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Establishing Evidence-Based Criteria for Directly Observed Hand Hygiene Compliance Monitoring Programs: A Prospective, Multicenter Cohort Study

  • Jun Yin (a1), Heather Schacht Reisinger (a2) (a3), Mark Vander Weg (a2) (a4), Marin L. Schweizer (a2) (a3), Andrew Jesson (a2), Daniel J. Morgan (a5) (a6), Graeme Forrest (a7), Margaret Graham (a3), Lisa Pineles (a5) and Eli N. Perencevich (a2) (a3)...



Hand hygiene surveillance programs that rely on direct observations of healthcare worker activity may be limited by the Hawthorne effect. In addition, comparing compliance rates from period to period requires adequately sized samples of observations. We aimed to statistically determine whether the Hawthorne effect is stable over an observation period and statistically derive sample sizes of observations necessary to compare compliance rates.


Prospective multicenter cohort study.


Five intensive care units and 6 medical/surgical wards in 3 geographically distinct acute care hospitals.


Trained observers monitored hand hygiene compliance during routine care in fixed 1-hour periods, using a standardized collection tool. We estimated the impact of the Hawthorne effect using empirical fluctuation processes and F tests for structural change. Standard sample-size calculation methods were used to estimate how many hand hygiene opportunities are required to accurately measure hand hygiene across various levels of baseline and target compliance.


Exit hand hygiene compliance increased after 14 minutes of observation (from 56.2% to 60.5%; P < .001) and increased further after 50 minutes (from 60.5% to 66.0%; P < .001). Entry compliance increased after 38 minutes (from 40.4% to 43.4%; P = .005). Between 79 and 723 opportunities are required during each period, depending on baseline compliance rates (range, 35%–90%) and targeted improvement (5% or 10%).


Limiting direct observation periods to approximately 15 minutes to minimize the Hawthorne effect and determining required number of hand hygiene opportunities observed per period on the basis of statistical power calculations would be expected to improve the validity of hand hygiene surveillance programs.

Infect Control Hosp Epidemiol 2014;35(9):1163-1168


Corresponding author

Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA 52246 (


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1. Klevens, RM, Edwards, JR, Richards, CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122(2):160166.
2. Girou, E, Stephan, F, Novara, A, Safar, M, Fagon, JY. Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients. Am J Resp Crit Care 1998;157(4):11511158.
3. Aiello, AE, Larson, EL. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2002;2(2):103110.
4. Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10 suppl 2):S65S164.
5. Boyce, JM, Pittet, D. 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. Infect Control Hosp Epidemiol 2002;23(12 suppl):S3S40.
6. Haas, JP, Larson, EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66(1):614.
7. Schermerhorn, JR, Hunt, JG, Osborn, R. Organizational Behavior. 6th ed. New York: Wiley, 1997.
8. Parsons, HM. What happened at Hawthorne?: New evidence suggests the Hawthorne effect resulted from operant reinforcement contingencies. Science 1974;183(4128):922932.
9. McCarney, R, Warner, J, Iliffe, S, van Haselen, R, Griffin, M, Fisher, P. The Hawthorne effect: a randomised, controlled trial. BMC Med Res Methodol 2007;7:30.
10. Fox, NS, Brennan, JS, Chasen, ST. Clinical estimation of fetal weight and the Hawthorne effect. Eur J Obstet Gynecol Reprod Biol 2008;141(2):111114.
11. Chen, LF, Carriker, C, Staheli, R, et al. Observing and improving hand hygiene compliance: implementation and refinement of an electronic-assisted direct-observer hand hygiene audit program. Infect Control Hosp Epidemiol 2013;34(2):207210.
12. Bittner, MJ, Rich, EC, Turner, PD, Arnold, WH Jr. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol 2002;23(3):120126.
13. Eckmanns, T, Bessert, J, Behnke, M, Gastmeier, P, Ruden, H. Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27(9):931934.
14. Pittet, D, Simon, A, Hugonnet, S, Pessoa-Silva, CL, Sauvan, V, Perneger, TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141(1):18.
15. Armellino, D, Hussain, E, Schilling, ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2012;54(1):17.
16. Muto, CA, Sistrom, MG, Farr, BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control 2000;28(3):273276.
17. Morgan, DJ, Pineles, L, Shardell, M, et al. The effect of contact precautions on healthcare worker activity in acute care hospitals. Infect Control Hosp Epidemiol 2013;34(1):6973.
18. Brown, RL, Durbin, J, Evans, JM. Techniques for testing constancy of regression relationships over time. J Roy Stat Soc B Met 1975;37(2):149163.
19. Zeileis, A, Leisch, F, Hornik, K, Kleiber, C. strucchange: an R package for testing for structural change in linear regression models. J Stat Soft 2002;7(2):138.
20. Pittet, D, Allegranzi, B, Boyce, J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30(7):611622.
21. Kirmeyer, SL. Employee reactivity and adaptation to observation on the job. J Environ Psychol 1985;5(4):355372.
22. Joint Commission. 2014 Hospital national patient safety goals. Accessed July 15, 2014.

Establishing Evidence-Based Criteria for Directly Observed Hand Hygiene Compliance Monitoring Programs: A Prospective, Multicenter Cohort Study

  • Jun Yin (a1), Heather Schacht Reisinger (a2) (a3), Mark Vander Weg (a2) (a4), Marin L. Schweizer (a2) (a3), Andrew Jesson (a2), Daniel J. Morgan (a5) (a6), Graeme Forrest (a7), Margaret Graham (a3), Lisa Pineles (a5) and Eli N. Perencevich (a2) (a3)...


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