Quality of hand hygiene performance: A systematic literature review

Abstract

Background: Hand hygiene (HH) is essential for infection prevention in health care, but the quality of its performance, meaning how well it is done, receives much less attention than compliance. This review examines how HH technique is assessed and can be improved among health care providers.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, 6 databases were searched through May 15, 2025. Studies assessing HH performance quality in health care were included. Quality indicators included technique completeness, product volume, and duration. Study selection, data extraction, and risk-of-bias assessments were performed independently by 2 reviewers.

Results: Forty studies met inclusion criteria. Despite compliance rates, ranging from 23.5% to 93.2%, proper technique was often lacking. Few HH events followed all recommended steps, and frequently missed areas included fingertips, thumbs, and wrists. Alcohol-based hand rubs (ABHRs) outperformed soap and water in quality and coverage. Interventions such as real-time feedback, ultraviolet markers, and augmented reality tools improved technique temporarily, though sustained improvement was rare. Educational interventions showed mixed long-term results.

Conclusions: HH performance quality remains suboptimal even with high compliance. Future efforts should prioritize technique-focused training, innovative feedback, and simplified protocols to enhance HH quality in clinical practice.

Keywords: Alcohol-based hand rubs; Compliance; Direct observation; Guideline adherence; Hand hygiene; Quality performance.