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Flaws of Direct Observation

Martyn Hodgkinson
April 03, 2018


Flaws of Direct Observation

Hand hygiene is widely recognised as the most significant aspect in reducing Healthcare Associated Infections (HCAIs). In the UK today, approximately 300,000 patients[1] contract an illness whilst being treated in Healthcare premises, costing the NHS £1 billion a year. With the cost of HCAIs to the NHS spiralling, it is essential that all stakeholders of the NHS work collectively to tackle the issue of HCAIs.


While direct observation is currently the norm to monitor hand hygiene compliance behaviour in hospitals, trusts inaccurately report over 90% compliance rates of hand hygiene events.[2]


Recent research[3] revealed that 98% of hospital trusts are indeed using direct observation, with 95% of trusts stating they tracked all of the 5 Moments in line with the World Health Organisation’s recommendations. Yet only 30% stated they felt direct observation to be a good approach to validate this important information.


Inaccurate and unreliable results


It is impossible for direct observation to capture every single hand hygiene moment. In fact, it only captures 1.2% to 3.5% of all hand hygiene events that take place within a Healthcare facility.[4]


However, it is proven that this effect has caused hand hygiene compliance rates to be overstated by up to 300%.[5] Whereas, electronic hand hygiene systems are capable of recording and capturing 100% of hand hygiene data to deliver real-time results based on the WHO 5 Moments for hand hygiene, thus painting a true picture of hand hygiene compliance and actual hand hygiene habits.


A recent How2 Benchmark Study looked at the employment of three techniques; the results demonstrated that direct observation showed compliance rates of 90-95%, while video monitoring was significantly lower at 65%. An electronic monitoring system was also deployed and has been shown to be statistically equally as effective as video monitoring, when measured against the WHO 5 Moments.


5 moments.png

False behaviour


Manual observation allows for the Hawthorne Effect, which is the alteration of behaviour by the subjects of a study due to their awareness of being observed.


Healthcare workers are more likely to change their behaviour patterns if they know they are being directly observed and go back to their original hand hygiene routine once the observation is complete. In return, this leads to the recording of inaccurate hand hygiene compliance data.  




Direct observation methods are expensive as they require more resources and staff time. More importantly, if hand hygiene is not being monitored correctly, this leaves hospitals at risk of an increase in HCAIs, therefore increasing costs and jeopardising patient safety.


Wastes useful time


Direct observation distracts staff from doing their job properly and interferes with their workflow. On the other hand, an electronic monitoring system is integrated in a Healthcare worker’s routine and therefore does not waste their time or cause distraction.


Due to the manual nature of direct observation, the reports are often not provided in a timely manner to help change behaviour quick enough.


The solution


While direct observation was once seen as the ‘gold standard’, many studies have proven that this method is highly inaccurate and unreliable. Electronic hand hygiene systems will ensure more precise hand hygiene compliance rates, and in turn, will help save lives through the reduction of HCAIs.


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Disruptive technology to drive better outcomes


Given that only 30% of Infection Prevention leaders believe direct observation to be a positive approach, coupled with the fact 46% ranked enhanced monitoring of hand hygiene in the trust’s priorities for the next 12 months, it is evident that the use of electronic hand hygiene systems will pave the way for a safer Healthcare environment for staff and patients.


Our message is simple: Let electronic systems do what they’re good at: being awake 24/7/365, and the humans do what they’re good at: positive interventions and training staff to maximise efforts in hand hygiene compliance, and ultimately reduce HCAIs.





[1] National Institute for Healthcare & Excellence, 2011

[2] Diller, T., Kelly, W.J., Blackhurst, D., Steed, C., Boeker, S., McElveen, D.C. Estimation of hand hygiene opportunities on an adult medical ward using 24-hour camera surveillance:

Validation of the HOW2 Benchmark Study. American Journal of Infection Control. 2004; 42:602-607.

[3] DebMed research findings

[4] Fries SL, Tolentino G, Thomas T, et al. Monitoring hand hygiene via human observers: how should we be sampling? Presented at 21st Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; Dallas, TX: 2011. Abstract 50. 

[5] (Srigley, Furness, Baker, & Gardam, 2014)



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