Implementation of hand hygiene programs has traditionally been the responsibility of healthcare infection prevention staff and was focused on the clinical staff. The following discussion will describe why comprehensive awareness and education training for infection prevention is necessary for Infection Prevention Managers, and how a multidisciplinary approach can achieve hand hygiene compliance and sustained reductions in HAIs. This type of approach involves including not just clinical staff, but also other healthcare staff members, patients and visitors, as key audiences for the hand hygiene program and campaign.

1. Preventing Healthcare-
Associated Infections
Through Hand Hygiene:
Training for Infection
Prevention Managers
Colleen Conklin, MSPH
Research Director, Sodexo Innovations 2 Solutions
Environmental Epidemiologist

2. 2
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
HEALTHCARE-ASSOCIATED INFECTIONS AND HAND HYGIENE
Healthcare-associated infections (HAIs) are a
significant issue for patient safety: a Centers for
Disease Control and Prevention (CDC) prevalence survey
reports an estimated 722,000 HAIs and 75,000 HAI-
related patient deaths in 2011 at acute-care hospitals.1
In 2009, direct annual costs to U.S. hospitals were
estimated as high as $45 billion.2
The World Health Organization (WHO) and The Joint
Commission have both identified hand hygiene
compliance as critical for improved patient safety and
care.3
In the absence of adequate prevention measures,
microorganisms and contaminants found on skin and
in healthcare settings are readily transmitted surface-
to-person and person-to-person. Such transmission is
a leading cause of HAIs. The standard means to reduce
the transmission of HAIs is proper hand washing and
hand disinfection.
Evidence-based studies conclude that hand hygiene
protocols can result in sustained reduction of HAIs.4,5
However, compliance with hand hygiene protocols is
poor.6,7
Sustained improvement has been achieved when
patient safety is a programmatic priority and hand
hygiene is factored into workflow practices.8
It is also
essential that hand hygiene messaging be included
in the full continuum of care, including during pre-
admission, throughout the patient’s stay, and during
post-discharge. Ongoing messaging reinforces the
desired hand hygiene behaviors and empowers patients
and visitors to take ownership of their role in patients’
health and recovery.
Several studies have found that implementation of
hand hygiene programs is cost effective. In 2011 a
benefit-cost ratio of 23.7 was reported for a four-year
hand hygiene program in Taiwan, meaning that every
US$1 spent on the program resulted in a US $23.70
benefit.9
A more recent study concluded the cost of
implementing a hand hygiene program was less than
1% of HAI-associated costs.10
In short, HAIs can be reduced cost effectively, and
sustained improvement in reduction of HAIs in
healthcare facilities has been observed with:
§§ creating a culture in which hand hygiene becomes
the norm;
§§ utilizing the latest, innovative technology in hand
hygiene;
§§ programmatic implementation of hand hygiene
protocols;

3. 3
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
§§ behavior modification resulting in hand hygiene
compliance;
§§ workflow process improvement; and
§§ feedback from ongoing monitoring.
Implementation of hand hygiene programs has
traditionally been the responsibility of healthcare
infection prevention staff and was focused on the
clinical staff. The following discussion will describe
why comprehensive awareness and education training
for infection prevention is necessary for Infection
Prevention Managers, and how a multidisciplinary
approach can achieve hand hygiene compliance and
sustained reductions in HAIs. This type of approach
involves including not just clinical staff, but also other
healthcare staff members, patients and visitors, as key
audiences for the hand hygiene program and campaign.
HAND HYGIENE TRAINING
Studies indicate prevention of HAIs is most effectively
achieved when hand hygiene protocols are consistently
utilized. Historically, the challenge in infection
prevention has been the ability to implement a hand
hygiene program that ensures compliance among not
only healthcare workers, but also among other staff,
visitors, family members, and patients. Robust training
is necessary to adequately train Infection Prevention
Managers to understand how a multidisciplinary
strategy employing various behavior modification
determinants, programmatic process improvement
methods, ongoing monitoring, and feedback should be
developed and implemented at their facility.
Existing training sources for Infection Prevention
Managers to learn about hand hygiene include:
§§ The Joint Commission offers infection prevention
books, manuals, periodicals, and online courses.
These media include hand hygiene as a component
of infection prevention.11
§§ CDC Guidelines for Hand Hygiene in Healthcare
Settings12
§§ Hand Hygiene Task Force
§§ WHO Patient Safety Research Guide for developing
training programs, offering educators’ suggestions
for curriculum development and online patient
safety resources.13
§§ Continuing Education (CE): RNs must complete
continuing education credits to maintain their
license, and CE courses are available for patient
safety and infection prevention that include hand
hygiene. However, only New York State requires
nurses to have CE in infection prevention.14
However, nursing CE courses do not target IPMs/
IPs who are epidemiologists or those who have
other backgrounds.
§§ State departments of public health and patient
safety centers.

4. 4
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
The trained Infection Prevention Manager often uses
traditional education methods (procedure manuals,
training classes, posters, etc.) to communicate hand
hygiene requirements to healthcare workers at their
facility. Awareness campaigns with posters, signs,
pamphlets, and video displays are also used to reinforce
protocols. The resources listed above are available
for use in traditional Infection Prevention Manager
training. However, to implement effective programmatic
solutions to reduce HAIs with sustained success,
Infection Prevention Managers should be provided with
a comprehensive toolkit that includes training and
innovative awareness and education materials. Their
training can also benefit from focusing on a broader
audience that includes both clinical and non-clinical staff,
as well as visitors and patients. This approach increases
the awareness, knowledge, and engagement of all
audiences involved in hand hygiene and HAI prevention.
ISSUES RELEVANT TO THE
SUCCESS OF HAND HYGIENE
PROGRAMS
Improving Hand Hygiene Compliance –
A Multidisciplinary Approach
Infection Prevention Managers must work with
healthcare administration and management to change
patient safety culture, modify behavior, and instill
accountability in healthcare workers at their facility. As
early as 2001, the need for a multidisciplinary approach
to improving compliance with hand hygiene practice
was identified based on an investigation conducted by
the University of Geneva Hospitals infection control
program.15
The World Health Organization reports that
adherence of healthcare workers to recommended hand
hygiene procedures has been reported as variable, with
mean baseline rates ranging from 5% to 89% and an
overall average of 38.7%.16
The average hand
hygiene compliance
rate among healthcare
workers is only 39%.
Factors contributing to noncompliance include:
§§ profession – physicians were found to be less
compliant than nurses;
§§ healthcare ward – healthcare workers in intensive
care units were least compliant, those in pediatrics
most compliant; and
§§ shift – workers were more compliant on weekends
rather than weekdays.
Based on these findings, the recommended strategy to
enhance compliance included modification of several key
institutional factors. These included realigning priorities
of management to instill an atmosphere of compliance

5. 5
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
with strong leadership in patient safety. In addition,
the strategy recommended the use of sanctions and
rewards, enhancement of education based on target
audience, and the provision of continuous feedback to
keep staff engaged in the initiatives. With this in mind,
it is essential that institutions have measurement
tools in place to monitor hand hygiene compliance and
other goals (e.g., knowledge and awareness of proper
hand hygiene techniques). This allows institutions to
communicate successful, increased compliance and to
reward employees accordingly.
Although the need for institutional modification was
identified as early as 2001, there is little evidence that
these methods have been employed by healthcare
administrations. Healthcare facilities have realized
little improvement in HAIs as hand hygiene compliance
continues to be poor among healthcare workers.17
The Role of New Technologies in
Healthcare Worker Hand Hygiene
Given the large number of hand hygiene opportunities
in healthcare facilities, direct observation to monitor
compliance can be inefficient. Other compliance
methods, including electronic handwash counters
and product volume measurement, lack utility for
determining the appropriateness and quality of hand
hygiene episodes. However, new technologies and
systems are emerging that not only record compliance
but also promote it.18
Infection Prevention Managers
should familiarize themselves with the available options,
and incorporate these into hand hygiene campaigns
when appropriate and feasible.
Examples of new technological innovations in hand
hygiene include sensors that detect alcohol vapors and
radiofrequency identification (RFID) to determine whether
hand hygiene has occurred. RFID receivers, incorporated
into a badge worn by the healthcare worker, are able to
transmit data on compliance wirelessly to a centralized
tracking station. This station can display individual
compliance rates for every healthcare worker, which
allows the use of a feedback loop in real time to improve
hand hygiene compliance. Feedback loops are very
effective tools for changing human behavior on the basis
of a simple premise — give people information about their
actions in near real time, and then show them how to
change those actions into better behaviors.19
SureWash is another innovation aimed at improving
hand hygiene in hospitals and designed to make
training and compliance much less labor intensive.20
The
SureWash product range helps hospitals to implement
the World Health Organization (WHO) hand hygiene
improvement strategy by ensuring that hand hygiene
training, evaluation and feedback is accessible to staff,
24-7. SureWash systems provide interactive reminders
for staff and visitors and this helps everyone improve
their hand hygiene. This technique is based on European
standards (EN 1500) and involves six distinct steps, or
poses, per hand hygiene action.
At present, these new technologies can be expensive and
may generate high maintenance costs, although these
costs will likely decrease over time. Having different
technologies available, however, allows healthcare
facilities to combine new tools with standard approaches
in order to achieve optimal hand hygiene compliance.

6. 6
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
A Key to Compliance:
Behavior Modification
A metadata review of 41 studies published between
2000 and 2009, conducted to identify determinants
in successful hand hygiene strategies, emphasizes
that behavior modification is key to hand hygiene
compliance.21
Among the studies reviewed, the most
frequently addressed determinants were knowledge,
awareness, action control, and facilitation of behavior.
Fewer studies addressed social influence, attitude, self-
efficacy, and intention.
The metadata review concluded that the best results in
hand hygiene compliance improvement were observed
when combinations of multiple determinants were
creatively applied in behavior modification strategies.
Healthcare administration and management commitment
to patient safety and active engagement in behavior
modification strategies reinforces infection prevention
staff efforts to achieve behavior changes necessary for
sustained hand hygiene compliance and HAI prevention.
Compliance Improvement with
Process Improvement
In 2010 The Joint Commission Center for Transforming
Healthcare published the results of their hand hygiene
robust process improvement (RPI) project.22
Eight
hospitals with existing RPI programs were selected to
participate in the hand hygiene project. The project
started with a process improvement approach to
defining and measuring hand hygiene and analyzing
data. The main factors contributing to poor hand
hygiene compliance were identified and included:
§§ location of hand sanitizer dispensers and sinks;
§§ lack of accurate compliance data;
§§ lack of accountability;
§§ insufficient safety culture;
§§ need for improved education;
§§ healthcare worker distractions, perceptions, and
workload; and
§§ misconceptions regarding hand hygiene when
gloves are used.
When it came to improving processes, a collaborative
team approach was used for evaluating and
standardizing workflow. Workflow changes included
working smarter to reduce the number of times
healthcare workers entered and exited patient
rooms, thereby reducing the opportunities for cross-
contamination and hand sanitation. Changes to
workflow processes included incorporating technology
to assist in monitoring compliance with hand hygiene
protocols. The Joint Commission also utilized its
Targeted Solutions Tool to identify key personnel, train
observers/data collectors with structured education
and testing, measure compliance, report compliance
results, communicate noncompliance solutions with
implementation guidelines, and sustain improvement
with a dynamic approach to continuous reinforcement.
Aggregated results for the eight participating
hospitals showed a 71% improvement in hand hygiene
compliance.23
RPI results were confirmed in pilot studies
at 27 additional U.S. hospitals. The Joint Commission
Center continues to deploy pilot programs and shares
effective solutions with their accredited healthcare
organizations. Dynamic training such as the Targeted
Solutions Tool used by The Joint Commission would be
useful for Infection Prevention Managers as they develop
comprehensive programs for their facilities.

7. 7
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
CONCLUSION
Infection Prevention Managers are challenged to
implement effective hand hygiene programs at
their healthcare facilities. Based on the results of
various studies summarized above, achieving hand
hygiene compliance is a challenge that requires a
multidisciplinary approach: a top-down implementation
by healthcare management and administration
to demonstrate commitment to patient safety;
accountability for all levels of healthcare workers,
including physicians, nurses, environmental services,
and support staff; accountability for visitors, families,
and patients through messaging that focuses on
empowerment and education; improvement of work
processes to facilitate incorporation of hand hygiene;
communicating feedback to healthcare workers; and
implementation of technological tools that provide real-
time information and communicate results.
Programmatic solutions have demonstrated success
in achieving hand hygiene compliance improvement
in a limited number of healthcare facilities. Healthcare
facilities need multidisciplinary hand hygiene training
beyond the traditional resources available. Dynamic
training should be developed to provide healthcare
administration, management, and Infection Prevention
Managers with educational and communication tools
to implement cost-effective hand hygiene protocols to
include process improvements, ongoing monitoring,
and feedback to achieve patient safety goals through
sustained hand hygiene compliance and measured
reductions in HAIs.
ABOUT THE AUTHOR
Colleen Conklin, MSPH, is the Director of Research
for Business and Industry at Sodexo. Colleen has
professional experience from various business
sectors where she has served in project management,
administrative management, technical and business
development roles: health research; U.S. government
including Departments of Defense and Energy, Federal
Aviation Administration, and National Parks Service;
technology – IBM; and utility – Florida Power, New York
State Electric and Gas. She has a Master’s degree in
Epidemiology and a Bachelor’s degree in Chemistry from
the University of South Florida.
CASE STUDY OF A MULTIDISCIPLINARY
APPROACH TO HAND HYGIENE
Tufts Medical Center,
dissatisfied with
research study results
for their healthcare workers’ hand hygiene
compliance, developed and implemented a
comprehensive hand hygiene campaign.24
The facility was utilizing a hand hygiene
strategy consisting of traditional educational
methods: use of posters and pins for awareness,
requirements for staff to attend training
conducted by the hospital’s Infection Prevention
Manager, and annual testing of hand hygiene
protocol. However, compliance with protocol
was observed to be only 43% to 76%. Hospital
leadership assumed responsibility of the hand
hygiene compliance campaign and identified
improvement as a hospital-wide priority.
A quality improvement group consisting of
physicians, nurses, quality assurance and
infection prevention personnel, and outside
consultants was organized to determine what
factors contributed to poor compliance. The
quality improvement group determined:
»» a professional marketing campaign
was needed to “get the message out” to
hospital staff;
»» hand sanitizing stations (sinks and hand
sanitizer dispensers) must be strategically
located in healthcare worker and patient/
visitor areas of the hospital;
»» education methods should include group
and online training, continuing education
credits, and grand round lectures; and
»» quality improvement observations and
evidence-based results needed to be
communicated routinely to hospital staff.
Upon implementing these multifaceted
methods, sustained hand hygiene compliance
improved to 94%.

8. 8
The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2015
REFERENCES
1. Magill, S.S., Edwards, J.R., Bamberg, W., et al. (2014).
Multistate point-prevalence survey of health care-
associated infections. New England Journal of Medicine,
370, 1198-208. Retrieved from http://www.cdc.gov/hai/
surveillance/ and http://www.nejm.org/doi/full/10.1056/
NEJMoa1306801
2. Scott, R.D.S. II. (2009). The direct medical costs of
healthcare-associated infections in U.S. hospitals and the
benefits of prevention. Retrieved from http://www.cdc.gov/
hai/pdfs/hai/scott_costpaper.pdf
3. Doron, S.I., Kifuji, K., Tyson Hynes, B., et al. (2011). A
multifaceted approach to education, observation, and
feedback in a successful hand hygiene campaign. The
Joint Commission Journal on Quality and Patient Safety,
37(1), 3-10. Retrieved from http://www.jcrinc.com/a-
multifaceted-approach-to-education-observation-and-
feedback-in-a-successful-hand-hygiene-campaign/
4. Ibid.
5. Pittet, D., Sax, D., Hugonnet, S., & Harbath, S.
(2014). Cost implications of successful hand
hygiene promotion. Infection Control and Hospital
Epidemiology, 25(3), 264-266. Retrieved from http://
www.jstor.org/stable/pdfplus/10.1086/502389.
pdf?&acceptTC=true&jpdConfirm=true
6. Pittet, D. (2001). Improving adherence to hand hygiene
practice: a multidisciplinary approach. Emerging Infectious
Diseases, 7(2), 234-40. Retrieved from http://www.ncbi.
nlm.nih.gov/pmc/articles/PMC2631736/
7. Doron, op. cit.
8. World Health Organization. (2014). Evidence of hand
hygiene to reduce transmission and infections by multi-
drug resistant organisms in health-care settings. Retrieved
from http://www.who.int/gpsc/5may/MDRO_literature-
review.pdf?ua=1
9. Chen, Y-C., Sheng, W-H., Wang, J-T., et al. (2011).
Effectiveness and limitations of hand hygiene promotion
on decreasing healthcare-associated infections. PLoS ONE
6(11). Retrieved from http://www.plosone.org/article/
fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.
pone.0027163&representation=PDF
10. Pittet (2014), op. cit.
11. Joint Commission Resources. (2014). http://www.
jointcommission.org/jcr.aspx
12. Centers for Disease Control and Prevention. (2002).
Guideline for Hand Hygiene in Health-Care Settings:
Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. Retrieved from http://www.
cdc.gov/mmwr/PDF/rr/rr5116.pdf
13. World Health Organization. (2012). Patient
safety research: a guide for developing training
programmes. Retrieved from http://apps.who.int/iris/
bitstream/10665/75359/1/9789241503440_eng.
pdf?ua=1
14. New York State Nurses Association. (2014). http://www.
nysna.org/nursing-practice/continuing-education#.
VDBlwPldWSo
15. Pittet (2001), op cit.
16. World Health Organization. (2009). WHO Guidelines on
Hand Hygiene in Health Care: a Summary. Retrieved from
http://www.who.int/gpsc/5may/tools/who_guidelines-
handhygiene_summary.pdf
17. Doron, op. cit.
18. Marra, A.R, & Edmond, M.B. (2014). New technologies
to monitor healthcare worker hand hygiene. Clinical
microbiology and infection, 20(1), 29-33. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/24245809
19. Ibid.
20. SureWash. (2015). SureWash: The Solution to a Major
Problem. Retrieved from http://www.surewash.com/
21. Huis, A., van Achterberg, T., de Bruin, M., et al. (2012).
A systematic review of hand hygiene improvement
strategies: a behavioral approach. Implementation Science,
7(92). Retrieved from http://www.implementationscience.
com/content/7/1/92
22. Health Research & Educational Trust. (2010). Hand hygiene
project: best practices from hospitals participating in the
Joint Commission Center for Transforming Healthcare
Project. Retrieved from http://www.hret.org/hand-hygiene/
index.shtml
23. Joint Commission for Transforming Healthcare. (2014).
Bringing the Leading Health Care Organizations Together
to Solve Challenging Health Care Problems. Retrieved
from http://www.centerfortransforminghealthcare.org/
assets/4/6/hand_hygiene_storyboard.pdf
24. Doron, op. cit.