Best Practices in Hand Hygiene

At the Antimicrobial Resistance conference in Birmingham, Dr Gerard Lacey, founder and CTO of SureWash gave a talk on the best practices in hand hygiene training and measurement. He has been researching hand hygiene systems and their evaluation in hospitals for 15 years and has also participated in multiple scientific publications. With the conference focusing on antimicrobial resistance (AMR), it was appropriate to discuss hand hygiene as it is the key activity in preventing infections.

The Wicked Problem of Hand Hygiene

Hand hygiene is an example of a wicked problem. However, it’s not easy to design a randomized control trial because results depend on human behaviour. This is impacted by social relationships, the physical space in which the trial is being conducted and the overall social context. As a result, we have to be cautious of over-interpreting the results of randomized control trials. Many studies are just the tip of the iceberg. Beneath the surface the mechanisms driving the behavior are often due to ergonomics, psychology and neuroscience.

The Good the Bad and the Ugly of Hand Hygiene

However, at a high level we do have a clear understanding of the good, the bad and the ugly when it comes to hand hygiene in healthcare settings. The good includes the World Health Organisation (WHO) multi-modal approach. This is a combination of the WHO hand hygiene guidelines, short and frequent coaching on the job and regular feedback and measurement. The bad involves what can be referred to as “tick box” training. This is provided in order to be seen to be doing something for an audit, but it has no lasting impact. Lastly, the ugly is where poor standards in hand hygiene and high HAI rates are tolerated. This is because it is believed that nothing can be done and infections are deemed as “normal”. However, infections are not normal and hospitals can significantly improve patient outcomes through better hand hygiene.

Measuring Hand Hygiene Compliance: Quantity X Quality

To measure hand hygiene effectiveness, we must examine both the 5 moments and WHO hand hygiene technique within the healthcare setting. Compliance is the multiplication of these two factors together. Currently, compliance with quantity is between 40-80%. However, with quality, compliance is much lower at 15-18%. When we multiply these, overall compliance is somewhere between 6-14%. The end result is that hands in clinical settings are frequently contaminated with dangerous pathogens as has been found in multiple studies.


Cover all surfaces with the WHO technique

Reilly et. al (2016) demonstrated the importance of technique in reducing the bio-burden on the hands. (1) Therefore, technique must be understood not as an afterthought, but critical to reducing the bio-burden on the hands.

Why is Learning Good Hand Hygiene so Hard?

We often hear complaints that the WHO hand hygiene technique is too complex, too hard to learn or too hard to remember. But the people who complain can drive a car or ride a bike. What is going on here? We blame inappropriate teaching methods for hand hygiene. Too often hand hygiene is taught as “knowledge” rather than as a “skill”. In clinical skills training, techniques are demonstrated, practiced with a coach and assessed to a proficiency standard before getting to practice on patients. Hand hygiene is also a psychomotor skill critical for patient safety and needs to be taught correctly or students are being set up to fail.

Psychomotor Skills Training

You can’t learn to ride a bike by watching a video. Why? because we are training a part of our brain that controls movement and it “learns by doing”. This part of our brain learns much more slowly but it also retains this knowledge for longer – hence the phrase “it’s like riding a bike, you never forget it”. Neuroscience tells us that we need to practice a psychomotor skill daily for 2 to 4 weeks to “automate” the skill. We should be able to perform the skill without conscious thought. Therefore, it is much better to have very short bursts of training separated by sleep rather than one long “massed” training session. This is because our brains consolidate motor learning while we are asleep.

How to Design a Skills Training Programme for Hand Hygiene?

A big part of creating an effective training program is understanding how we learn. We go through 4 stages of learning:

1. Unconscious incompetence – this is where we are unaware of our lack of knowledge and this is where objective assessment is critical to confront learners with their overconfidence.
2. Conscious Incompetence – after a failed assessment we now appreciate the performance gap and work to close it through practice and feedback.
3. Conscious Competence – here we are able to follow the technique but we are still using prompts and reminders.
4. Unconscious competence – we have automated the skill and can perform it flawlessly with no prompts and even while talking to someone.

Moving through the 4 stages takes practice and feedback. Ideally the feedback system should be automated so that learner can be self-directed and independent of the hand hygiene coach.

Culture Eats Strategy for Breakfast

There are a number of studies that have investigated culture, personal relationships, a team’s self-image and the impact on hand hygiene. There is a management maxim that culture eats strategy for breakfast. Therefore, to be successful, a hand hygiene strategy needs to address the culture of the organisation. Senior leadership needs to repeatedly signal the importance of hand hygiene. Local teams need to have a sense of ownership of the program and shape some of the content, what Didier Pittet from the WHO call “Adapt to Adopt”. A technique which combines both training and culture is the “safety stand down”.

Technology to Support Quality Improvement in Healthcare

When it comes to hand hygiene training and measurement in the 21st century, artificial intelligence (AI) plays a critical role through automatic video auditing and objective real time feedback. Subsequently, this improves how training is delivered and assessed. However, the issue with using technology to support our learning is that we become dependant on it. This is what we refer to as cognitive offloading e.g. We use our mobile phone to remember our phone numbers. Challenges appear when technology is not available all of the time. Therefore, technology needs to be implemented into learning in a strategic way if it is used as a learning tool. Individuals need to be assessed, challenged and provided with feedback to receive a high standard of learning.

The Solution

Hand hygiene training and measurement is essential to help achieve compliance, reduce the spread of infections and improve patient outcomes. Compliance can only be achieved when there is a focus on both the quantity and quality in hand hygiene. However, learning the WHO hand hygiene technique can be difficult. This is where the SureWash technology can aid healthcare workers in their hand hygiene training. It teaches staff, patients and visitors the WHO technique by measuring hand motions and providing real-time feedback. It follows the 4 stages of learning discussed and assesses the technique standard over a period of time.

Visit the SureWash ELITE or GO webpage to learn more about the training system and its benefits. View our sample reports to identify how infection control can track users learning progress.

Watch the full talk below:


  1. Reilly et. al (2016) A Pragmatic Randomized Controlled Trial of 6-Step vs 3-Step Hand Hygiene Technique in Acute Hospital Care in the United Kingdom, Available at: