Skip to main content

The hand hygiene program Clean In, Clean Out has been part of the landscape here at the UNC Medical Center for just over four years – recently passing the amazing milestone of half a million observations. As part of International Infection Prevention Week, we look back at some of the ways it has changed the culture in Chapel Hill and look forward to the next big thing in hand hygiene at the Medical Center.

The hand hygiene program Clean In, Clean Out has been part of the landscape here at the UNC Medical Center for just over four years – recently passing the amazing milestone of half a million observations. As part of International Infection Prevention Week, we look back at some of the ways it has changed the culture in Chapel Hill and look forward to the next big thing in hand hygiene at the Medical Center.


Hand washing is one of the most basic infection control protocols, and, according to the Centers for Disease Control and Prevention, it is also one of the most overlooked at hospitals across the country: health care providers may need to wash their hands as many as 100 times in a 12-hour shift, depending on the number of patients and the intensity of care, but adherence is often less than half that.

Part of the challenge of improving hand hygiene adherence, and in so doing, reducing infection rates across the hospital, is changing the culture around hand washing.

For the Clean In, Clean Out program, that has meant creating an environment in which providing feedback, whether it’s as a compliment or a reminder, is encouraged. Earlier this year, Clean In, Clean Out observations passed the half a million mark of observations. Over the same four-year period, hospital-associated infections at the Medical Center have also been on the decline.

Making Hand Hygiene Observations Part of Daily Life

“There are lots of different ways to measure good hand hygiene practices,” says Emily Sickbert-Bennett, PhD, assistant professor of Infectious Diseases and director of Hospital Epidemiology for the UNC Health Care System. “Unfortunately, most of them have some pretty glaring weaknesses, too, so there’s a trade-off.”

Some hospitals use paid observers to record hand hygiene occurrences, sometimes even recruiting students trying to make a few extra dollars.

“Not only does this model set up an antagonistic relationship between observers and the rest of the staff, you often aren’t able to gather accurate data – people know who is keeping an eye on them and will sometimes start scrubbing up when they see the observers coming.”

Other hospitals employ more technological solutions, often in the form of badge-readers that can track each individual’s activity at hand hygiene stations. As one might expect, the cost associated with this method can be very high. There are other disadvantages too, according to Sickbert-Bennett.

“It can give the operation a ‘Big Brother’ feel, which nobody likes.”

Clean In, Clean Out takes the most effective features of these two measures – peer-to-peer observations and data collection – and brings them together into a program that encourages constructive feedback and creates a culture where co-workers can encourage each other to adhere to best hygiene practices.

Recording observations across the hospital is an important part of the program, but Sickbert-Bennett said that the feedback component is even more important.

“When you are in the habit of giving feedback about hand washing practices, even if it’s something as simple as saying ‘thank you’ when you notice someone doing it, it’s going to make you more cognizant of your own habits.” Even more than the volume of observations, Sickbert-Bennett said the number of individual participants is crucial.

“We’d rather have 100 people doing five observations a month, than five diligent people doing 100 observations each.”

Creating a Fertile Environment for Feedback

Hand hygiene first came into common practice in 1846 when a Hungarian physician named Ignaz Semmelweis instituted rigorous sanitary procedures to help combat rates maternal mortality rates at Vienna General Hospital, where he worked.

A lot has changed since the early 19th century, but hand hygiene remains one of the simplest ways to prevent the spread of infection. Clean In, Clean Out has helped transform how colleagues interact with one another around UNC Medical Center by getting them talking about hand hygiene.

Rebecca Michael, RN, a nurse in the Cardiothoracic ICU, said that Clean In, Clean Out has made her more attentive to handwashing practices. “Whenever I see anyone wash their hands, whether it’s a nurse, doctor, attending, physical therapist, I thank them. It doesn’t matter what their job title is or even if I know who they are.”

For Michael and her team, handwashing isn’t just about infection prevention. It also gives them an opportunity to let someone know they are doing a good job.

“I think everyone likes to be thanked for doing something, and this is an easy way to show appreciation.”

Clean In, Clean Out has averaged more than 340 observations per day over the life of the program and as the number of observations recorded with feedback has grown, that’s a lot of gratitude passing between co-workers.

On Michael’s unit, feedback has helped transform how her team approaches hand hygiene.

“Giving hand hygiene feedback has become a competition some days to see who can thank someone first, who can give the best thank you, and it’s to the point where two of us will wait for someone to wash their hands so we can say thanks. I know some days when I start thanking people for washing their hands, everyone starts showing me and pointing out that they are also washing their hands. It’s contagious.”

Stephanie McAdams, assistant director of Therapy Services at UNC Medical Center, said that her team faces unique challenges, since they are often travelling from unit to unit.

“We talked to our team about what’s getting in the way of recording their observations, and how we could help them overcome that. One member of our support staff really became a champion for us. She created a system of reminders. She’s offered to enter data for people using paper forms for observation. With her help, we found a way to make hand hygiene observations part of our daily life and support our staff to make it work. We’ve even gone so far as to make it part of our Taleo goals.”

Getting Patients Involved and Other Goals for the Year

For Alison Cleary, RN, a nurse on the Acute Inpatient Rehab Center, the nature of her unit means that hand washing is something that not only happens as caregivers move in and out of rooms, but something that patients can get involved in too.

“For the staff, hand hygiene means cleaning our hands when we leave and enter the nursing station as well as when going from room to room. Most of our patients don’t stay in their rooms. We encourage them to get up, shower and dress for the day and participate in unit activities. So the traditional paradigm of minimizing the passage of microbes by staff from one patient room to another loses its effectiveness when applied to our community. We also encourage patients to wash their hands – we remind them of this when we conduct a community group each morning, including when to do it and why it’s important,” said Cleary.

One of the big operational goals of Clean In, Clean Out year five is to get patients and their families more involved in hand hygiene around the hospital.

Stephanie McAdams said this is one of the things she is most excited for and looking ahead to in the newyear.

“I want patients and families to feel empowered to offer handwashing feedback. I want them to know how important it is, because if they know how important it is for us then they will know how important it is for themselves and their visitors. That’s going to have an impact far beyond the hospital.”

Sickbert-Bennett said that improving the percentage of observations recorded with feedback is another goal, one that is designed to continue improving on the success of the program.

“Feedback is a really important part of Clean In, Clean Out. If you’re giving feedback to other people about their hand hygiene it’s more likely that you’ll also be thinking about it when you are going into a patient room. One of the most exciting features of this program is that it has encouraged a widespread an ongoing conversation about hand hygiene. And I think that’s a huge victory.”

Learn more about the Clean In, Clean Out Program here. Or you can watch this video in which Emily Sickbert-Bennett is interviewed by Gojo (makers of Purell) about the program and read the published analysis detailing the effect Clean In, Clean Out has had on hospital associated infections.