Hand Hygiene Compliance in Healthcare: A Comparison of International and U.S. Models
By Robert P. Lee
This article originally appeared in the Nov-Dec 2025 issue of Healthcare Hygiene magazine.
Hand hygiene remains one of the most effective interventions in preventing healthcare-associated infections (HAIs), yet achieving and sustaining high compliance among healthcare workers continues to be a global challenge. Different countries and health systems approach hand hygiene compliance in varied ways, particularly when comparing the international framework led by the World Health Organization (WHO) to the more regulatory-focused approach in the United States, spearheaded by the Centers for Disease Control and Prevention (CDC) and oversight bodies like The Joint Commission.
While both models aim to improve hand hygiene and reduce HAIs, they differ significantly in design, implementation, monitoring, and cultural integration, which in turn affects their clinical effectiveness.
Framework and Approach
The WHO promotes the “5 Moments for Hand Hygiene,” a model rooted in human factors engineering and workflow analysis. It encourages healthcare workers to perform hand hygiene at five critical moments during patient care: before patient contact, before aseptic tasks, after exposure to body fluids, after patient contact, and after contact with patient surroundings. This approach is behaviorally focused and context-driven, emphasizing the integration of hand hygiene into the natural flow of care.
In contrast, the U.S. model, guided by CDC protocols, focuses more on procedural compliance — ensuring hand hygiene is performed before and after patient contact and during specific clinical tasks. It is often reinforced through hospital policy, compliance audits, and performance metrics. This model fits well within the highly regulated U.S. healthcare environment, where institutions are often held accountable by accrediting bodies such as The Joint Commission.
Monitoring and Measurement
Monitoring hand hygiene compliance also differs between the models. The WHO primarily recommends direct observation, using standardized audit tools. This method provides rich contextual insights but is labor-intensive and prone to observer bias. In many low- and middle-income countries (LMICs), electronic monitoring is rarely feasible due to cost or infrastructure limitations.
In the United States, a mix of direct observation, electronic monitoring systems, and product usage tracking is common. Many hospitals use sensor-based technologies that track dispenser use and staff movement, allowing for more frequent and automated data collection. This enhances enforcement and supports quality improvement efforts, especially when linked to institutional performance indicators or financial incentives.
Enforcement and Incentives
Another significant difference is the degree of regulatory enforcement. In the U.S., hand hygiene compliance is often tied to accreditation, public reporting, and even reimbursement. Non-compliance can carry serious consequences, including citations or loss of funding. This creates a strong incentive for healthcare organizations to prioritize compliance and invest in systems that track it.
In many other countries, especially those following WHO guidelines, enforcement varies widely and may be minimal, depending on national health policy, resources, and infrastructure. The WHO model is designed to be adaptable and sustainable, particularly in low-resource settings, with an emphasis on building a safety culture rather than enforcing compliance through penalties.
Clinical Effectiveness
Both models have been shown to reduce infection rates when implemented effectively. Studies of the WHO’s multimodal hand hygiene strategy — which includes education, system change, performance feedback, reminders, and culture change — have demonstrated compliance improvements of up to 60% and HAI reductions as high as 41%. Similarly, U.S. hospitals using a combination of monitoring methods and strict policy enforcement have seen hand hygiene compliance rates exceed 85%, resulting in significant declines in infections such as central line-associated bloodstream infections (CLABSIs) and ventilator-associated pneumonia (VAP).
However, there are important nuances. The WHO model, though less technologically driven, is often seen as more clinically integrated and sustainable, embedding hand hygiene within the behavioral patterns of care. It builds habits that are more likely to persist beyond formal audits. The U.S. model, while highly measurable and enforceable, sometimes suffers from issues like the Hawthorne effect (where staff perform better when observed), compliance fatigue, or even gaming the system to appear compliant.
Conclusion and Observations
In principle, the WHO model may be more clinically effective, particularly because it addresses behavior, context, and sustainability. It is also more adaptable to different healthcare environments, especially those with limited resources. In contrast, the U.S. model benefits from advanced technology, regulatory accountability, and strong institutional support, making it highly effective in well-resourced healthcare systems.
Suggestions and Recommendations
Ultimately, the best results may come from a hybrid approach: combining the WHO’s contextual, behavior-driven framework with the U.S. model’s rigorous monitoring and enforcement mechanisms. Such an integrated strategy would not only improve compliance rates but also ensure that hand hygiene becomes a deeply embedded part of patient safety culture across healthcare systems worldwide.
It should be noted that many hospitals in the US claim to follow the International standards of the WHO 5 Moments, but do not. They fail to monitor how the healthcare worker interacts with the patient during care, the patient environment and to measure all the opportunities for hand hygiene (70% of all the hand hygiene opportunities happen inside the room during patient care. Clack, et al). Are we really measuring hand hygiene compliance or are we just “checking the box”?
Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX- The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.
When Low Hand Hygiene Compliance Could Still Mean High-Quality and Safety: Understanding the Data
By Robert P. Lee
This article originally appeared in the July-August 2025 issue of Healthcare Hygiene magazine.
When we talk about infection prevention in healthcare or high-stakes environments like pharmaceutical manufacturing, hand hygiene is often held up as the gold standard. It's true: hand hygiene is the number one preventative technique in limiting the transmission of pathogens. But here's a provocative thought: What if hand hygiene alone isn’t enough?
Imagine a facility where every room, every unit, and every object was completely free of pathogens. In such an environment, whether or not someone washes their hands would matter far less. Sounds unrealistic? Perhaps, but it's a critical mindset shift worth exploring.
Understanding the Ecosystem of Infection Risk
To truly grasp how pathogens spread and how infections occur, we must go beyond hand hygiene and dive deep into the science of pathogen behavior and facility dynamics. This means understanding several key areas:
Pathogen Mobility
Pathogens aren’t stationary. They travel via hands, air, water, surfaces, tools, and people. Knowing how pathogens move — whether airborne, contact-based, or droplet spread helps identify weak spots in your infection prevention strategy.
Pathogen Portals
Infection risk isn't isolated to the patient or the clinician. Every point of contact is a potential “portal” for pathogens. Key portals include:
• The patient
• High-touch room surfaces: bed rails, call buttons, mattresses, curtains
• Healthcare personnel
• Visitors
• Medical equipment
• Sinks, drains and toilets
• Air quality
• Floors and horizontal surfaces
• Dust and particulate matter
When these portals are not addressed systemically, even perfect hand hygiene compliance won't stop transmission.
Workflow and Contamination
Every step in a patient care workflow can be an opportunity for contamination. A nurse adjusts a bedrail, a technician handles a ventilator, a visitor touches a chair. Unless those touchpoints are part of a larger contamination-control strategy, risks accumulate quickly.
Facility Health: Beyond the Patient Room
Infection prevention must be a facility-wide goal. Storage rooms, maintenance spaces, elevators, and equipment closets are often overlooked. Infection control cannot be compartmentalized. We must define facility health comprehensively—from complex surgical units to seemingly mundane support areas.
Rethinking the Role of Hygiene
Let’s be clear: hand hygiene is crucial, but it should be understood as one layer in a broader defense system. Too often, we default to a “pill mentality” — believing that the next disinfectant, antimicrobial coating, or stronger chemical is the answer. While these tools have value, they’re reactive by nature.
What we need is a proactive, data-driven system that prevents infection before it has a chance to take hold.
The Power of Data, Sensors, and Predictive AI
To truly modernize infection prevention, we need to bring it into the 21st century with the help of technology:
• Sensors and IoT devices can track hand hygiene compliance, surface cleanliness, room entry and exit logs, and even microbial load in real time.
• Artificial intelligence (AI) can analyze this data to identify patterns, predict high-risk scenarios, and suggest interventions—before infections occur.
• Visualization tools can give administrators a 180-degree view, looking from the inside out and from the outside in, understanding how people, processes, and pathogens interact.
Rather than reacting to infections after they happen, we can shift to a predict-and-prevent model where data leads the strategy, and zero infections is the target.
Why “Zero” Must Be the Goal
Today’s infection prevention strategies often aim for “acceptable” infection rates. But what does that even mean? Is a 5 percent or 10 percent infection rate tolerable when those infections are preventable? Would we accept a pilot landing 90 percent of the time? Of course not.
If we truly believe in the ethos of “do no harm,” then anything short of zero harm, zero healthcare-associated infections (HAIs), must be considered unacceptable. Lowering expectations to meet industry averages is not only negligent, it can be fatal. This isn’t about being idealistic. It’s about being accountable.
Training, Protocols, and the Creative Mindset
Prevention starts with people. Robust training and standardized protocols are essential—but they must be dynamic, evolving with the latest insights, data, and technologies. Compliance improves not only with enforcement, but also through education, ownership, and a culture that values safety over convenience.
We must don our creative hats. What if our hospitals were built with antimicrobial materials? What if airflow was intelligently managed in every room? What if we mapped pathogen behavior like we map hospital logistics? The solutions exist—but they require vision and investment.
Seeing the Microscopic War
Many healthcare professionals think they understand infection prevention, but when was the last time they truly looked at the problem microscopically? There’s a microbial war raging in plain sight, one we can only fully appreciate with the right tools and perspective.
Imagine trying to fly a plane with no instruments — no map, no altimeter, no radar. That’s what it’s like trying to prevent infections without data. It's time we acknowledge the gaps and start flying with our full toolkit.
Conclusion: A Call to Think Differently
Low hand hygiene compliance doesn’t have to mean high infection risk but only if we adopt a multi-layered, technology-driven, and facility-wide approach to infection prevention. We must:
• Think beyond handwashing
• Redefine what a “safe” facility looks like
• Leverage data, sensors, and AI to prevent—not just detect—HAIs
• Set our sights on zero, and nothing less
This isn’t just a medical imperative, it’s a moral one. Every infection we fail to prevent represents a human cost. So, let’s look through the microscope, see the battlefield, and do everything in our power to stop the war before it starts.
Questions and comments may be sent to: Medicaldatamanagement@gmail.com
Robert P. Lee, BA, is CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, home of THE IPEX – The Infection Prevention Exchange, a digital collaboration using data, tech, and AI to reduce the risk of healthcare-associated infections (HAIs).
What You Should Know Before Admission to the Hospital
By Robert P. Lee
This article originally appeared in the May-June 2025 issue of Healthcare Hygiene magazine.
At the Infection Prevention Exchange (IPEX), we are assessing the critical but often overlooked factor in a patient’s journey to recovery, the patient’s hospital room. Infection prevention is a series of strategic actions applied synchronously to prevent hospital acquired infections. This layered, systems-based approach is a horizontal rather than the more traditional vertical or single-intervention method.¹
Unfortunately, our healthcare system is often reliant on pharmaceuticals as its frontline defense against infection. While important, this mindset can downplay critical non-pharmacological interventions that rely on science, structure, and consistent execution to prevent pathogen transmission and potential infection.
The Hidden Risks in Hospital Rooms
Let’s consider this issue in more depth. Hospital rooms are not only a focus of recovery from surgery and illness but also potential locations for pathogen transmission. Fomites are essential to pathogen movement from one patient to another, one environmental site to another or from environmental surfaces to the patient, whether equipment, objects, hands and/or surfaces. From ceiling to floor, a patient room can act as a reservoir for harmful microorganisms. The room may look clean or smell clean, but true decontamination is far more complex. A recent genomic study that tracked Clostridioides difficile (C. diff) transmission in ICU settings concluded: “These results challenge the idea that nosocomial transmission is not a primary source of acquisition and underscore the importance of hand hygiene and environmental decontamination… Understanding the transmission pathways of C. difficile within healthcare facilities, particularly the roles of environmental surfaces and health care personnel hands, is critical to improving infection control measures.”²
Why Design and Workflow Matter
Take a look inside any single-occupancy hospital room with a bed, sink, bathroom, chairs, workstations, and a hodgepodge of medical equipment, usually arranged with no standard workflow in mind. This randomness extends to safety practices such as hand hygiene, which remains one of the most effective yet underutilized interventions to prevent the spread of infection.
Without a standardized layout and process, staff and patient interactions become unpredictable and this chaos engenders poor hand hygiene compliance, putting both patients and healthcare workers at unnecessary risk.
Consider these questions:
1. Can hospital rooms be designed for greater safety and efficiency?
2. Can we reduce hand hygiene burden while improving compliance and outcomes?
3. Can this be done cost-effectively?
Let’s consider the hospital room of the future, designed for better outcomes:
✅ Standardize Workflow
• Analyze room layout and flow per unit using Lean Six Sigma and value stream mapping.
• Align workflows with best safety practices.
• Standardization = e, with consistent cleaning protocols and fewer “missed” spots.
✅ Create Protection Zones
• Establish designated zones for furniture, equipment, and staff-patient interaction.
• Implement a “patient protection zone” to track and monitor hand hygiene more effectively.
✅ Introduce a Safe Zone (No Hand Hygiene Required)
• Use visual cues (e.g., red tape at the doorway) to define entry zones where hand hygiene is not mandatory unless there is patient or critical environmental contact occurs.
• This approach, already used in ORs, could reduce hand hygiene events by up to 50%.
✅ Audit & Optimize Hand Sanitizer Placement
• Add dispensers near at critical locations: both sides and foot of the bed, workstations, and equipment areas.
• Consult fire safety guidelines for placement approval.
✅ Invest in Training & Simulation
• Use simulation centers (or create your own on-site) to train staff on standardized workflows and safety protocols.
• Track compliance and provide real-time feedback using scoreboards or dashboards.
Final Thoughts
With the rise utilization of genomics and real-time data, the link between environmental cleanliness and infection risk is becoming scientifically validated. By redesigning patient rooms with considering safety, efficiency, and standardization in mind, we can significantly enhance infection prevention for protect patients and healthcare workers alike.
Want to lift morale? Let your team know how these changes could cut decrease hand hygiene requirements by 50% —while concurrently improving improve safety.
Need support? THE IPEX TEAM is here to help.
Robert P. Lee, BA, is CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, home of THE IPEX – The Infection Prevention Exchange, a digital collaboration using data, tech, and AI to reduce the risk of healthcare-associated infections (HAIs).
References:
¹ Septimus, E., et al. (2014). Approaches for Preventing Healthcare-Associated Infections. Infection Control and Hospital Epidemiology, 35(7), 797–801.
² Keegan, L.T., et al. (2025). Environmental and HCP Sampling & Unobserved C. diff Transmission in ICU. JAMA Network Open, 8(4): e252787.
Is Less Data Better Than More Data When It Comes to Hand Hygiene?
By Robert P. Lee
This article originally appeared in the March-April 2025 issue of Healthcare Hygiene magazine.
Data is the new currency in the marketplace, whether managing a business, fighting a war, flying an airplane, navigating a ship, going to space, or working in the healthcare environment. Just as DNA is the foundation of life, data is the critical component of our processes, whether simple or complex. At times, within the infection prevention arena, the importance of real time, robust and accurate data is minimized. Rationalizations proposed often include not cost effective, inefficient, too much work, or time could be better spent on education, training and culture. For discussion, I reference a recent study by Reese, et al. (2024) who said their findings suggest hospitals could reduce hand hygiene (HH)observations to 50 per unit per month without affecting data quality even at lower adherence. It is recommended that standards shift focus from monitoring (with fewer observations) to training, education, culture, infrastructure, and feedback.”1
This study suggests that healthcare facilities can reduce the number of HH observations from 200 or 100 to 50 and the quality of data regarding HH compliance is not significantly impacted. It should be noted that the World Health Organization (WHO) recommends 200 and the Centers for Disease Control and Prevention (CDC) recommends 20 observations.2 Also, the Leapfrog Group indicated that its guideline was based on the more stringent WHO standard of 200.
There are important considerations regarding this recommendation. There may be no difference between 200 and 50 observations in evaluating changes from one point in time to another, i.e., a monitor of consistency. However, is it an accurate number to measure HH compliance according to the WHO? Should the number of data points actually be greater than 200? Why were 200 observations chosen as the point of comparison? A third consideration is the number of observations necessary to provide sufficient feedback for training and education to assure maximum compliance with HH standards. Are we limiting maximizing HH compliance and its consequent importance in decreasing HAI?3
Our internal research has shown:
During a typical shift, nurses may find the need to sanitize their hands over 200 times as opposed to WHO findings of 5 to 42 time/shift2
HH compliance averages less than 30 percent as opposed to WHO/CDC findings (38.7%)2
HH compliance typically improves by 50 percent when technology is employed to monitor HH
With improved HH compliance, healthcare-associated infections (HAI) are reduced, typically by 50 percent
Typical data reported per day using technology is 20,000 to 40,000 HH observations
Data is reported daily by individual, unit, department, facility and IDN
Here are some other questions: Can we have compliance and accountability without good data? And does the 20/100/200 observations represent 20/100/200 person or 20/100/200 unit? Can we train and educate without good data if we are measuring these few observations per unit? Can we become predictive versus reactionary without good data? How unprepared around data were we with COVID-19?
The Secret Shopper approach is not a favorite endeavor of infection preventionists (IPs) or those designated to support this activity. Typically, Secret Shoppers stand in an inconspicuous manner and location to observe and record HH compliance. In most instances, they do not enter the patient’s room where 70 percent of HH opportunities occur.4 Is 50, 100, 200 an accurate measure of HH compliance and is data acquired from these numbers actionable?
From these questions, a consideration is HH technology; it may provide the HH data that provides the numbers actually required to accurately access HH compliance. It does not require observing personnel and records data both inside and outside the patient rooms with wearable recorders for all personnel. Is technology a solution for your facility, especially considering the preceding discussion? Using a return on investment (ROI) calculation, a trial at your institution could significantly improve the number of observations and a more accurate assessment of HH compliance, negating the calculation of 50 versus 200 observations.
Listed are five ideas to consider when assessing your HH program:
Embrace the power of big data, technology and AI
Because many technologies are portable, you can rent, lease or buy room modules and move between units as needed. Renting is a good way to meet your Leapfrog requirements without having to buy a full system.
Learn how to cost justify hand hygiene technology
Educate IP to enhance their access and voice with the administration
Use your performance improvement teams (Lean 6 Sigma)
If data is the new currency in the marketplace, automation, technology and AI are the future. With the cost of HAI more than $47 billion annually and HH one of the most effective methods to reduce HAI, it is unlikely that the cost of enhancing HH compliance and consequent reduction in HAI is unaffordable.
And as always, if you need help, please reach out to THE IPEX TEAM for assistance.
Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX - The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.
References:
Reese SM, Knepper BC, Crapanzano-Sigafoos R. Right-sizing expectations for hand hygiene observation collection. Am J Infect Control. 2024 Dec 5:S0196-6553(24)00857-5. doi: 10.1016/j.ajic.2024.11.017. Epub ahead of print. PMID: 39708046.
Who Guidelines of Hand Hygiene in Healthcare / First Global Patient Safety Challenge/Clean Care is Safer Care. https://iris.who.int/bitstream/handle/10665/44102/9789241597906_eng.pdf
LeapFrog Hospital Survey /Factsheet: Hand Hygiene. https://ratings.leapfroggroup.org/sites/default/files/2024-03/2024%20Hand%20Hygiene%20Fact%20Sheet.pdf
Clack L, Scotoni M, Wolfensberger A, Sax H. "First-person view" of pathogen transmission and hand hygiene - use of a new head-mounted video capture and coding tool. Antimicrob Resist Infect Control. 2017 Oct 30;6:108. doi: 10.1186/s13756-017-0267-z. PMID: 29093812; PMCID: PMC5661930.
Instructions for Use and Hand Hygiene Science
By Robert P. Lee
This article originally appeared in the January/February 2025 issue of Healthcare Hygiene magazine.
Hand hygiene science is understanding how, when, where and under what conditions sanitizing your hands might prevent pathogens from transferring from surfaces in your environment, to other surfaces and then to persons (hosts). We know from the World Health Organization (WHO) 5 Moments for Hand Hygiene guidelines that Moment 5 plays an important role in pathogen migration and transfer. Moment 5 encompasses all “things” within the patient space which might be touched or handle by hands. More specifically, equipment, medications, and other objects (fomites) are included.
Instructions for use (IFUs) are provided by manufacturers of medical devices, instruments and equipment. If hand hygiene is the No. 1 preventive protocol for preventing infection, other than mentioning hand hygiene, why aren’t these IFUs more specific on how, when, where and under what conditions to follow and perform “hand hygiene science”? Let’s see how IFUs are defined by several entities with purview within the healthcare sector.
According to the Food and Drug Administration (FDA), an IFU is a set of written and visual instructions that help healthcare professionals safely and effectively use and/or reprocess medical products and devices.
According to the Joint Commission, an IFU refers to the manufacturer's written guidelines on how to properly use, clean, disinfect, reprocess, and store medical devices, ensuring healthcare providers follow the correct procedures for safe patient care; essentially, it's a set of instructions that come with a medical device outlining its proper usage and maintenance.
I remember flying to Boston several years ago and meeting with personnel developing a new technology designed to improve hand hygiene compliance. One statement during that presentation remains fresh in my memory: “Hand hygiene compliance among healthcare workers was less than 25 percent.” Although I initially thought this highly unlikely, I subsequently learned that the information was correct. As I think back, I missed many opportunities to provide better guidance for my clients had I known the importance of proper hand hygiene and the use of products in my portfolio.
With more than 50 years of corporate experience with customers in the medical device and supply industry, I have never reviewed an IFU or participated in an in-service/education session that addressed hand hygiene, hand hygiene science and the proper use of products directed to proper hand hygiene protocols. If hand hygiene is the No. 1 method to reduce the risk of infection, it would seem appropriate that the medical device/supply companies would emphasize the most effective methods to handle their product in a safe manner.
Logically speaking, the use of a product usually involves the use of one’s hands. So, why wouldn’t there be specific instructions about hand hygiene and the handling of their product? Just saying, “Perform hand hygiene” is not sufficient. IFUs must be more specific related to the when, how, how often, and list the possible examples of hand hygiene events and opportunities with this product. As I have noted previously, “Pathogens don’t have legs, we give them legs.”
If you are a manufacturer/supplier and you do not include in your IFU detailed instructions on hand hygiene and ensure that the consumer is well trained to effectively employ proper hand hygiene protocols when using your product, then this would be similar to flying a plane with no training or giving the keys to your car to a novice teenage driver.
Current infection rates at hospitals are 10 percent to 12 percent according to the Centers for Disease Control and Prevention (CDC), with 100,000 deaths consequent to healthcare-associated infections (HAI) and more than 2 million infections annually, at a cost to providers, insurers, and patients of $47 billion.
Why is there this disconnect in product information and hand hygiene science?
I hope this discussion compels corporate leadership and executives to ensure their marketing and sales teams employ hand hygiene science as a critical component of their in-service/education and IFUs. And, as always, if you need help, please reach out to The IPEX team for assistance.
Robert P. Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX - The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.