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

  • Aiman El-Saed
    Affiliations
    Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Community Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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  • Seema Noushad
    Affiliations
    Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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  • Elias Tannous
    Affiliations
    Quality and Patient Safety Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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  • Fatima Abdirizak
    Affiliations
    School of Public Health, Georgia State University, Atlanta, GA
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  • Yaseen Arabi
    Affiliations
    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

    King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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  • Salih Al Azzam
    Affiliations
    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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  • Esam Albanyan
    Affiliations
    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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  • Hamdan Al Jahdalil
    Affiliations
    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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  • Reem Al Sudairy
    Affiliations
    Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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  • Hanan H. Balkhy
    Correspondence
    Address correspondence to Hanan H. Balkhy, MD, Pediatric Infectious Disease, King Saud bin Abdulaziz University for Health Sciences, Infectious Diseases, King Abdullah International Medical Research Center, and Infection Prevention and Control, King Abdulaziz Medical City, PO Box 22490, Riyadh 11426, Saudi Arabia. (H.H. Balkhy).
    Affiliations
    Infection Prevention and Control Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

    King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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      Highlights

      • The accuracy of direct hand hygiene observation is challenged by Hawthorne effect.
      • Hawthorne effect was quantified at a tertiary care setting in the current study.
      • Overall hand hygiene compliance was 87.1% using overt observation.
      • Overall hand hygiene compliance was 44.9% using covert observation.
      • The overestimation was seen in all professions, hospital settings, and indications.

      Introduction

      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.

      Objectives

      To compare HH compliance using both overt and covert methods of direct observation in different professional categories, hospital settings, and HH indications.

      Methods

      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.

      Results

      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.

      Conclusion

      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.

      Key Words

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