Hand Hygiene Compliance

Hand Hygiene Compliance is a measure of how often health care workers clean their hands when they should. Hand hygiene is defined as washing our hands with soap and water or cleaning them with an alcohol-based foam or gel.

Why this matters

Keeping our hands clean is one of the most important things we can do to prevent infections that patients get while in the hospital. These hospital acquired infections can make a patient much sicker, prolong recovery and increase the length of time patients are in the hospital as well as costs.

How we measure

Health care workers take care of many different patients during their work hours, so there are many opportunities for them to clean their hands. These include:

  • Before/after direct contact with patients
  • Between dirty-to-clean procedures on the same patient
  • After contact with patient secretions or excretions
  • After touching surfaces in patient’s immediate environment
  • After contact with contaminated equipment
  • Before/after any procedure on patients
  • Before/after gloving
  • Before/after eating or drinking
  • After performing a personal body function

We have specially trained people who secretly watch our staff throughout the hospital to make sure they clean their hands when they should. We watch all types of health care workers – doctors, nurses and respiratory care staff, just to name a few. Each month the specially-trained hand hygiene watchers observe a specific number of health care providers. We then divide the number of times hand hygiene was done correctly by the total number of opportunities. This gives us the percent compliance.

What we are doing to improve hand hygiene compliance

  • Monitor health care workers and report results
  • Engage physicians and employees in developing ways to improve
  • Meet regularly to share best practices between units
  • Make it convenient for health care workers to clean their hands by increasing the number of foam and gel containers throughout the hospital
  • Place reminders throughout the hospital

We also participate in the city -wide “Come Clean” Campaign. Hospitals throughout the Memphis area have joined together to improve hand hygiene in our health care community. Le Bonheur Children’s is proud to be a part of this improvement effort.


Le Bonheur Children’s Hand Hygiene Compliance Improvement Team received a “Challenge Award” from the Memphis Area Chamber of Commerce. This award recognizes organizations committed to developing quality initiatives.