Major articleThe World Health Organization hand hygiene observation method
Section snippets
Profile and task of observers
Observers collect data during routine care activity of HCWs to assess their adherence with the recommended indications for hand hygiene. Ideally, these observers should have basic training and experience in patient care as professionals and, importantly, a clear understanding of the logic of the care sequence. The observers must be aware of the potential biases introduced by the observation process and can help minimize these through a complete understanding of the methodology. Stringent
Understanding the concept
The concept of “My five moments for hand hygiene” has been described in detail elsewhere.19 In brief, health care activity is envisioned as a succession of tasks during which HCWs' hands touch an array of surfaces, including patients, objects, and furniture (Fig 1). Each transition between 2 hand-to-surface exposures can result in the hand transmission of microorganisms (Table 1). When patient care is involved, transmission is associated with a risk of colonization or infection. Applying hand
Training and validation of observers
The first step in the observer's training is to gain an understanding of the “My five moments for hand hygiene” concept during patient care.19 Subsequently, the observer must learn to apply the observation method and use the data collection form. Before conducting observation sessions, an observer must be validated, ideally by parallel observation jointly with a confirmed observer, or by the WHO training film included in the WHO implementation toolkit.22 In the first case, 2 observers engage in
The observation form
Observations are noted on a paper form using a pencil and an eraser for corrections or using a portable electronic device for onsite data entry. Each form represents a separate observation session. The form comprises 2 main sections (http://www.who.int/gpsc/5may/Observation_Form.doc). A header contains institutional-level characteristics and information on the session. The main part consists of 4 columns of 8 blocks representing a sequence of opportunities from top to bottom. Each column is
Determining the scope of an observation period
Before the start of an observation period, the scope of observations must be determined. If the aim is to build a comparison between 2 or more observation periods, then special attention should be given to controlling for potential confounding factors. This can be done by predefining a target number of opportunities by profession, wards, and/or time of day. To minimize interobserver variability, the observer or team of observers should remain the same across the different periods studied.
The
Selection of location and time
A representative mix of wards and time of day should be obtained. Observers tend to conduct their activity at times and in locations with a high density of care, to allow them to gather a greater number of opportunities more quickly. But observers must be aware that changing the method of time selection and location of observations between observation periods can lead to bias, because there is usually an association between the density of opportunities and adherence.4 We strongly suggest
Selection of Health Care Workers
Once location and time are determined, observers must choose the HCWs to be observed during a session. Selection bias should be minimized by selecting the first HCW who becomes involved in care activity on a ward (random convenience sampling). In the case of repeated observation periods in particular, observers may be aware of the intrinsic performance of individual HCWs. Selecting HCWs with extreme hand hygiene behavior (eg, unusually high or low performers) could easily influence the overall
Conducting an observation session
The observer should introduce himself or herself to the observed HCW(s) and patient(s) by indicating unobtrusively the reason for his or her presence, and maintain a discreet presence to avoid interference. How this introduction is handled depends on the local social and medical culture. The observer should aim to avoid excessive observation bias by not being too obvious, while not deceiving the observed HCW about the purpose of observation. The session should be concluded after 20 minutes ± 10
Analysis
Hand hygiene opportunities represent the level of analysis. Overall adherence is calculated by dividing the number of hand hygiene actions by the total number of opportunities. It is useful to stratify adherence by institutional sector, professional category, and indication (moment) for hand hygiene using the “My five moments for hand hygiene” as strata.19 For the rare instances in which opportunities involve more than one indication, we suggest retaining only a single indication for simplicity
Reporting of results
Providing feedback on results to the HCWs is a very powerful promotional tool and should first address groups with a strong sense of group identity, eg, physicians and nurses. Avoiding a delay between observation activity and reporting of results may increase the impact of feedback. However, feedback of suboptimal results not accompanied by an intervention to facilitate improvement should be avoided, as it could discourage HCWs and possibly jeopardize the adoption of future promotional messages.
Discussion
An ideal indicator of hand hygiene performance would produce an unbiased and exact measure of how appropriately HCWs practice hand hygiene. Ideally, this would require a technology that does not interfere with the behavior of those being observed, assesses the microbiological outcome of each hand hygiene action in real time, and reliably captures each moment requiring hand hygiene even during complex care activities. Furthermore, the method used should not require excessive staffing time and
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The World Health Organization takes no responsibility for the information provided or the views expressed in this article. The authors report no conflicts of interest.