Is Automated Monitoring of Hand Hygiene the New Gold Standard?

Updated: Sep 12

By Paul Gallese, PT, MBA

As the Vitalacy team works with healthcare organizations across the nation to improve patient safety performance, we have learned a great deal about the pros and cons of direct observation as a method to monitor the workflow and compliance of caregivers to protocols designed to improve patient safety and reduce healthcare-acquired infections and conditions (HAIs and HACs).

It’s important to understand the pros and cons of direct observation within the context of reducing these infections while considering the availability of automated workflow monitoring solutions (Vitalacy, 2019) that can improve purposeful nurse rounding efficacy, hand hygiene compliance and patient safety. First, let’s look at the advantages of direct observation in reducing infections.

Direct observation advantages

Direct observation allows observers to witness all “five moments” of hand hygiene. The direct human observation of hand hygiene was adopted by the World Health Organization as the gold standard in 2009 for monitoring compliance. This standard was crafted assuming observers have the ability to witness a care provider perform hand hygiene in the “five moments”: washing hands 1) before touching a patient, 2) before clean/aseptic procedures, 3) after body fluid exposure/risk, 4) after touching a patient, and 5) after touching patient surroundings. A human observer can see and note whether or not hand hygiene was performed properly in each of these five stages.

Direct observation gives observers the opportunity to intervene if hand washing opportunities are missed and to provide just-in-time coaching to care providers. During any of the five moments, a direct observer can tell a caregiver if a step was missed and to provide advice about how to properly perform each step. For example, proper hand hygiene requires vigorously rubbing hands, palm to palm, for at least 20 seconds. Any deviation from the correct procedure can be noted and the caregiver can be coached about the proper method, helping to improve patient safety. Even if an automated monitoring method is used, direct observation can supplement it by providing immediate feedback and coaching.

Disadvantages of direct observation monitoring

Direct observation monitoring overestimates compliance rates because compliance drops off when care providers are not being observed. When care providers are not being observed, compliance drops off, due to the Hawthorne effect. Simply put, the Hawthorne effect – the alteration of behavior by the subjects of the study due to their awareness of being observed – greatly increases estimated hand hygiene compliance rates. Studies show the overestimation to be as high as 300 percent since compliance drops off significantly when healthcare workers are not directly observed, and most hand hygiene events are not directly observed (Hagel et al., 2015; Srigley et al., 2014).

Direct observation is expensive and time-consuming. Both Boyce, 2017, and Gould et al., 2017, note that for direct observation to be valid, healthcare organizations must invest considerable time and expense for the adequate training and periodic validation of observers, who in turn, must devote considerable time repeatedly observing caregivers in multiple clinical areas. Healthcare organizations often have difficulty achieving an adequate number of observations, especially on night and weekend shifts. This is a costly process to ensure ongoing effectiveness.

Direct observation often depends upon an insufficient sample size leading to statistical invalidity.

Boyce and Gould add that compliance rates determined by direct observation often have an insufficient sample size. Due to the time required for direct observation, only a very small fraction of hand hygiene opportunities can be observed, from which massive and inaccurate extrapolations sometimes are generated. Studies estimate that only 1.2 to 3.5 percent of hand hygiene opportunities are captured via direct observation because of the tremendous number that occur, according to the Electronic Hand Hygiene Compliance Organization. For example, in an acute-care hospital with 1,000 beds, more than 171 million hand hygiene opportunities occur per year in inpatient and emergency areas (Boyce, 2017).

Variations in direct observers training and how observations are conducted affect compliance rates

Variations in how observers are trained and validated and how they conduct observations can clearly affect compliance rates. “Unintentional observer bias, as well as the Hawthorne effect, is likely when observations on a nursing unit are made by nurses who routinely work on the unit, rather than by non-unit observers. The distance of the observer from the healthcare provider being observed, the location of the observer on the unit, the level of activity on the unit, the duration of each observational session, and even the time of day when observations are made can influence compliance rates,” Boyce states. Perhaps the most serious criticism of direct observation is that the presence of observers can potentially influence caregivers’ usual behavior and therefore reduce the validity of the findings (Gould et al., 2017).

Direct observation alone doesn’t present a true picture

In McCalla et al. (2017), researchers come to the conclusion that “it may be impossible to obtain a true measure of compliance through human observation. Because observers are unlikely to be utilized during the hospital’s full hours of operation, no institution can determine whether results from limited human observation will accurately reflect actual hand washing compliance in the 24 hours a day, seven days a week healthcare setting.”

In sum, there is a growing consensus that direct observation is flawed primarily because it cannot produce a true measure of hand hygiene performance. However, there is also a lingering perception that direct observation is the only process available. That is changing. A 2019 Vitalacy white paper, Finding New Ways to Prevent Healthcare-Acquired Infections and Conditions, further explores both direct observation and automated workflow monitoring solutions within the context of reducing HAIs and HACs and improving the efficacy of nurse rounding and hand hygiene compliance.


Boyce JM. State of the Science Review: Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance. American Journal of Infection Control, May 2017;45(5):528-535.

Gould D, et al: Impact of observing hand hygiene in practice and research: a methodological reconsideration. Journal of Hospital Infection, 2017;95(2):169-174. 10.1016/j.jhin.2016.08.008 file.

Hagel S, et al: Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observations with automated hand hygiene monitoring, Infection Control and Hospital Epidemiology, August 2015;38(8):957-62.

McCalla S, et al: An automated hand hygiene compliance system is associated with improved monitoring of hand hygiene. American Journal of Infection Control, May 2017;45(5):492-497.

Nour-Omid J. Vitalacy blog. Introducing Vitalacy’s latest product updates: workflow monitoring & purposeful rounding. Feb. 20, 2019.

Srigley JA, et al: Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system,: a retrospective cohort study, BMJ Quality & Safety, Dec. 2014;23(12):974-980.

Vitalacy, Inc. Finding new ways to prevent healthcare-acquired infections and conditions. (2019).

World Health Organization 2009. Guidelines on hand hygiene in healthcare. WHO. Geneva.

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