Major article
The World Health Organization hand hygiene observation method

https://doi.org/10.1016/j.ajic.2009.07.003Get rights and content

Monitoring hand hygiene adherence and providing performance feedback to health care workers is a critical component of multimodal hand hygiene promotion programs, but important variations exist in the way adherence is measured. Within the framework of the World Health Organization's (WHO) First Global Patient Safety Challenge known as “Clean Care is Safer Care,” an evidence-based, user-centered concept, “My five moments for hand hygiene,” has been developed for measuring, teaching, and reporting hand hygiene adherence. This concept is an integral part of the WHO's hand hygiene improvement strategy conceived to translate the WHO Guidelines on Hand Hygiene in Health Care into practice. It has been tested in numerous health care facilities worldwide to ensure its applicability and adaptability to all settings irrespective of the resources available. Here we describe the WHO hand hygiene observation method in detail—the concept, the profile and the task of the observers, their training and validation, the data collection form, the scope, the selection of the observed staff, and the observation sessions—with the objective of making it accessible for universal use. Sample size estimates, survey analysis and report, and major bias and confounding factors associated with observation are discussed.

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

References (30)

  • D.J. Gould et al.

    Measuring handwashing performance in health service audits and research studies

    J Hosp Infect

    (2007)
  • J.P. Haas et al.

    Measurement of compliance with hand hygiene

    J Hosp Infect

    (2007)
  • J. McAteer et al.

    Development of an observational measure of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT)

    J Hosp Infect

    (2008)
  • Pittet D, Boyce J.M. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis...
  • World Health Organization

    WHO guidelines for hand hygiene in health care

    (2009)
  • Cited by (296)

    View all citing articles on Scopus

    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.

    View full text