Improving the communication of hand hygiene procedures: Controlled observation, redesign, and randomized group comparisons

OBJECTIVE: To assess the clarity and efficacy of the World Health Organization (WHO) hand-rub diagram, develop a modified version, and compare the 2 diagrams. DESIGN: Randomized group design preceded by controlled observation and iterative product redesigns. SETTING: The Cognitive Ergonomics Lab in the School of Psychology at the Georgia Institute of Technology. PARTICIPANTS: We included participants who were unfamiliar with the WHO hand-rub diagram (convenience sampling) to ensure that performance was based on the diagram and not, for example, on prior experience. METHODS: We iterated through the steps of a human factors design procedure: (1) Participants simulated hand hygiene using ultraviolet (UV) absorbent lotion and a hand-rub technique diagram (ie, WHO or a redesign). (2) Coverage, confusion judgments, and behavioral videos informed potentially improved diagrams. And (3) the redesigned diagrams were compared with the WHO version in a randomized group design. Coverage was assessed across 72 hand areas from multiple UV photographs. RESULTS: The WHO diagram led to multiple omissions in hand-surface coverage, including inadequate coverage by up to 75% of participants for the ulnar edge. The redesigns improved coverage significantly overall and often substantially. CONCLUSIONS: Human factors modification to the WHO diagram reduced inadequate coverage for naïve users. Implementation of an improved diagram should help in the prevention of healthcare-associated infections.