Background
Hand hygiene is among the oldest and most important methods of preventing the transmission of pathogens in health care.Reference Boyce and Pittet1 Although no formal benchmarks exist, the hand hygiene compliance of healthcare workers is often lower than expectations, with large studies reporting 40–50% compliance.Reference Erasmus, Daha and Brug2,Reference Bredin, O’Doherty, Hannigan and Kingston3 Improvement in hand hygiene compliance has been linked to objective improvements in patient outcomes,Reference Banks and Phillips4 but achieving and sustaining improved compliance can be challenging. Lean Six Sigma is a management and process improvement approach that combines Lean (to eliminate waste and improve flow) with Six Sigma (to reduce variation and defects) that produce better quality, faster results, and reduce costs. Although numerous studies have reported on improvement programs for hand hygiene, very few have incorporated formal process improvement methodology.Reference Carboneau, Benge, Jaco and Robinson5–Reference Eldridge, Woods and Bonello7 The aim of this study is to describe the design, implementation, and results of a Lean/Six Sigma intervention to improve hand hygiene compliance in a major healthcare facility.
Methods
This was a prospective quality improvement project at Lahey Clinic, a 334-bed tertiary academic medical center in Burlington, MA. Alcohol-based hand sanitizer (Purell, Gojo Industries Inc, Akron OH) was available via manual hand-pump dispensers beside the entrance of each inpatient room. Healthcare workers were trained on proper hand hygiene technique upon hiring. The primary outcome was total hand hygiene compliance among healthcare workers in inpatient and procedural areas; outpatient areas were excluded. Hand hygiene observation data were collected by unannounced silent observers, including the compliance result (compliant vs non-compliant), the unit location, the timing (day vs night), the role of the healthcare worker (provider, nurse, various others), and whether the observation involved the use of gloves or carrying supplies. Compliance was defined as performing hand hygiene prior to touching the patient, patient zone, or the hallway environment after having made contact with the patient or the patient zone. The role of the healthcare worker was determined through both ID badge hang tags, when visible, and context clues. Observations were not collected when the observer did not have a direct view of the healthcare worker throughout the interaction, nor during patient care emergencies. Quality of hand hygiene was not evaluated. Data were stored in an online database and displayed using a scorecard that was accessible to all staff. During the 12 months prior to the project, there were 10 observers, consisting of part-time employees, light duty workers, and Infection Preventionists. During the study period, there were seven different observers, from the same roles. Three observers overlapped between the two periods.
A project team was formed, including the hospital epidemiologist (DAC), an infection preventionist (LR), the associate chief nursing officer (LW), and a process improvement expert (MMJ). Starting in July 2025, this team implemented a Lean/Six Sigma project using an A3 format. The baseline performance was assessed and a measurable, time-sensitive goal was set. A RCA was completed using a cause-tree format, and an ease-impact matrix was used to select countermeasures. For each countermeasure, a measurable performance goal was set and tracked prospectively. As a quality improvement project, this study was exempt from Institutional Review Board approval.
Results
The baseline rate of overall hand hygiene compliance was 75% during the 12 months prior to this project, July 2024–June 2025 (Table 1). During this period, the majority (74%) of observed interactions involved nurses or nursing assistants. Provider hand hygiene compliance was 67%, whereas nurse/nursing assistant hand hygiene compliance was 76%. Hand hygiene compliance was lower on medical-surgical units (74%) and emergency departments (55%) compared to intensive care units (88%). Non-compliance before or after using gloves and while carrying supplies into a room accounted for 21% and 12% of total non-compliant events, respectively. The goal for overall hand hygiene compliance was set at >90% within 12 months from project start.
Results from the primary outcome and countermeasures
Table 1. Long description
table presents data on hand hygiene compliance across various units and roles over a 12-month project period. It includes baseline and goal percentages for overall compliance, intensive care units, medical-surgical units, nurses, and providers. The table also lists countermeasures such as real-time observation and feedback, signs in front of glove boxes, and RN staffing. Row 1: Baseline, Goal, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. Row 2: Overall, 75 percent, greater than 90 percent, 71 percent, 69 percent, 78 percent, 83 percent, 75 percent, 80 percent, 85 percent, 92 percent, 85 percent, 89 percent, 91 percent. Row 3: Intensive care units only, 85 percent, greater than 90 percent, 82 percent, 83 percent, 81 percent, 96 percent, 94 percent, 95 percent, 93 percent, 96 percent, 91 percent, 94 percent, 95 percent. Row 4: Medical-surgical units only, 71 percent, greater than 90 percent, 72 percent, 68 percent, 76 percent, 79 percent, 72 percent, 75 percent, 82 percent, 92 percent, 86 percent, 88 percent, 89 percent. Row 5: Nurses (RN) only, 75 percent, greater than 90 percent, 71 percent, 72 percent, 81 percent, 83 percent, 77 percent, 82 percent, 85 percent, 94 percent, 87 percent, 90 percent, 92 percent. Row 6: Providers only, 62 percent, greater than 90 percent, 68 percent, 63 percent, 63 percent, 87 percent, 64 percent, 80 percent, 91 percent, 91 percent, 74 percent, 87 percent, 91 percent. Row 7: Real-time observation and feedback, 0/9 units, 8/9 units, 7/9, 8/9, 9/9, 9/9, 9/9, 9/9, 9/9, 9/9, 9/9, 9/9, 9/9. Row 8: Signs in front of glove boxes, 0/7 units, 5/7 units, 0/7, 0/7, 0/7, 4/7, 4/7, 5/7, 6/7, 6/7, 6/7, 6/7, 6/7. Row 9: RN staffing (FTE), 1,183, 1,230, 1,199, 1,223, 1,224, 1,221, 1,230, 1,223, 1,234, 1,231, 1,196, 1,188, 1,195.
FTE, full-time equivalent.
a Includes medical-surgical units, intensive care units, emergency department, procedural areas, and step-down units
b Denominator is lower because 2 units do not have hallway glove boxes; applies to medical-surgical units only.
A root cause analysis (RCA) was completed by the project team and all medical-surgical nurse managers and displayed in the form of a cause tree (Figure 1). Three primary root causes for low compliance were identified: 1) culture, 2) equipment and supplies, and 3) data and measurement (eg, imperfect accuracy of observations). Secondary and tertiary causes were listed for each root cause. Three countermeasures were selected from an ease-impact matrix: 1) physical signs in front of hallway-facing glove boxes (which were present on medical-surgical units only) as reminders for hand hygiene, 2) increasing nurse staffing, and 3) hand hygiene observations of medical-surgical nursing staff by their nurse manager (16 per week) with real-time feedback; these observations were not counted for the primary outcome of overall hand hygiene compliance.
Cause tree displaying the root cause analysis.
During the project period, each countermeasure progressed to its goal (Table 1). The overall hand hygiene compliance rate began to increase at month #4 and reached the goal of 90% compliance at month #8. Both nursing and provider compliance improved, reaching 94% and 91% by month #8, as did compliance on both medical-surgical and intensive care units, reaching 92% and 96% by month #8, respectively.
Discussion
Numerous strategies have shown efficacy for hand hygiene improvement in the healthcare setting. In this study, we describe a successful Lean/Six Sigma approach to the challenge of inpatient hand hygiene compliance. The strengths of Lean/Six Sigma methodology include an emphasis on a robust understanding of the process in question, the root causes of failures or inefficiencies in that process, and measurement to track both the primary goal and any countermeasures. This approach requires a deep commitment to hand hygiene improvement throughout organizational leadership and may take considerable time to see results.
In our RCA, we identified three primary root causes of low hand hygiene compliance (Figure 1). Although the individual contribution of each root cause cannot be determined, we believe that unit culture—and in turn accountability and buy-in—are the most important determinants of hand hygiene performance. Therefore, we employed two countermeasures to intervene on unit culture: increasing nurse staffing and nurse manager hand hygiene observations with real-time feedback. Increasing nurse staffing is a significant investment and was pursued for reasons beyond hand hygiene compliance but may improve unit culture by reducing workloads and demonstrating leadership support. Manager-led observations and feedback contribute to a culture of safety by holding colleagues accountable and demonstrating the importance of the issue to unit leadership. These interventions are resource-intensive but effective in strengthening the culture of safety, which was reflected in rising hand hygiene compliance over time.
To maximize the impact of the countermeasures, we focused where baseline data showed the greatest opportunity in terms of both compliance rate and the number of observations: nursing staff on medical-surgical units. However, there was a similar improvement observed among providers and intensive care units; this may reflect a “creep” of positive cultural changes that extended to other units and disciplines, or some other unmeasured factor that contributed to improvement.
The limitations of this study include its quasi-experimental nature and the potential influence of other unmeasured factors affecting hand hygiene compliance. Root causes of non-compliance may vary by institution and may differ depending on the roles or perceptions of those involved in the RCA process. Given the nature of the project, we did not use statistical methods to judge significance and thus cannot rule out that increased compliance may have resulted by chance. Sustained improvement requires sustained countermeasures and may require separate actions to prevent backsliding. Finally, our study was performed at an academic medical center and may not be generalizable to other settings.
Conclusion
Hand hygiene compliance at an academic medical center was successfully improved using a Lean/Six Sigma methodology. This approach offers a potential pathway for other facilities that wish to improve hand hygiene compliance in the interest of preventing healthcare-associated infection.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2026.10937
Financial support
None reported.
Competing interests
All authors report no conflicts of interest relevant to this article.
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