Client Stories

UK Hospital Hand Hygiene Effort Pays Off, Saves Lives

Leaders at a large London hospital heeded the call to reduce hospital-acquired infection, starting with a well-known basic: hand hygiene. They wanted to take it farther than the baseline infection prevention requirement of “in and out”—ensuring that everyone sanitizes their hands when going into and coming out of a patient room.

Instead, the leadership decided to broaden the hand hygiene mandate. The goal would be for every worker to sanitize their hands appropriately for each of the “Five Moments” set forth by the World Health Organization (see below).

The hospital sought to make superlative hand hygiene part of hospital culture. Leaders recognized that when an effort is viewed as an “initiative” or a “campaign,” it will likely fail, as employees wait for it to pass, and something else to pop up in its place. Instilling hand hygiene as part of the way of doing things would require a deeper commitment.

To kick off this new hospital-wide program, the hospital contracted with Healthcare Performance Partners (HPP) to conduct a five-day performance improvement exercise. Through prior work at one Colorado-based hospital, staff members from HPP had discovered what it took to engage people in a systematic change of behavior. They also showed that increasing compliance with known hand sanitizing procedures did indeed lower the rate of hospital-acquired infections (See Figure 1).

The Kickoff

The five-day kickoff included staff members from every corner of the hospital, from housekeeping to clinical care. The staff champion for this work was the infection prevention and control (IPC) nurse.

The IPC nurse and the HPP trainers used the scientific method to train small teams in the skill of observing and measuring hand hygiene correctly. Together, they set out to determine accurately hand hygiene compliance across the hospital in all five of WHO’s hand hygiene “moments.

Figure 1

The good news was that, with trained staff members conducting their observations the same way, they would come up with unusually accurate information. But the bad news, predictably, was a low measured baseline of compliance. The observations concluded that staff members complied with hand hygiene guidelines only about a third of the time.

Figure 2

Now what? Typical vs. Lean Approach

At this point, the temptation would be for management to jump to the conclusion that staff members are either unenlightened or unmotivated, and admonish better performance. Often, the top-down solution is to “enforce” hand hygiene requirements, install posters, hold meetings, raise awareness and demand compliance.

Instead, the Lean approach is quite different, more systematic, more systemic and long-lasting. Instead of asking the blame-laden questions, “Why don’t you? Why won’t you?” Lean seeks to ask, “Why can’t you? What stands in your way? How shall we work together to remove those obstacles?”

Instead of starting with preconceived notions about a solution, hospital staff began with a root cause analysis, and discovered different root causes within their hospital:

  • The hand sanitizer dispenser was in the wrong place, not easy enough to use in the course of work.
  • The work process itself was too complicated, triggering many additional hand hygiene events.
  • The attitude about the importance of hand hygiene had slipped.

Standard work

Under the IPC nurse’s leadership, the team conducted a hospital-wide review of the placement of hand sanitizer dispensers and glove boxes. They began to look at standardizing typical tasks, and so standardizing the time and place for hand hygiene.

For example, catering workers were unsure about hand hygiene rules during tray delivery. They might wash and glove, but then deliver several trays, entering and exiting several rooms.

To make it easy to follow hand hygiene guidelines every time, the team looked at the way work was done. Using a schematic of the room, they created a standard work map and checklist, including where to park the cart, how to wash on entry, place the tray, then wash on exit. Gloving had actually never been required, so it was eliminated.

As part of the expectation, catering workers were coached in the new standard procedure in the course of work, or “just in time.” Then they turned around and coached others. Hand hygiene compliance soared.

“Just in time” coaching requires leadership

The hospital is in the second year of its Lean journey. For several years before that, the hospital had embraced a safety culture, which engendered collaboration and the safety to call out problems.

From the start, the hospital’s top leadership made it clear to the entire staff: When it comes to hand hygiene, expect to be coached, and expect to coach others.

If an employee was seen in a hand hygiene lapse, another employee would immediately begin a coaching session. It would happen in the course of work. No one would be exempt. No one would avoid coaching or being coached. This new coaching expectation became known as “Operation Snowball.

Over the long term, weekly hand hygiene graphs and reviews kept the issue at the forefront. Hand hygiene competency was included in a performance appraisal system for staff members.

As one staff member says, “We had a safe culture to begin with. That’s a good thing, because you have to feel safe if you are going to remind a physician to sanitize her hands.


At the hospital, efforts to weave hand hygiene into the culture of the institution have paid off. Hand hygiene compliance in all five of the WHO moments hovers at more than 90 percent, where it has been sustained for nearly a year.

Ongoing benefits

For her work in helping to increase hand hygiene, the IPC nurse was recognized by a prominent infection control vendor with a national award. The honor for her and her team is well deserved, as their efforts brought hand hygiene compliance from 30 percent to more than 90 percent, where it remains.

Now that hand hygiene and coaching are part of standard work in the hospital, time and energy can be directed toward the reduction in HAIs of all types. They key, as one staff member noted, was that with Lean, the idea is not to push a preconceived solution, but to teach the scientific method for continuous process improvement.