Intended for healthcare professionals


Keeping hand hygiene high on the patient safety agenda

BMJ 2013; 346 doi: (Published 01 May 2013) Cite this as: BMJ 2013;346:f2699
  1. Sheldon Stone, senior lecturer1,
  2. Graziella Kontowski, founder of Clostridium difficile support group 2,
  3. Rose Gallagher, nurse adviser, infection prevention and control3,
  4. Julie Storr, president4,
  5. Louise Teare, consultant microbiologist and infection control doctor5
  1. 1Royal Free Campus, University College London Medical School, London NW3 2PF, UK
  2. 2Clostridium Difficile Support Group, London, UK
  3. 3Royal College of Nursing, London, UK
  4. 4Infection Prevention Society, Bathgate, UK
  5. 5Broomfield Hospital, Chelmsford, UK
  1. s.stone{at}

WHO’s call to action reminds us that “patients have a voice too”

The World Health Organization’s annual global hand hygiene day is on 5 May ( The day offers participating hospitals tools to improve hand hygiene and supports WHO’s first global patient safety challenge, launched in 2005 to reduce the global burden of healthcare associated infection through sustained improvements in hand hygiene. By 5 May last year, 130 countries had registered with WHO’s “save lives: clean your hands” initiative ( This year the number is 170. WHO’s call to action for 5 May 2013 asks hospitals to “continue to focus on hand hygiene monitoring and feedback” and reminds them that “patients have a voice too.” This reminder has particular resonance for the English NHS in light of recent events where patient safety had low priority, even though England and Wales were the first, in December 2004, to roll out a national Cleanyourhands campaign.1

Research published in the BMJ a year ago showed that the Cleanyourhands campaign, coordinated by the National Patient Safety Agency, was highly successful.2 The study found strong independent associations between procurement of alcohol hand rub and soap and declining rates of meticillin resistant Staphylococcus aureus and Clostridium difficile. The hand hygiene intervention now offered to countries through the WHO save lives initiative is similar.

The campaign’s external reference group advised the National Patient Safety Agency that the Cleanyourhands campaign should continue but change focus to concentrate on techniques of hand hygiene audit and feedback, in a prescient echo of the current call to action by WHO. However, the government closed the campaign in December 2010. Worried that the gains from the campaign might be lost, members of the reference group formed the Independent Alliance of Patients and Health Care Workers for Hand Hygiene ( The alliance aims to ensure that a high standard of hand hygiene, based on the best available evidence, continues to be observed by all healthcare workers. It plans to achieve this through working with the agencies that emerge in the newly configured NHS for commissioning, regulation, and education. Responding to a letter from WHO expressing concern at the campaign’s closure, the then health minister wrote: “Hand hygiene is now an established part of clinical care.” The alliance does not agree. Although audits by ward staff regularly report compliance levels of 90% or more, independent audits conducted by infection control teams commonly show compliance rates of 30-40%.

The evidence base regarding what works in terms of monitoring, audit, feedback, and improvement of hand hygiene compliance has grown considerably in the past few years. WHO has made a big contribution through its “five moments tool,” its technical guides for hand hygiene observation,4 and its multimodal hand hygiene intervention, as has the six year programme of research funded in the United Kingdom by the now defunct Patient Safety Research Programme. Hand hygiene observation tools are now robustly standardised,5 we know how long an observer should observe for,6 and evidence from a randomised controlled trial shows that coupling audit and feedback to a repeating cycle of personalised action planning improves hand hygiene significantly.7 We also know that hospitals use different hand hygiene observation tools, few of which are standardised or have detailed standard operating procedures, and that hand hygiene deteriorates if gloves are worn.8

The technique of hand hygiene observation has to be taught. This was recognised by the Cleanyourhands campaign’s expert reference group, which suggested that observation of technique should form the focus of a renewed campaign. Correct observation requires several hours training, as does the technique of effective feedback ( However, bedside observation is labour intensive and does not record compliance at all times. Electronic alternatives such as video recording and direct feedback are available and require exploration alongside technical means to overcome problems of privacy, dignity, and data protection.9

Hand hygiene is the most basic of all patient safety interventions. Three years after closure of the Cleanyourhands campaign we still need to ensure that hand hygiene really is “an established part of clinical care.” On 8 May the hand hygiene alliance will meet NHS England, the Care Quality Commission, National Institute for Health and Care Excellence, and other agencies responsible for patient safety in the NHS to explore future partnerships, using hand hygiene as an exemplar of how to work together to achieve a common vision of patient safety. One patient representative says of hand hygiene, “It’s such an easy thing to do, why isn’t it done?” The answer is that it is not as easy as it seems. Initiatives like the annual global hand hygiene day keep hand hygiene high on the patient safety agenda and enable its advocates, including patients, to make their voices heard.


Cite this as: BMJ 2012;346:f2699


  • Competing interests: we have read and understood the BMJ Group policy on declaration of interests and declare the following interests: SS has received grant funding from GOJO industries; RG is a steering group member for Irisys, a small business research initiative. JS, LT, and GK have none.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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