Are hand washing rates posted by Ontario hospitals believable?

Ontario’s hospitals are required to publicly report how often staff wash their hands.

There is large variation in hand washing rates between hospitals.

This variation more likely reflects how hospitals measure hand washing, rather than the frequency of hand washing itself.

Ontario’s hospitals are required to publicly release information about how often staff wash their hands. Across Ontario the numbers vary widely… is this because some hospital staff are better at hand washing? Or are hospitals counting hand washing numbers differently?

The Issue

Health care workers carry bacteria from one patient to the next, which can spread infections in a hospital. One way to reduce the risk of infections is for these workers to wash their hands before and after seeing patients.

Health care workers often see many patients, and are under time pressures. Depending on the type of care they provide, some health care workers can be in contact with patients over 50 times per shift, meaning that they should be washing their hands over 100 times. This can be difficult because thorough hand washing takes time away from patient care, and can cause rashes and painful, dry skin.

How can hand washing be improved?

One way is through education. The Ontario Ministry of Health and Long-Term Care has supported a number of initiatives to help staff improve hand washing, emphasizing the ‘4 Moments for Hand Hygiene’.

In addition, the MOHLTC supports the position that publicly reporting the frequency of hand washing by staff working at Ontario hospitals will encourage hospitals to pay more attention to hand hygiene. This information, which is provided to the MOHLTC by each hospital, is available here.

What the numbers report

You can use the graph below to see what Ontario hospitals report about hand washing at their institution. This graph shows the percentage of staff who say that they washed their hands before seeing patients, and after seeing patients and if you scroll over the dots on the graph the hospital name and handwashing rates will pop up.

What is behind the numbers?

Two things are noteworthy about this graph. The first is that there is huge variation in the frequency of hand washing reported by hospitals. At one extreme, reported completion rates were 100% at one hospital; at the other extreme, fewer than 30% of health care providers washed their hands before seeing patients at another hospital. At least that is what the data suggest.

The second interesting thing about this graph may only be apparent to experts who study the hand washing behaviors of health care professionals. The average frequency of hand washing being reported (67%) is much higher than research has found to be the case. Most research has found hand washing to occur in about 40% of patient encounters.

Our inquiry into hand washing practices suggests that the reported frequency of hand washing in Ontariois unrealistically high. While there definitely are true variations in the frequency of hand washing among hospitals, much of the variation in the graph above is likely caused by differences in the way hand washing was measured. contacted infection control specialists at three Ontario hospitals to ask how they measured hand hygiene at their hospital.

A suburban community hospital, which reported that over 95% of staff washed their hands before and after they saw a patient, was contacted. The director of infection control suggested that one of the reasons why their numbers were so high is that they had tried to observe hand washing covertly, without staff knowing, but staff felt that their privacy was being intruded upon. To deal with these privacy concerns, the audit of hand washing was announced to staff in advance, and the persons measuring hand washing announced their presence when they were on the unit. The director of infection control suggested that “given a second chance, I’d do it another way.”

The next hospital contacted was an urban community hospital, which reported that around 35% of staff washed their hands before seeing a patient, and over 50% of staff washed their hands after seeing a patient. The check was done covertly; with staff being told that they could expect hand washing checks at any time, but were not given specific information. This hospital is trying to improve hand washing by educating staff on the importance of hand hygiene, with all staff completing online education programs on why washing hands is so important in order to stop the spread of infections in the hospital. The director of infection control suggests that improving hand washing is a long process and that their numbers reflect “what is really happening out there.”

Finally, we spoke with someone who works as a director of infection control across a number of hospital sites. That person reported major differences in hand washing between sites which were attributed to different patient safety cultures at each site. However, it was noted that cultural differences are getting smaller because of a persistent focus on education. In addition, there were challenges in measuring hand washing across these organizations. When staff recognized the individual conducting the hand washing audit, their compliance with hand washing was high. However, if an unfamiliar auditor was used, the rates were lower.

We believe that these three examples support suggest that many of the hand washing numbers that are reported on the Ministry web site are not accurate.

What’s happening outside Ontario?

Ontario is the only province in Canada that reports publicly on hand washing. National patient safety organizations like the Canadian Patient Safety Institute and Safer Healthcare Now! recommend different measurements to monitor how frequently health care workers wash their hands. They look at the processes involved in washing hands, such as how much hand soap and antibacterial gel is used, and the availability of places for staff to wash their hands, because these processes tend to be more accurate indicators of whether hand washing by workers is improving. Hospitals are encouraged to not compare their progress on hand washing with other hospitals, but rather to focus on how they have improved from month to month.

Final observations

Public reporting of outcomes in health care is valuable. However in order for this information to be useful, it needs to be accurate. That is clearly not the case with the reporting of hand washing in Ontario’s hospitals. welcomes your thoughts about whether Ontario should spend more time and effort ensuring the accurate measurement of hand washing across the province, or whether public reporting of hand washing should be abandoned.

The comments section is closed.

  • Lusine A says:

    It would be interesting to see if these numbers at least correlate with reported hospital infection rates or other outcomes. Ideally one would need a good case-mix adjustment tool for such analyses.

  • Golfer says:

    Stethoscopes are known to harbour bacteria on their faces. Can these germs be transferred from patient to patient by physicians who do not wipe the stethoscope between patient contacts? Are there any scientific studies that address this issue?

    • andreas says:

      interesting question. i just did a quick literature search, and there is lots written to suggest that stethoscopes are an important source of infection transmission, but i am not aware of any initiatives focused on getting docs and nurses to wash stethoscopes between patients (i must admit that i almost never do ).

      on a slightly tangential, but related topic, i remember hearing that the National Health Services in the UK was going to prohibit physicians from wearing ties at work because ties are an unrecognized source of infection. does anyone know if i am dreaming?

      here is the link for the pubmed search on stethoscopes:

  • Seesall says:

    Hand washing by medical staff is certainly important but other issues such as 2-patient and 4-patient rooms all sharing a common toilet must contribute to cross-contamination among patients. It seems primitive with our current understanding of microbial biology to have multi-bed rooms. All hospitals should immediately embark upon a long-term renovation program and convert to single- patient rooms each with toilet and sink.

  • Greg says:

    Ontario needs independent auditors to evaluate this metric (and others) if we want a true picture of hand washing rates. Some hospitals are not very good at policing themselves.

  • Susan says:

    Hospitals should have a sink basin at each and every bedside to encourage handwashing and to decrease the spread of microorganisms from one patient to another. In many hospital situations, the caregiver (physician and nurses) have to wash either outside the patient room or in the bathroom. If there was a basin (with foot controls) beside each bed it would be more convenient for the caregiver and it would be obvious to the patient that handwashing has been accomplished.

  • Kate says:

    It is important to keep evaluating hand washing to make sure that health care workers are not spreading infection. Information is key and as long as workers are informed they will see the importance of the evaluation.

  • Charles B. says:

    I think people often learn from authority figures and if we expect everyone to wash they’re hands then yes I think rating hospitals on hand washing is an important lead by example tool.


Karen Born


Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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