title: A nationwide covert observation study using a novel method for hand hygiene compliance in health care.
abstract: BACKGROUND
  Evaluation and feedback is a core hand hygiene (HH) improvement strategy. The covert observation method avoids observation bias inherent to the overt method. The aim of the study was to observe HH compliance by a novel covert method in a real-world setting.
  
  
  METHODS
  We conducted a 2-year, nationwide, prospective, observational study in teaching hospitals across Taiwan. Medical students and students who may have contact with patients in their careers were recruited as participants. A novel, shorthand notation method for covert observation was used. Observation results were reported through a study website.
  
  
  RESULTS
  There were a total of 25,379 HH opportunities covertly observed by 93 observers. Overall HH compliance was 32.0%. Health care workers had the highest HH compliance for indication 4 (42.6%), and the lowest for indication 5 (21.7%). Overall handrubbing percentage was high, reaching 83.6%. The HH compliance increased significantly with an increase in the number of indications within 1 HH opportunity (P < .001).
  
  
  CONCLUSIONS
  The overall HH compliance by the covert observation method was low. An innovative shorthand notation method facilitated covert observation, and website reporting was demonstrated to be feasible for large-scale observation.
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Kuan-Sheng
authors.initials: KS
authors.lastname: Wu
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Graduate Institute of Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan.
authors.forename: Yao-Shen
authors.initials: YS
authors.lastname: Chen
authors.affiliation: Department of Health-Business Administration, Fooyin University, Pingtung, Taiwan.
authors.forename: Huey-Shyan
authors.initials: HS
authors.lastname: Lin
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: E-Lun
authors.initials: EL
authors.lastname: Hsieh
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Jui-Kuang
authors.initials: JK
authors.lastname: Chen
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Infection Control Unit, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Hung-Chin
authors.initials: HC
authors.lastname: Tsai
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Yen-Hsu
authors.initials: YH
authors.lastname: Chen
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Infection Control Unit, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
authors.forename: Chun-Yu
authors.initials: CY
authors.lastname: Lin
authors.affiliation: Infection Control Unit, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
authors.forename: Ching-Tzu
authors.initials: CT
authors.lastname: Hung
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Cheng Len
authors.initials: CL
authors.lastname: Sy
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Yu-Ting
authors.initials: YT
authors.lastname: Tseng
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan. Electronic address: ssjlee28@yahoo.com.tw.
authors.forename: Susan Shin-Jung
authors.initials: SS
authors.lastname: Lee
mesh_terms: D019983:Guideline Adherence / Q000706:statistics & numerical data*; D063373:Hand Hygiene / Q000379:methods*; D006268:Health Facilities; D006801:Humans; D019370:Observation / Q000379:methods*; D011446:Prospective Studies; D013337:Students, Medical; D013624:Taiwan
keywords: Compliance; Covert observation; Hand hygiene; Handrubbing percentage; Taiwan