Hand Hygiene

Novel approach combining goal setting and performance feedback at group level improves hand hygiene


Hand hygiene (HH) is one of the key measures to prevent healthcare-associated infections. Although several intervention strategies already exist to improve hand hygiene compliance (HHC), HHC rates are still too low. Therefore, new strategies that expand and complement existing programmes are urgently needed. Socio-psychological behavioural approaches such as goal setting and performance feedback could help to develop novel strategies. In order to further develop this hypothesis, a German research team, together with the HARTMANN SCIENCE CENTER, investigated the potential of goal setting and performance feedback to improve HHC at the group level in a prospective, controlled before-and-after intervention study.

Electronically counted hand hygiene events and on-screen performance feedback

The study was conducted between April and August 2017 in a German tertiary hospital on four normal wards. A 4-week adjustment phase was followed by the equally long baseline, intervention and post-intervention phases. To enable electronic counting of hand hygiene events (HHE), existing wall mounted dispensers were replaced by electronically counting dispensers and increased to the extent that at least one dispenser per two beds was available. This allowed dispenser usage data to be transmitted directly via WLAN and continuously recorded as an HHE, with all dispenser activations within 2 seconds counting as one HHE. After completion of habituation and baseline phases, each of the four stations started with its assigned condition. While one station implemented the combination of feedback + goal setting, the other three each applied either feedback only, goal setting only or no intervention (control). For goal setting, after receiving introductory information, the ward team set out to achieve a common target HHC rate. This was written on a poster and put on the noticeboard. Feedback on their group performance was continuously given to the workers through screens on the wards, which revealed the mean HHC rate of the last 7 days - calculated from the electronically counted HHE. In addition, trained staff observed and documented the extent to which the HHE actually matched the HHC as recommended by the World Health Organisation (WHO) in its Five Moments.

Goal setting and performance feedback together significantly increase hand hygiene frequency

Over the course of the study, a total of 1,894 HHE were electronically registered, of which 422 were registered during the adjustment phase, 427 during the baseline phase, 576 during the intervention and 469 after it (post-intervention). This showed that only the combination of feedback + goal setting significantly increased the mean number of daily HHE per patient room compared to baseline - both during the intervention and afterwards. In contrast, the two wards that used either feedback only or goal setting only did not achieve a statistically significant increase.

The results for the number of HHE per patient day also spoke a clear language. Goal setting + feedback almost doubled the mean HHE per patient day compared to baseline (from 4.8 to 9.2); the number remained elevated at 6.5 after the intervention. Furthermore, the observational data confirmed that HHC and frequency of donor use were strongly correlated across all wards and study phases - i.e. the Five Moments“ were implemented.

Conclusion: The study successfully demonstrated that the combination of performance feedback and group-level goal setting significantly increased hand hygiene frequency. While the WHO only recommends feedback to improve HHC, it may prove useful to also include goal setting in compliance-promoting HH programmes.


1.Diefenbacher S et al. (2019) A quasi-randomized controlled before-after study using performance feedback and goal setting as elements of hand hygiene promotion. J Hosp Infect 101: 399–407. https://doi.org/10.1016/j.jhin.2019.02.001

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