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Service Delivery Innovation Profile

Ongoing Monitoring, Prompt Feedback, and Reminders Improve Hand Hygiene in a Busy, Urban Emergency Department

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The Brigham and Women's Hospital Emergency Department implemented a multifaceted strategy to improve adherence to appropriate hand hygiene protocols. The strategy revolves around ongoing auditing, with unit leaders and staff receiving daily feedback on adherence rates. A multidisciplinary committee meets monthly to review these data, brainstorm solutions, and implement strategies to improve adherence, such as increasing the number of waterless hand sanitizer dispensers and providing education, training, and real-time reminders to staff. The program increased adherence significantly during a 10-month study period, from 36 to 91 percent. The majority of this improvement has been maintained since the end of the study, with rates remaining above 80 percent over the last 3 years.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of staff (both overall and by staff type) adhering to established hand hygiene protocols.
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Developing Organizations

Brigham and Women's Hospital
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Date First Implemented


Problem Addressed

Hospital-acquired infections are common and costly, yet frequently preventable. Appropriate hand hygiene represents the best way to avoid such infections, yet providers often do not fully adhere to established protocols. Providers in the emergency department (ED) face unique challenges that make it especially difficult to adhere to hand hygiene practices.
  • A common, costly, yet preventable condition: Hospital-acquired infections—such as methicillin-resistant Staphylococcus aureus (MRSA) infections—are an increasingly common problem with major health consequences. For example, in 2005, an estimated 94,360 people developed serious MRSA infections in hospitals, while 18,650 hospitalized patients died of causes related to serious MRSA infections. In 2004, MRSA accounted for 63 percent of staphylococci infections, up from 2 percent in 1974 and 22 percent in 1995.1 The average hospital-acquired MRSA infection costs $20,000 to treat and extends the patient's stay by 9.1 days. The total cost burden to the U.S. health care system from MRSA infections is estimated at more than $2.5 billion annually.2 One-third or more of all health care-related infections can be prevented.3
  • Lack of adherence to hand hygiene protocols: Hand washing by providers between caring for patients represents the single most important way to prevent infections. Hand hygiene guidelines established by the Centers for Disease Control and Prevention (CDC) require hospital staff to disinfect their hands before and after every contact with a patient or a patient's environment. However, staff adherence to appropriate hand hygiene techniques remains relatively low, at approximately 40 percent, with the estimated cost of each nonadherent event being roughly $52.4
  • Special challenges in the ED: ED-based providers face unique challenges in ensuring appropriate hand hygiene. For example, Brigham and Women's ED staff cite the diverse staff working in the ED, crowded conditions, and frequent patient contacts as major barriers to hand hygiene adherence. The presence of multiple types of ED-based providers creates a challenge, including specialist consultants, emergency medical personnel, patient transporters, and other patient care teams, thus making deployment of a single educational intervention impractical. Finally, the need for many different types of ED room configurations—ranging from large resuscitation bays to the patient in a hallway—leads to variable placement of hand hygiene equipment, thus making ED staff seek out such equipment in multiple locations.

What They Did

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Description of the Innovative Activity

The Brigham and Women's Hospital ED implemented a multifaceted strategy to improve adherence to appropriate hand hygiene protocols. The strategy revolves around ongoing auditing, with unit leaders and staff receiving daily feedback on adherence rates. A multidisciplinary committee meets monthly to review these data, brainstorm solutions, and implement strategies to improve adherence, such as increasing the number of waterless hand sanitizer dispensers and providing education, training, and real-time reminders. More details on this initiative include:
  • Ongoing, direct observation of hand hygiene: Unmarked observers (ED research assistants) record adherence to hand hygiene protocols before and after patient contact through direct observation on a daily basis. Observers note adherence by type of staff (e.g., physician/physician assistant, nurse, environmental services staff, patient transporter, emergency medical services personnel, or other). Observations occur at various times each day, with a total of 5 to 10 hours of observation per week. ED staff know that such observation takes place but do not know exactly when it occurs during the day or who observes them. Following the World Health Organization (WHO) hand hygiene observation protocol, the research assistants use a standardized form to collect data and then enter it into computerized spreadsheets.
  • Regular reporting and dissemination of adherence rates: Research assistants tally adherence rates by staff type and by attending physician in charge, and then produce regular performance reports that are shared with staff, physicians, and department leaders, as outlined below:
    • Almost real-time reporting to physicians, nurses, and ED administrators: Attending physicians and charge nurses receive daily summary reports of their teams' hand hygiene adherence immediately following each observation session, along with a request to share these results with their teams. ED and Acute Trauma/General Surgery Services administrative leaders receive daily reports by e-mail. Results are also posted in staff areas for dissemination.
    • Weekly report via e-mail: ED attending physicians and residents, nurse administrators, ED physician administrators, environmental services leaders, and other departmental representatives receive a weekly e-mail that summarizes adherence rates. These e-mails also encourage them to discuss the data with their teams and periodically include recent hand hygiene articles or reports.
    • Review during regular staff meetings: All staff review hand hygiene adherence rates as part of regularly scheduled meetings. During these sessions, staff use these data to brainstorm new ways to improve hygiene practices.
  • Multidisciplinary hand hygiene team: A multidisciplinary hand hygiene team includes physicians, the ED nurse manager, the ED assistant nurse administrator, an ED nurse, infection control staff, the patient transport manager, and environmental services staff. Theses team members are known as "champions," and they take ownership of the improvement process and become actively engaged as departmental quality leaders. The team meets monthly to review hand hygiene adherence and staff feedback to managers/attending physicians, brainstorm solutions, implement process changes, and provide feedback to ED leadership. Examples of activities undertaken by the team in conjunction with ED staff include the following:
    • Strategic placement of waterless sanitizer dispensers: The ED reviewed the locations of all hand sanitizer dispensers in the ED and identified critical locations where dispensers were not present and areas such as the trauma bay and observation unit where opportunities for improvement existed. The hospital then provided additional dispensers to increase the number in the ED from fewer than 100 before the program to 146 after the review.
    • Hand hygiene promotion, education, and reminders: Staff members review hand hygiene protocols during inservice training sessions that emphasize the need to adopt appropriate practices. Signs and staff buttons challenge patients to ask providers if they have cleaned their hands. In addition, boxes containing latex gloves have conspicuous stickers that remind staff to follow appropriate hand hygiene protocols before putting the gloves on and after taking them off.

Context of the Innovation

A 777-bed tertiary care facility, Brigham & Women's Hospital handles approximately 44,000 inpatient admissions and 56,000 ED visits each year. The ED has 45 beds, 17 assigned hallway spaces, and 45 sinks for hand washing. While examining new ways to meet and exceed Joint Commission guidelines, ED leaders noted that lack of communication and accountability undermined consistent hand hygiene. One particular problem related to the relatively limited observation of hand hygiene in the ED, with such observations occurring only once a month, thus making it easy for providers to deny that a problem existed or their role in accountability. As a result, ED leaders formed a multidisciplinary team to identify strategies for improving hand hygiene.

Did It Work?

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The program increased adherence to hand hygiene protocols significantly during a 10-month study period, from 36 to 91 percent. The majority of this improvement has been maintained since the end of the study, with rates remaining above 80 percent over the last 3 years.
  • Sustained improvement in hand hygiene: Adherence to hand hygiene protocols increased from 36 percent before implementation to 91 percent 10 months later. Adherence has remained above 80 percent since that time (a period of more than 3 years).
  • Improvements across all staff: Adherence improved significantly for all types of staff, including physicians and physician assistants (which improved adherence rates by 48 percent), nurses (56 percent), nursing technicians (43 percent), and nonclinical staff (63 percent).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of staff (both overall and by staff type) adhering to established hand hygiene protocols.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Forming multidisciplinary team: Administrators and representatives from all levels of care within the ED formed the aforementioned hand hygiene team. Initial meetings addressed barriers to adherence, including difficulty accessing waterless sanitizer dispensers and lack of hand hygiene reminders. This team continues to meet monthly to identify barriers and propose solutions.
  • Developing educational materials: The team compiled educational materials and developed inservice training sessions for staff, using a variety of Web sites and the hospital infection control team as resources. (See the "Tools and Other Resources" section for more information on these Web-based resources.) With the support of a nurse manager, nursing staff designed posters and promotional buttons that incorporate staff photographs and slogans related to hand hygiene. A local printer produced these materials.
  • Purchasing and mounting additional dispensers: The ED purchased and mounted the additional hand sanitizer dispensers in the fall of 2008.
  • Deploying auditing system: In January 2009, existing ED research assistants received training on how to observe ED staff using the WHO hand hygiene observation protocol and a standardized tracking form. Staff received notice that they would be observed on a regular basis. (As noted earlier, however, staff do not know when such observations take place or who observes them.)
  • Initiation of glove box sticker campaign: In October 2009, the ED launched the glove box sticker campaign, with environmental services associates placing 2,000 customized stickers (purchased from a local office supply store) on the glove boxes during their daily cart restocking routine.

Resources Used and Skills Needed

  • Staffing: The program requires 5 to 10 hours of time from an ED research assistant to engage in direct observation of hand hygiene. Brigham and Women's used existing research assistants to perform this role.
  • Costs: The primary costs consist of salary and benefits for the ED research assistant time spent on observation. Other, minor costs include printing the glove box stickers and promotional materials. Given the high costs of a hospital-acquired infection, ED leaders think the program produces a positive return on investment.
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Funding Sources

Brigham and Women's Hospital
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Tools and Other Resources

Information about the WHO hand hygiene observation method can be found in the following article: Sax H, Allegranzi B, Chraïti M-N, et al. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37:827-34. [PubMed]

WHO hand hygiene tools are available at

The "Just Clean Your Hands" campaign from the Ontario Ministry of Health and Long-Term Care provides a number of promotional resources for hospitals, available at

United States hand hygiene guidelines and promotional materials are available from the CDC at

Infection control posters can be downloaded from

A humorous and thorough overview of hand hygiene promotion from the Florida Department of Health can be found at

Adoption Considerations

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Getting Started with This Innovation

  • Involve key ED leaders, clinicians, and staff: A hand hygiene campaign cannot be successful without the solid support of top leaders in the ED and the involvement of all types of staff.
  • Identify barriers: Ask team members and other staff leaders to poll their colleagues on the biggest barriers to appropriate hand hygiene, both physical and cultural.
  • Implement feedback, monitoring, and data sharing: Effective hand hygiene depends on ongoing tracking of outcomes, which allows for the quick identification and addressing of barriers to adherence. Staff should regularly be informed of their performance so as to create a desire to improve and foster a culture of improvement.
  • Use praise, not penalties: Unannounced observation may face resistance from staff if those who perform poorly receive punishment. Instead, disseminate results and praise good performance.

Sustaining This Innovation

  • Respond to staff feedback: Offer multiple mechanisms for staff to provide feedback to the hand hygiene committee. Monitor and respond to this feedback on an ongoing basis, which helps to keep staff supportive of and focused on appropriate hand hygiene, thus ensuring strong performance over time.
  • Promote positive outcomes to leaders: Make hospital administrators aware of the results achieved through hand hygiene interventions and the positive benefits associated with such achievements, such as fewer hospital-acquired infections and lower costs.
  • Refresh the message: Adherence may slip if staff do not receive fresh reminders to wash their hands. For example, old dispensers and posters may fade into the background if not periodically updated. Frontline staff can often come up with new, creative ways to educate their peers (e.g., through new posters, videos, etc.); their involvement also serves to engage them in continuous improvement.
  • Focus the message: Additionally, it is important to prioritize a simple and sustained message focused on patient protection as the reason for providers to follow hand hygiene protocols.

Additional Considerations

  • Consider expansion to other units: With the active support of unit leaders, this program can be deployed effectively in other busy departments where hand hygiene adherence remains challenging, such as critical care and surgical units. Such expansion may require hospital-level financial support because the benefits of reduced disease transmission for admitted patients permeate throughout the facility.
  • Consider other observation approaches: Look for opportunities to engage others in observing hand hygiene. For example, hospital volunteers can be trained to observe adherence to hand hygiene protocols, thus reducing program-related costs. Additionally, technology can be used to collect information about hand hygiene adherence. One recent study found that hand hygiene adherence rates significantly improved when video auditors observed health care providers performing hand hygiene on entering and exiting patient care areas.5

More Information

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Contact the Innovator

Jeremiah Schuur, MD, MHS
Director of Quality, Safety & Performance Improvement
Department of Emergency Medicine
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115
(617) 525-8872

Nadia Huancahuari

Stephanie Kayden, MD, MPH
Brigham & Women's Hospital
75 Francis Street
Boston, MA 02115

Eric Goralnick, MD
Assistant Clinical Director
Brigham & Women's Hospital
75 Francis Street
Boston, MA 02115

Innovator Disclosures

Dr. Schuur, Dr. Kayden and Dr. Goralnick have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Venkatesh AK, Pallin DJ, Kayden S, et al. Predictors of hand hygiene in the emergency department. Infect Control Hosp Epidemiol. 2011;32(11):1120-3. [PubMed]


1 Centers for Disease Control and Prevention. MRSA: Methicillin-resistant Staphylococcus aureus in healthcare settings. CDC Features [Web site]. Accessed 2010 December. Available at:
2 Institute for Healthcare Improvement (IHI). Reducing MRSA infections: staying one step ahead [Web site]. Available at:
3 Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, et al. 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. Society for Healthcare Epidemiology of America/Association for Professional in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. [PubMed]
4 Cummings, KL, Anderson, DJ, Kaye, KS. Hand hygiene noncompliance and the cost of hospital-acquired methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol. 2010;31(4):357-64. [PubMed]
5 Armellino, D, Hussain, E, Schilling, M, Senicola, W, 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 Jan 1;54(1):1-7. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.