Virtually everyone in health care agrees that to sharply reduce the number of illnesses and deaths attributable to health care-associated infections, proper hand hygiene must be practiced routinely before and after all patient encounters. Caregivers know this as well as anyone, yet many hospitals still fall short of achieving the goal.

Video: 10 Primary Causes of Poor Hand Hygiene 

The reasons for deviation from best practices are diverse and often complex, but many hospitals and health systems are getting to the bottom of the problem. They’re learning essential process improvement techniques to identify and address factors that impede the universal observance of hand-hygiene protocols.

"Compliance is better than it was, but we still have some ways to go," says Sujan Reddy, M.D., medical director of the Prevention Epicenters Program of the Centers for Disease Control and Prevention. 

Supporting article: Sensors Could Be Key to Hand-washing Compliance Efforts

Hospitals seeking to improve hand hygiene can obtain help from a significant body of information on the topic. For example, the Joint Commission Center for Transforming Healthcare has developed a wealth of data and insights after working with more than 600 health care organizations that have used its web-based Targeted Solutions Tool on 4,500 hand-hygiene projects since 2010.

Framing the Issue

  • Hand hygiene has improved at hospitals, but there's still more work to be done.
  • While every hospital is unique, there are a number of common sources of poor hand hygiene and a number of common solutions.
  • Good measurement systems are key to good compliance.
  • A number of organizations provide tools and guidance on improving hand hygiene. 

Klaus Nether, director of solutions development for the center, says the causes of hand-hygiene shortfalls vary. "The true solution is to have a good measurement system and get an understanding of your contributing factors," he says.

10 Primary causes of poor hand hygiene

Recognizing that there are commonalities across the spectrum of hospitals, the Joint Commission Center for Transforming Healthcare has identified 10 primary causes of poor hand hygiene.

  1. Ineffective placement of dispensers or sinks
  2. Hand-hygiene compliance data are not collected or reported accurately or frequently
  3. Lack of accountability and just-in-time coaching
  4. The safety culture does not stress hand hygiene at all levels
  5. Ineffective or insufficient education
  6. Health providers, such as those carrying supplies, have their hands full
  7. Wearing gloves that interfere with hand hygiene
  8. The perception that hand hygiene is not needed if wearing gloves
  9. Health care workers forget to perform hand hygiene
  10. Distractions

Positive program

The center's Targeted Solutions Tool recommends using data collectors who will not be readily identified as such by hospital health providers. "When the infection control nurse is on the floor, a lot of folks know why they're on the floor," Nether says.

The TST is based on the concepts of Lean Six Sigma and change management, and what the center calls “Robust Process Improvement.” 

"It's a systematic approach," Nether says. "Within the tool itself we have training modules for the data collectors to get to an accurate measurement system. That's the goal."

The center's guidelines measure compliance upon entry to and exit from a patient's room, while CDC and World Health Organization guidelines look at whether health care providers wash their hands before and after patient contact.

5 recommendations to improve hand hygiene, such as:

  1. Always wash hands upon entering/exiting a patient care area and before and after patient care.
  2. Make it easy; examine the workflow of health care workers to ensure ease of washing hands. "If people are coming in [to a patient's room] on the right side, the dispenser should be on the right side, so it will be in sight," says Klaus Nether, director of solutions development.
  3. Make it comfortable. "There are so many different types of hand hygiene gel out there," Nether says. "You want to make it comfortable for your health care providers to use them. Some cause dryness, chapping and cracking. Work with your health care providers and staff to understand what works well for them."
  4. Tailor education in proper hand hygiene for specific disciplines. For example, Nether says, nurses bringing supplies into a patient's room can be trained to put those supplies on a shelf upon entry, which would free their hands for washing.
  5. Use trained, certified independent observers to monitor the appropriateness of hand hygiene. Nether says some of the solutions recommended by the center, such as holding everyone accountable and responsible for hand hygiene, are predicated on a culture of safety permeating a hospital. "Everybody should be involved. There should be a commitment from leadership to achieve good hand-hygiene compliance. Everybody in the organization should be a coach and a role model," he says.

Nether says the center bases its observations on actions that occur when entering and exiting a room because the center believes it would bias results if a data collector went into patient rooms with providers to observe their behavior.  

Data on hand-hygiene compliance rates among hospitals that have participated in the TST program indicate positive results. The initial group of eight hospitals that participated in the program started with an average baseline compliance rate of 47.5 percent. Initial data revealed 41 different causes of noncompliance, which were condensed into 24 groups of causes. Key causes varied greatly among the hospitals, which developed and implemented specific interventions. The changes were associated with a 70.5 percent improvement in compliance across the eight hospitals — from 47.5 to 81 percent.

Of the 174 hospitals that used the tool from 2010 to 2013, the aggregate rate of compliance rose from 57.9 to 83.5 percent, Nether says.

Resources on hand hygiene

The Hospital Improvement Innovation Network, run by the American Hospital Association’s Health Research & Educational Trust, addresses hand hygiene in its UP Campaign at

More information about the Joint Commission Center for Transforming Healthcare’s hand-hygiene project is available at

The Centers for Disease Control and Prevention has information at