more accurate data. When we have honest data (60%) and not fake data (100%), we could probably get resources to implement and innovate including testing your leveraging Hawthorne effect idea.


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