Finding new solutions to hand hygiene problems

Hand hygiene is an important issue for improved surgical patient outcomes in that it helps prevent the risk of infection. Nonetheless, compliance with hand hygiene requirements is still a significant problem.

Nearly 2 million health care-associated infections (HAIs) are reported every year, and one in every 20 inpatients will contract an HAI. These infections lead to 99,000 deaths annually and to an estimated $28 to $34 billion in additional direct medical costs. HAIs are a significant public health issue, and their prevention should be at the forefront of patient safety efforts.1-4

A national challenge

Improving hand washing among health care professionals is one of the most effective ways to prevent HAIs, yet national compliance with recommended hand hygiene guidelines is approximately 40 percent to 50 percent.5 To sustain improvement and make a difference, a simple slogan or campaign is not enough, and demanding that health care workers try harder probably is not the answer either. Comprehensive, systematic, and sustainable change is the only solution.

In a recent hand hygiene project led by the Joint Commission Center for Transforming Healthcare, eight U.S. hospitals and health systems that volunteered to measure their hand hygiene rates were surprised to find that, when using a consistent and reliable measurement system, their rate of hand hygiene compliance averaged 48 percent.

To address the endemic challenge of hand washing compliance, the Joint Commission Center for Transforming Healthcare developed a tool, which has demonstrated 40 percent improvement in compliance by systematically addressing the entire improvement process. The tool leads health care organizations to solutions that have proven effective in mitigating organization-specific barriers to hand hygiene, leading to higher compliance and lower HAI rates. The tool is available free of charge to the 20,000 health care organizations in the U.S. that The Joint Commission has accredited. For a typical 200-bed hospital, implementing the Targeted Solutions Tool  (TST) can annually prevent 130 to 140 HAIs and eight deaths and save $2.3 to $2.8 million in direct medical costs.

The physician champion

Persistent safety issues such as hand hygiene compliance are complex and multifactorial. The TST is a secure, password-protected, Web-based application that allows hand hygiene teams to break down the complex problem of guideline compliance and focus on the specific factors that affect an organization’s performance. This targeted approach allows for customization and sustainability of the solutions implemented, acknowledging that complex problems cannot be addressed using a one-size-fits-all solution.

A TST hand hygiene project team should include a strong physician champion and a project leader to facilitate meetings and help gain buy-in from stakeholders. Project teams can be expected to spend up to four hours a week collecting and entering compliance data, attending team meetings, and implementing solutions during the 12 weeks of the project. Team members can expect to spend four hours each month sustaining the gains achieved through the hand hygiene improvement strategies.

TST hand hygiene solutions

The center’s hand hygiene solutions were developed using Lean Six Sigma and change management tools and methods that had proven effective in a variety of settings. The TST was designed to be self-directed and includes the use of video tutorials, training materials, implementation guides, change management tips, and data collection tools.

The TST hand hygiene solutions address:

  • Measuring the specific, high-impact causes of hand hygiene failures in a facility
  • Targeting solutions to those specific causes
  • Using resources effectively and efficiently to improve compliance
  • Making washing hands a habit as automatic as looking both ways when crossing the street or fastening a seat belt before driving a car
  • Serving as a role model by practicing proper hand hygiene
  • Holding everyone accountable and responsible—physicians, nurses, food service staff, housekeepers, chaplains, technicians, and therapists
  • Saving lives through the reduction of HAIs

The TST directly addresses issues of hand hygiene compliance. For information on hand washing methods, visit the Centers for Disease Control website.

For more information about the TST and hand hygiene, visit the Joint Commission Center for Transforming Healthcare or e-mail


  1. Klevens RM, Edwards JR, Richards CL, Horan T, Gaynes R, Pollock D, Cardo D. Estimating healthcare-associated infections in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
  2. Centers for Disease Control and Prevention. Healthcare-associated infections (HAIs). The burden. Available at: Accessed August 19, 2013.
  3. Scott RD. Centers for Disease Control and Prevention. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. 2009. Available at: Accessed August 19, 2013.
  4. Centers for Disease Control and Prevention. Healthcare-associated infections (HAIs). Preventing healthcare-associated infections. Available at: Accessed August 19, 2013.
  5. McGuckin M, Waterman R, Govednik J. Hand hygiene compliance rates in the United States—A one-year multicenter collaboration using product/volume useage measurement and feedback. Am J. Med Qual. 2009; 29(3): 205-213.

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