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September 2021

Direct observation vs. electronic monitoring systems:

What’s the best way to monitor hand hygiene?

Know the important role both people and technology play in best practice.

Electronic vs manual hand hygiene monitoring

Many organizations including the Joint Commission, APIC, SHEA and The Leapfrog Group have guidelines and recommendations for hand hygiene compliance in acute care hospitals. Among them, The Leapfrog Group has established a leadership position by developing best practices for hospital hand hygiene (HH). Those practices are integrated into their evolving Hand Hygiene Standard with five performance domains hospitals must meet:

  1. Training and education
  2. Infrastructure
  3. Monitoring
  4. Feedback
  5. Culture

This column focuses on compliance monitoring, but getting hand hygiene right requires meeting the performance criteria for all five domains. We’ll consider inpatient units in acute-care hospitals here, but similar principles would apply to emergency departments and outpatient units.

Many infection preventionists and C-suite leaders choose between the two main options for compliance measurement—either direct observation or a validated electronic compliance monitoring system that captures both hand hygiene opportunities (HHOs) and events (HHEs).

Studies have shown that the combination of electronic monitoring for measurement with direct observation for coaching and intervention can lead to significant improvement in hand hygiene compliance.3

The evidence suggests1,2 that hospitals use direct observation for coaching and intervention—identifying and removing hand hygiene barriers.

Studies also show that combining electronic monitoring for measurement and direct observation for coaching and intervention can achieve significant compliance improvement.3

But when it comes to accurate, reliable and cost-effective measurement, which makes more sense?

5 essential factors to consider

1 | Direct observation, the Hawthorne Effect and data quality

The Hawthorne Effect describes the reality that people behave differently when observed. In hand hygiene, direct observation as a measuring tool can overstate compliance by up to 300%.4 Inaccurate reporting can lead to staff and leadership complacency and put patients at risk of avoidable harm. On the other hand, a validated electronic monitoring system, capable of capturing virtually all hand hygiene opportunities and events 24/7, eliminates the Hawthorne Effect risk and generates reliable data on facility-wide hand hygiene behavior.

Hawthorn Effect icon

2 | Observer bias

Hospitals using direct observation need a system for training and validation of hand hygiene compliance observers. This is essential to achieve inter-rater reliability. Observers have been shown to be biased5 and controlling for inter-rater reliability takes time, effort and practice. An electronic monitoring system eliminates the bias and the need to validate direct observers for bias.

Observer Consistency icon

3 | Timeliness of feedback

A hospital typically doesn’t provide feedback from direct observation for up to 30 days. To be effective and actionable, feedback should be timelier. Some electronic monitoring systems deliver feedback in less than 24 hours. Some have real-time worker alerts that prevent missed events. Data from an electronic monitoring system along with front line staff feedback has delivered proven results: higher compliance, reduced infections, elimination of costs due to extended length of stays and positive impact on safety culture.6

Timeliness of Feedback

4 | Sufficiency of sample size

Hospitals using only direct observation for hand hygiene monitoring are targeting 200 direct observations or 1.7% of total hand hygiene opportunities per unit per month. There is, however, a much larger and richer potential dataset to mine when one considers the estimated number of HHOs based on the HOW 2 Study.7

Type of unit/facility Target direct observations/per unit/per month WHO 5 moment HHOs per unit/per month based on HOW2 study for inpatient units (estimated)
20 bed medical unit: teaching hospital 200 42,960
10 bed ICU: teaching hospital 200 53,640
20 bed medical unit: small, acute care community hospital 200 18,180
10 bed ICU: small, acute care community hospital 200 21,270

Electronic monitoring systems available today can capture every HHO and HHE and provide robust and actionable data. For example, based on the HOW2 study, a 15-unit, 250 bed academic hospital could have an estimated 8.3 million total annual inpatient HHOs (assuming 100% occupancy; 200 medical unit beds and 50 ICU beds)—rich insights for frontline staff feedback.

5 | The economics of direct observation

For a 250-bed academic medical center with 10 medical units (20 beds each) and 5 ICUs (1 beds each) the cost of 200 direct observations per unit per month alone could exceed $76,000 per year (assumes a $55/hour cost including benefits for trained direct observers). Cost would be even higher for a community hospital. Electronic monitoring systems are available for similar or lower annual costs and deliver more timely, comprehensive and actionable data.

value comparison icon

When considering the goal of 200 observations per unit per month, either method can be used. Direct observation has significant limitations. Automated electronic monitoring systems offer much more robust clinical and economic benefits.

While either method can be used, it becomes clear that direct observation has significant limitations while electronic monitoring systems offer much more robust clinical and economic benefits.

Hospitals should refer to Leapfrog’s full-text version Leapfrog Hand Hygiene Standard, for the most complete information and decision support found in the Leapfrog Group 2020 Hospital Survey.8

Paul Alper

Paul Alper, BA, VP, Patient Safety Innovation for Medline Industries, LP

Paul invented the first electronic hand hygiene monitoring system designed to improve hand hygiene performance while reducing infections and costs. He is an innovative and mission-driven leader with more than 35 years of experience in hand hygiene and patient safety solutions. Paul also shares hand hygiene insights as a monthly contributor to Healthcare Hygiene Magazine.

Looking for more ways to improve hand hygiene and reduce HAIs facility-wide?

Explore new strategies to make hand hygiene second nature.

Read more about best practices from hand hygiene expert Paul Alper in the latest issue of Healthcare Hygiene Magazine.

Zone in on zero harm. Learn how to create a culture of safety and fight the spread of pathogens.

Disclosure: Medline is a 2021 member of the Leapfrog Partners Advisory Committee and has a collaborative relationship with a company that offers electronic hand hygiene monitoring services.


  1. Kelly W, Blackhurst D, Steed C, Boeker S and McAtee W. Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand Hygiene Compliance. Paper presented at the 2016 SHEA annual meeting.
  2. Son, C., Chuck, T., Childers, T., Usiak, S., Dowling, M., Andiel, C., Sepkowitz, K. (2011) Practically speaking: Rethinking hand hygiene improvement programs in health care settings. American Journal of Infection Control, 39(9), 716–724. doi:10.1016/j.ajic.2010.12.008
  3. Boyce JM. Electronic Monitoring in Combination with Direct Observation as a Means to Significantly Improve Hand Hygiene Compliance. (2017) Am J Infect Control. 45(5), 528-535.
  4. Srigley JA, Furness CD, Baker GR and Gardam M. Quantification of the Hawthorne Effect in Hand Hygiene Compliance Monitoring Using an Electronic Monitoring System: a Retrospective Cohort Study. (2014) BMJ Qual Saf. 23, 974-80.
  5. Dhar, et al. Observer bias in hand hygiene compliance reporting. (2010) Infec Contr Hosp Epidemiol; 31(8):869-70
  6. Kelly JW, Blackhurst D, McAtee W and Steed C. Electronic Hand Hygiene Monitoring as a Tool for Reducing Health Care Associated Methicillin- Resistant Staphylococcus aureus Infection. (2016) Am J Infect Control. 44(8), 956-957.
  7. Steed C, Kelly JW, Blackhurst DW, Boeker S, Diller T, Alper P. Hospital hand hygiene opportunities: where and when (HOW2)? The HOW2 benchmark study. (2011) Am J Infect Control;39:19-26.
  8. Leapfrog Group. (2020 , April 13). Leapfrog Hospital Survey. Retrieved from