The development of hand hygiene compliance imperatives in an emergency department

•Many attempts have been made to improve and sustain hand hygiene compliance in emergency departments.•A quality improvement methodology was used to understand the barriers, opportunities, and context of care to improve compliance.•Hand hygiene expectations were ambiguous, and clinicians were disengaged.•Hand hygiene imperatives were developed and agreed on with clinicians.•The conclusion was drawn that sometimes requirements of urgent care supersede rigid hand hygiene requirements. Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance. To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department. A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed. Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff. Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work. The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations.