Using Data to Improve Hand Hygiene and Prevent the Spread of COVID-19


The COVID-19 pandemic has had enormous impact on the entire health care system. The effects are especially felt in nursing homes. The vulnerable nature of the nursing home population, combined with the inherent risks of congregate living in a health care setting, have required aggressive and detailed efforts to limit COVID-19 exposure.

A nursing home in the St. Louis, Mo. area experienced a serious COVID-19 outbreak in May 2020, striking 44 residents and 13 staff and causing 16 resident deaths. Unfortunately, more residents tested positive after the Thanksgiving holiday. The nursing home determined the surge was related to holiday-related exposures.


The nursing home participated in an innovative Medicare program through its Quality Innovation Network-Quality Improvement Organization (QIN-QIO). Using a targeted response system, the Centers for Medicare & Medicaid Services (CMS) connects facilities battling COVID-19 infection with the QIN-QIO in their region. Health Quality Innovation Network (HQIN), the QIN-QIO serving Missouri, met with facility leaders to determine which infection prevention methods needed improvement, and provided coaching and resources to address the need.

The nursing home had previously conducted staff training for hand hygiene (hand washing and use of alcohol-based hand sanitizer), complete with observation and immediate feedback on proper technique. HQIN recommended the addition of a hand hygiene auditing checklist developed by academic experts in infection prevention. The audit tool measured how often staff washed their hands and used hand sanitizer correctly, capturing the steps in the hand hygiene process where mistakes typically occur.

HQIN created a data collection spreadsheet with the audit questions that was programmed to measure hand hygiene compliance by unit, staff type and shift, and automatically generated a run chart displaying performance over time. With these new audit tools, the nursing home management team identified and trained units and staff who were not consistently using proper methods. In one training exercise, staff applied a special orange paint to their hands to help visualize failures of hand washing. 

HQIN served a vital role supporting the nursing home​’s infection control improvement efforts. In addition to coaching on the auditing process, data collection and the use of audit results to target interventions, HQIN provided the nursing home with a training video and other resources from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). The facility used these and other evidence-based tools to coach and provide ongoing education for staff.

HQIN assessed the facility’s infection control practices in response to the new post-holiday outbreak, verified that the facility continued to observe and reinforce best practices for infection control and led the nursing home through a technique known as root-cause analysis (RCA) to identify other areas for improvement to keep COVID-19 at bay.


With these new tools, this facility reduced its COVID-19 infection rate by 96% and its death rate by 83% over a five-month period. No new COVID-19 cases arose between August and early November 2020, even as cases increased in the same county by over 130%. Staff compliance with these hygiene practices started at 78% and rose to 91% over a few months.

Nursing home leaders estimated that 45 COVID-19 cases and 15 life-threatening resident hospitalizations were avoided when the hand hygiene audits and targeted education were paired with its other infection control practices.

Speaking of their experience working with HQIN, the nursing facility’s director of nursing said, ​“We are grateful for the professional support and guidance HQIN offered us to enhance our stringent infection control standards and to provide a layer of accountability to not only collect the data, but to utilize it in our Quality Assurance and Performance Improvement process for improved outcomes.”