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Positive Deviance A New Strategy for Improving Hand Hygiene Compliance


To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units.


A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene.


Two 20-bed step-down units at a tertiary care private hospital.


The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units.


During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (P = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days.


A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Corresponding author
Avenue Albert Einstein, 627/701, Intensive Care Unit, Hospital Israelita Albert Einstein, 5th Floor, Morumbi, Sao Paulo 05651-901, Brazil (
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