Does your staff know precisely when and how they're supposed to be washing their hands? Ask around and the answer might surprise you. Here at Dartmouth-Hitchcock Medical Center, we came up with a new teaching method that would both educate employees about their handwashing duties and confirm their competency in this task. We call this process "Hand Hygiene Certification."

1. Sink-side observation. An infection prevention practitioner (IPP) meets with the employee up for certification at a sink, where the employee demonstrates proper technique for washing hands with soap and water. While she's washing, the IPP is able to immediately correct any improper techniques and offer hand hygiene compliance tips, such as ways that the employee can minimize skin irritation by using tepid water instead of hot water, using just the right amount of soap rather than too much and patting hands dry with a paper towel.

2. Sink-side interview. In addition to observing the practice, the IPP also asks the employee a few questions to test her knowledge of hand hygiene protocols. When we first started the certification program, we used to give employees a quiz on paper, but we found it was much better to verbally ask the questions during observation. This lets the IPP tailor questions to the employee's position and practice area. Some examples of questions we ask:

• "When do you need to do hand hygiene?" Correct answer: Before, after and sometimes during patient contact; before donning and after removing sterile gloves; before touching an invasive device; before you eat; after you use the bathroom.
• "How can you accomplish hand hygiene?" Using soap and water or an alcohol-based hand rub.
• "Do you need to do hand hygiene when you take gloves off?" Yes — gloves are not a substitute for hand hygiene.
• "What would you do if you saw a co-worker forget to do hand hygiene?" Gently remind them to wash their hands before touching a patient; we all need reminders sometimes.

If the employee doesn't know an answer, direct her to the correct answer. In the few minutes that you spend with each employee, you can provide them with the information they need to understand proper hand hygiene, give encouragement to improve their compliance, and discover and then dispel any myths or misconceptions.

3. Certification. When the employee successfully answers the questions and demonstrates proper handwashing technique, she receives a small sticker with a red hand to put on her ID badge, signifying that she's been certified in hand hygiene. No one "fails" certification. We do on-the-spot education to correct any mistakes employees make or misunderstandings they may have about the process before applying the stickers. The program holds staff accountable: An employee with a red hand sticker on her badge can't say she didn't know she was supposed to wash her hands.

Getting results
At our 400-bed hospital, we've certified more than 3,000 employees since the program began in March 2008. New employees are certified as part of the orientation process, while existing employees are given the opportunity to be certified during the hospital's annual Patient Safety Fair, on Hand Hygiene Certification days, at meetings and during special times that have been arranged with units or departments. During larger gatherings, we use a portable, 3-sink unit built by our engineering department, which can be set up in any area where there's a water source and drain. But for individuals or small groups, certification can take place at any handwashing sink.

Conducting these certifications in person, one-by-one (or sometimes two-by-two) is a time-consuming and labor-intensive process, but we've found it to be well worth the effort. In the first 8 months of the certification program, our hand hygiene compliance rate rose from 80% to 90%. Now for that last 10 percent.