Measuring Hand Hygiene Compliance Research Articles

Comparison of hand hygiene compliance among healthcare workers in Intensive care units and wards of COVID-19: A large scale multicentric study in India

BackgroundHand hygiene is a significant component involved in preventing transmission of health care associated infections including COVID-19. Compliance to hand hygiene among the health care workers (HCWs) requires evaluation and timely feedback. “You can't improve what you can't measure” is a famous saying and this multicentric study was designed to measure hand hygiene compliance and have birds eye view on hand hygiene compliance in COVID Intensive care units (ICUs) and wards across India. MethodsA prospective multicentric observational study was conducted for a period of 6 months in 92 health care facility across India which included varied type of public and private hospitals. Hand hygiene audit was conducted in COVID ICU and COVID non-ICU wards in all these facilities by their HCWs using the IBHAR mobile application based on WHO's hand hygiene audit tool. Hand hygiene total adherence rate (HHTAR) and hand hygiene complete adherence rate (HHCAR) were analyzed and compared between 2 locations. Adherence rates were analyzed based on the zones, institute type, profession and for each WHO moments. ResultsA total of 1,61,056 hand hygiene opportunities were documented and adherence rates were recorded higher in COVID wards (HHTAR-61.4%; HHCAR-28.8%) than COVID ICUs (HHTAR-57.8%; HHCAR-25.6%). Overall, the adherence rates were observed higher in COVID wards (HHTAR- 68.1%; HHCAR-38.3%) of private hospitals, COVID wards of the west zone (HHTAR- 70.2%; HHCAR-36.8%), cleaning staffs of the COVID ward scores better compliance than all other professions in COVID ICUs and COVID wards. HHTAR was found to be the higher in moment 3 (After body fluid exposure-76.3%) followed by moment 4 (after touching patient-73.7%) done in COVID wards compared to moments done in ICUs. ConclusionsThis study highlights the practice of hand hygiene in COVID care locations across India. Effective strategies need to be implemented in COVID ICUs across the facilities to improve the compliance.

Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey

BackgroundHand hygiene is an important measure to prevent healthcare-associated infections in long-term care facilities.ObjectivesTo evaluate compliance with hand hygiene recommendations by different nursing professionals in long-term care facilities and to investigate determinants potentially influencing hand hygiene and whether these differed between the different cadres of staff.MethodsWe conducted two sub-studies: we measured hand hygiene compliance of 496 professionals in 14 long-term care facilities (23 wards) through direct observation using World Health Organisation’s ‘five moments of hand hygiene’ observation tool. In addition, we performed a survey to examine determinants that may influence hand hygiene and to determine differences between different cadres of staff. We used a principal component analysis approach with varimax rotation to explore the underlying factor structure of the determinants.ResultsWe found an overall mean hand hygiene compliance of 17%. There was considerable variation between wards (5–38%) and between specific World Health Organization hand hygiene moments. In addition, hand hygiene compliance varied widely within and between different cadres of staff. The determinant analysis was conducted on 177 questionnaires. For all nursing professionals, we found multiple determinants in four domains: ‘social context and leadership’, ‘resources’, ‘individual healthcare professional factors’ and ‘risk perception’. In two domains, several barriers were perceived differently by nursing assistants and nurses. In the domain ‘social context and leadership’, this included (1) how the manager addresses barriers to enable hand hygiene as recommended and (2) how the manager pays attention to correct adherence to the hand hygiene guidelines. In the ‘risk perception’ domain, this included a resident's risk of acquiring an infection as a result of the nursing professional’s failure to comply with the hand hygiene guidelines.ConclusionHand hygiene compliance was low and influenced by multiple factors, several of which varied among different cadres of staff. When designing interventions to improve hand hygiene performance in long-term care facilities, strategies should take into account these determinants and how they vary between different cadres of staff. We recommend exploring hand hygiene determinants at ward level and among different cadres of staff, for example by using our exploratory questionnaire.Trial registrationRegistration number 50-53000-98-113, ‘Compliance with hand hygiene in nursing homes: go for a sustainable effect’ on ClinicalTrials.gov. Date of registration 28-6-2016.

A user's view of commercial mobile applications designed to measure hand hygiene compliance by direct observation

Mobile applications (apps) that facilitate the measurement of hand hygiene (HH) compliance rates by direct observation (DO) are widely available. Their usefulness for infection prevention and control (IPC) professionals has neither been recently reviewed nor formally assessed. To present a critical analysis of hand hygiene measurement apps. Mobile apps were identified from four sources: PubMed, Apple app store, Google Play app store, Google search engine. Individual apps were then evaluated against a novel scoring system using seven key criteria considered relevant for IPC professionals. These included availability, price, automated data analysis, training requirement, compliance measured against the World Health Organization (WHO) 5 moments of HH, recent updates, and average app store rating. For each criterion, possible scores ranged from zero to two, with a maximum available score of 14 per app. A total of 32 apps were identified of which 13 were suitable for analysis. Only three apps (19%) scored ≥12. Twelve apps (92%) allowed compliance to be measured against the WHO 5 moments of HH. Five apps (38%) were completely free to use, seven apps (54%) allowed for automatic analysis and reporting of HH data and only six apps (46%) had high app store ratings. The current mobile apps available for DO of HH generally scored poorly. In order to make these apps more useful to IPC professionals, they should be user-friendly and require less training prior to use. National IPC organizations should develop core standards for these apps to guide future development.

Methodological and technical considerations for video-based auditing of hand hygiene compliance in clinical practice: an exploratory study

Direct observation is the gold standard method for measuring hand hygiene compliance but its utility is increasingly being questioned. Various alternative electronic methods have been proposed, yet there is a paucity of research examining the use of these according to the World Health Organization's (WHO) '5 Moments for Hand Hygiene'. As a part of the process of developing a video-based monitoring system (VMS) capable of measuring hand hygiene compliance against the 5 moments criteria this paper reports methodological and technical issues that might arise from the use of a VMS for auditing in clinical practice. In-depth semi-structured interviews were conducted with 27 Australian content experts in hand hygiene auditing and infection prevention to explore their responses to proposed VMS auditing approaches. Transcripts were analyzed using thematic and content analysis. Technical and methodological considerations for the use of VMS were interrelated and included concerns surrounding privacy, footage security, fears of surveillance and the potential for medico-legal consequences. Additionally, possible detrimental impacts on healthcare worker (HCW) -patient relationships, issues of cost versus benefits, HCW and patient safety and changes to feedback were also identified. The primary methodological and technical issues to overcome in order to implement VMS for hand hygiene auditing in clinical practice, centered upon issues of acceptability to patients and health professionals, privacy, consent and liability. COREQ.

Hand hygiene feedback impacts compliance

Health care-acquired infections are one of the top causes of mortality in the United States (Stone, 2009; Scott, 2009). Hand hygiene (HH) can reduce the incidence of such infections. Adherence to HH practices remains challenging for health care workers (World Health Organization, 2014). This investigation compared results of private and public HH feedback at the team and individual level. A quality improvement study was conducted in 2 units utilizing HH radiofrequency identification (RFID) technology. Each unit was assigned either private or public feedback mechanisms. The study was divided into 3 phases; baseline, team, and individual. Time series analysis compared HH compliance by health care workers' role and feedback mechanisms. Individual HH compliance were the highest in both groups. The private group compliance was 63.3% (P ≤ .0001) and the public group compliance was 55.4% (P = .0001). During the team feedback phase, HH compliance decreased in the private group to 42.79% (P = .006); however, compliance increased in the public feedback group to 42.5% (P = .2661). The physician role in the private group decreased by 12% (P = .1804) during the individual phase. HH data provided at the individual level and posted publicly could improve HH compliance. Use of RFID measurement technology can provide organizations with tools to measure HH compliance.

Hand Hygiene Compliance in the ICU: A Systematic Review.

To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene. Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened. English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included. Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels. Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%). Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

Moving beyond hand hygiene monitoring as a marker of infection prevention performance: Development of a tailored infection control continuous quality improvement tool

Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool. The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery. Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system. Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.

The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs

Covert observation (CO) is reliable for measuring hand hygiene compliance (HHC). However, the benefit of adding CO to overt observation (OO) is uncertain. We evaluated whether incorporating CO into an OO-based hand hygiene (HH) promotion program improves HH rate. Health care worker's HH activities were observed through 5 monitoring sessions (2 in phases 1 and 2 and 1 in phase 3) of simultaneous CO and OO. An intervention was applied-barrier identification interview-only in phase 2. Overall HHC was 91.0% for OO, and 49.3% for CO. HHC in phase 1 was not changed by repeated CO (34.7% and 34.0%, P = .70). HHC based on CO increased to 66.9% in phase 2 after the application of an intervention (P < .01), but decreased to 57.5% in phase 3 (P < .01). HHC based on OO increased significantly between only the first and second sessions in phase 2 (90.8% and 94.5%, respectively, P = .01). Although CO did not significantly change behavior, HHC with CO responded promptly to the application and cessation of a new intervention. CO reflects HHC change more reliably than does OO. However, it is uncertain whether CO will improve HHC.

Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia

Although direct human observation of hand hygiene (HH) is considered the gold standard for measuring HH compliance, its accuracy is challenged by the Hawthorne effect. To compare HH compliance using both overt and covert methods of direct observation in different professional categories, hospital settings, and HH indications. A cross-sectional study was conducted in 28 units at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between October 2012 and July 2013. Compliance was defined as performing handrubbing or handwashing during 1 of the World Health Organization 5 Moments for HH indications (ie, opportunities). Overt observation was done by infection preventionists (IPs) who were doing their routine HH observation. Covert observation was done by unrecognized temporarily hired professionally trained observers. A total of 15,883 opportunities were observed using overt observation and 7,040 opportunities were observed using covert observation. Overall HH compliance was 87.1% versus 44.9% using overt/covert observations, respectively (risk ratio, 1.94; P < .001). The significant overestimation was seen across all professional categories, hospital settings, and HH indications. There is a considerable difference in HH compliance being observed overtly and covertly in all categories. More work is required to improve the methodology of direct observation to minimize the influence of the Hawthorne effect.

Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study

Compliance with hand hygiene (HH) has often not proved satisfactory; high workload is a commonly self-reported reason. Previous studies comparing workload and compliance have not measured workload precisely and have focused on certain times of day. This study aimed to investigate the association between HH compliance and workload, both electronically defined 365/7/24 (primary endpoint). In addition, the quality of commonly used compliance defining methods (hand disinfectant usage, direct observation) was investigated (secondary endpoint). Correlation of electronically measured HH compliance (hand-rub activities (HRA)/HH opportunities) with electronically determined workload (nursing time output/nursing time input) was undertaken over one year at a stem cell transplant unit at University Hospital Basel, Switzerland. HRA and procedures requiring HRA according to the five World Health Organization indications were recorded continuously (365/7/24) using electronic dispensers and electronic documentation, and compliance was calculated accordingly. Hand disinfectant usage was calculated using spending records for one year; direct observation was performed for approximately 1800 HH opportunities. During the investigation, 208,184 HRA, translating into 57 [standard deviation (SD) 10] HRA/patient-day (PD), were performed. Electronically determined compliance ranged from 24% to 66% [mean 42.39% (SD 8%)]. The higher the workload, the lower the compliance (R=-0.411; P<0.001). HRA/PD (r=-0.037), hand disinfectant usage (mean 160mL/PD) and observed compliance (95%; 1734 HRA/1813 HH opportunities) were not found to be associated with workload. Calculated compliance was inversely associated with nurses' workload. HRA/PD, observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.

Do physicians clean their hands? Insights from a covert observational study.

Physicians are notorious for poor hand hygiene (HH) compliance. We wondered if lower performance by physicians compared with other health professionals might reflect differences in the Hawthorne effect. We introduced covert HH observers to see if performance differences between physicians and nurses decreased and to gain further insights into physician HH behaviors. Following training and validation with a hospital HH auditor, 2 students covertly measured HH during clinical rotations. Students rotated off clinical services every week to increase exposure to different providers and minimize risk of exposing the covert observation. We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Covert observation produced much lower HH compliance than recorded by hospital auditors during the same time period: 50.0% (799/1597) versus 83.7% (2769/3309) (P < 0.0002). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2% vs 54.2%); for nurses this difference was much higher at 40.7% (85.8% vs 45.1%) (P < 0.0001). Physician trainees showed markedly better compliance when attending staff cleaned their hands compared with encounters when attending did not (79.5% vs 18.9%; P < 0.0002). Our study suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences about performance by professional groupings due to relative differences in the Hawthorne effect. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees. Journal of Hospital Medicine 2015;11:862-864. © 2015 Society of Hospital Medicine.

Hand hygiene compliance in Penang, Malaysia: Human audits versus product usage

Hand hygiene auditing is mandatory for all Malaysian public hospitals; nonetheless, the burden of auditing is impacting the support and sustainability of the program. We report an alternative method to routinely measure hand hygiene compliance with the aim to test whether alcohol-based handrub purchase data could be used as a proxy for usage because human auditing has decreased validity and reliability inherent in the methodology.

Physician report cards and rankings yield long-lasting hand hygiene compliance exceeding 90%.

IntroductionHand hygiene is an effective, low-cost intervention that prevents the spread of multidrug-resistant bacteria. Despite mandatory education and reminders, compliance by physicians in our hospital remained stubbornly low. Our objective was to study whether surveillance by our unit coordinator (secretary) paired with regular feedback to chiefs of service would increase physician hand hygiene compliance in the ICU.MethodThe ICU unit coordinator was trained to observe and measure hand hygiene compliance. Data were collected on hand hygiene compliance at room entry and exit for 9 months. Percentage compliance for each medical and surgical subspecialty was reported to chiefs of service at the end of each month. Comparative rankings by service were widely distributed throughout the physician organization and the medical center.ResultsThe hand hygiene compliance rate among physicians increased from 65.1 % to 91.6 % during the study period (p <0.0001). More importantly in the succeeding 24 months after study completion, physician hand hygiene compliance remained >90 % in every month.ConclusionsPhysician hand hygiene compliance increased as a consequence of the surveillance conducted by a full-time ICU team member, leading to a highly significant increase in the number of observations. In turn, this allowed for specific comparative monthly feedback to individual chiefs of service. Over the next 2 years after the study ended, these gains were sustained, suggesting an enduring culture change in physician behavior.

Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding.

Emergency department (ED) crowding results from the need to see high volumes of patients of variable acuity within a limited physical space. ED crowding has been associated with poor patient outcomes and increased mortality. The authors evaluated whether ED crowding is also associated with reduced hand hygiene compliance among health care workers. A trained observer measured hand hygiene compliance using standardized definitions for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto, Ontario, Canada. ED crowding measures, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours, were obtained from hospital administrative and human resource databases. Known predictors of hand hygiene compliance, including the indication for hand hygiene and the health care workers' professions, were also measured. Hand hygiene data, measured during 20-minute observation sessions, were linked to aggregate daily results for each crowding metric. Crowding metrics and known predictors of hand hygiene compliance were then included in a multivariate model if associated with hand hygiene compliance at a p-value of <0.20. Hand hygiene compliance was 29% (325 of 1,116 opportunities). Alcohol-based hand rinse was used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with the remaining 14% attributed to nonphysician, nonnurse health care workers. The most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. In multivariate analysis, time to physician assessment>1.5 hours was associated with lower compliance (odds ratio [OR]= 0.67, 95% confidence interval [CI] =0.51 to 0.89). Additionally, compliance was lower for nonnurse, nonphysician health care workers (OR= 0.51, 95% CI=0.33 to 0.79) and higher for hand hygiene performed after contact with the patients or his/her environment, compared to hand hygiene performed before contact with the patient or his/her environment (OR= 2.0, 95% CI=1.5 to 2.7). Daily patient volumes and nursing hours were not associated with hand hygiene compliance. ED hand hygiene compliance was low. Increased time to physician assessment was associated with reduced compliance, suggesting an association between crowding and compliance. Strategies that minimize ED crowding may improve ED hand hygiene compliance.

Malaysia: can ABHR purchasing data used to measure hand hygiene compliance?

After three years of mandatory quarterly hand hygiene audits in public Malaysian hospitals the burden of auditing is impacting the support and potential sustainability of the program. We looked to alternative methods to routinely measure compliance because human auditing has decreased validity and reliability inherent in the methodology.

Measuring hand hygiene compliance rates at hospital entrances

Despite the importance of hand hygiene in the health care setting, there are no studies evaluating hand hygiene compliance at hospital entrances. The study was prospectively performed over a 33-week period from March 30, 2014-November 15, 2014, to evaluate hand hygiene compliance in 2 hospital reception areas. We compared electronic handwash counters with the application of radiofrequency identification (GOJO SMARTLINK) (electronic observer) that counts each activation of alcohol gel dispensers to direct observation (human observer) via remote review of video surveillance. We found low hand hygiene compliance rates of 2.2% (99/4,412) and 1.7% (140/8,277), respectively, at reception areas A and D, detected by direct observation. Using the electronic observer, we measured rates of 17% (15,624/91,724) and 7.1% (51,605/730,357) at reception areas A and D, respectively. For the overall time period of simultaneous electronic and human observation, the human observer captured 1% of the hand hygiene episodes detected by the electronic observer. Our study showed very low hand hygiene compliance in hospital reception areas, and we found an electronic hand hygiene system to be a useful method to monitor hand hygiene compliance.

Measuring hand hygiene compliance rates in different special care settings: a comparative study of methodologies

The purpose of this study was to compare methods for assessing compliance with hand hygiene in an intensive care unit (ICU), a step-down unit (SDU), and a hematology-oncology unit. Over a 20-week period, we compared hand hygiene compliance measurements by three different methods: direct observation, electronic handwash counter for alcohol gel, and measuring the volume of product used (alcohol gel) in an ICU, an SDU, and a hematology-oncology unit of a tertiary care, private hospital. By direct observation we evaluated 1078 opportunities in the ICU, 1075 in the SDU, and 517 in the hematology-oncology unit, with compliance rates of 70.7%, 75.4%, and 73.3%, respectively. A total of 342,299, 235,914, and 248,698 hand hygiene episodes were recorded by the electronic devices in the ICU, SDU, and hematology-oncology unit, respectively. There were also 127.2 ml, 85.3 ml, and 67.6 ml of alcohol gel used per patient-day in these units. We could find no correlation between the three methods. Hand hygiene compliance was reasonably high in these units, as measured by direct observation. However, a lack of correlation with results obtained by other methodologies brings into question the validity of direct observation results, and suggests that periodic audits using other methods may be needed.

Review of technologies available to improve hand hygiene compliance - are they fit for purpose?

Hand hygiene has been empirically proven to prevent cross-transmission of infection, which has led to the development of global guidelines such as the World Health Organization's 'My 5 Moments for Hand Hygiene.' Because of the relatively recent launch of these guidelines (2009) technology designed to assist in measuring hand hygiene compliance appears not to fully acknowledge the influence of the WHO 5 Moments for hand hygiene Consequently, they may not be fit for purpose (FFP). This paper uses a review of the literature on current hand hygiene technology to assess the extent to which these are FFP based on these global guidelines. The results show that there are a variety of technologies available to assist with the monitoring and measurement of hand hygiene levels. However, none appear to explicitly achieve detection of all WHO 5 Moments for hand hygiene, limiting their effectiveness. The authors conclude that a systems approach offers a potential aid for developers aspiring to meet domain specific FFP requirements. Human factors may help guide such developments to meet user and context specific needs.

Common infection control practices in the emergency department: A literature review

BackgroundHealth care-associated infections (HAIs) are a major health concern, despite being largely avoidable. The emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices.MethodsThe purpose of this review was to examine published literature regarding adherence rates among ED personnel to selected infection control practices, including hand hygiene (HH) and aseptic technique during the placement of central venous catheters and urinary catheters. We also reviewed studies reporting rates of ED equipment contamination. PubMed was searched for studies that included adherence rates among ED personnel to HH during routine patient care, aseptic technique during the placement of central venous catheters and urinary catheters, and rates of equipment contamination.ResultsIn total, 853 studies was screened, and 589 abstracts were reviewed. The full texts of 36 papers were examined, and 23 articles were identified as meeting inclusion criteria. Eight studies used various scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles examined central venous catheters inserted in the ED or by emergency medicine residents. Detail of aseptic technique practices during urinary catheterization was lacking. Four papers described equipment contamination in the ED.ConclusionStandardized methods and definitions of compliance monitoring are needed to compare results across settings.

Comprehensive survey of hand hygiene measurement and improvement practices in the Veterans Health Administration

Veterans Health Administration (VHA) is a national health care system with variation in hand hygiene (HH) measurement and improvement practices across its facilities. The objective of this national survey was to characterize this variability and identify opportunities for standardization. Survey covered 3 major areas of HH: (1) methods of measuring HH compliance, (2) interventions to improve HH compliance, and (3) site-specific targets for HH compliance. One hundred forty-one (100%) VHA medical centers returned the survey. A majority (98.6%) of the medical centers conduct direct observations to measure HH compliance rates. Fewer than half (45.3%) validate the observer process at the onset, and fewer still (39.6%) continue to validate observers. Main behaviors that are considered HH opportunities are room entry (69.1%) and exit (71.9%). Improvement interventions include posters (97.2%), feedback (eg, 98.6% to leadership), and improved access to HH products (eg, 90.6% provide individual hand sanitizers to staff). Mandatory education programs for clinical staff are conducted in 88.5% of the medical centers. The majority of the medical centers (77.3%) set their HH compliance target over 90%. Although HH improvement interventions are relatively similar across VHA medical centers, variation exists in compliance monitoring. Findings will assist in standardizing surveillance and next steps in hand hygiene policy in VHA.