Response: Re: Hand Hygiene and Face Touching in Family Medicine Offices: A Cincinnati Area Research and Improvement Group (CARInG) Network Study

To the Editor: We thank Dr. Walsh for highlighting valuable points about how best to improve the quality of hand hygiene in the office setting. A recent Cochrane review titled “Interventions to Improve Hand Hygiene Compliance in Patient Care” found only 4 studies meeting criteria for review—all hospital based, and none of high quality.¹ The review corroborates Dr. Walsh's points by noting that education and training, even that rigorously performed within research studies, was insufficient to improve compliance and that, while multiple strategies may be helpful—including involving staff in planning activities or applying social marketing strategies—more research is needed.¹ We agree that system changes are imperative not only to sustain behavior change but also to achieve and measure safety practices such as hand hygiene. System changes such as those outlined by Dr. Walsh, however, must be implemented with attention to “resilience,” which is the ability of systems to anticipate and adapt to the potential for surprise, workarounds, and failure.² Not only is vigilance in the design of new systems for hand hygiene, such as those described, which “make it impossible for physician to commit this error,” needed, but attention must be paid to other system changes in primary care practice that may inadvertently make hand hygiene more difficult by correcting one problem but potentially creating new errors or disrupting work flow.