Staff views need to be at the centre of electronic hand hygiene monitoring system development.

We read with great interest Kelly et al.’s qualitative study of healthcare worker (HCW) perceptions of an electronic hand hygiene monitoring system (EMS) (2021). It is excellent to read of a successful implementation of a new innovative approach to hand hygiene (HH) monitoring in a busy NHS hospital. Though the qualitative analysis (from the 11 frontline HCWs interviewed) demonstrated mixed opinions, this study does provide cautious optimism about the longterm adoption of EMS technology by NHS staff. This should encourage other Infection Prevention and Control (IPC) teams to evaluate the impact of EMS technology in their own clinical practice. As demonstrated in this study, staff members recognise the importance of embracing change and the opportunities that EMS technology can bring in improving HH compliance and reducing healthcare-associated infections (HCAI). We therefore commend the authors’ initiative in wishing to seek HCW views of an implemented EMS. For any HH initiative to be effective, staff must be at the centre of the innovation process, and must be assured that they have ownership and control of the process. However, a limitation of this study is that interviews were restricted to a small group of nursing staff and healthcare assistants. As medical staff are well recognised to have low rates of HH compliance, (Pittet et al., 2000) it would have been useful to explore the perspectives of this staff group. A large staff survey which analysed 1200 responses across two acute NHS trusts (Cawthorne and Cooke, 2020) indicates that all staff groups take HH seriously, have concerns about direct observation (DO) audits and are generally supportive of new technological innovations. As part of a team of innovators working in an acute specialist NHS trust, we are taking a very different approach to EMS development compared to the system used by Kelly et al. and other current commercial applications. Our approach, Hy-genie (Cawthorne et al., 2022), has been underpinned by extensive staff consultations which is why the theme of exploring staff acceptability of how feedback is delivered is so critically important. As highlighted by Kelly et al., their chosen EMS may ‘monitor how effective we are but doesn’t make us more effective’. Many EMS, including the one used in their study, measure HH compliance, that is, HH opportunities taken against total HH opportunities available (HHOA). This means that EMSmust accurately be able to capture all HHOA. A concern raised in this study was that HCWsmay disagree with the EMSwhen recognising an HHOA. Thus, some HCWs found the EMS to undermine their own clinical judgement on when HH should be performed (‘I haven’t touched any patients but I have been in their bed space which says I should gel but I haven’t touched anyone’). In the development of our own EMS, we have sought an alternative approach to overcome this technical challenge. Rather than measuring HH compliance, our EMS simply measures HH frequency. It is widely accepted that HCWs do not perform HH enough, and progress on changing HH behaviour has been slow and typically shortlived. However, simply encouraging HCWs to perform HH more frequently could empower them to reflect on their own clinical practice and decide where and when they could make these improvements. Such a quantitative approach will not, of course, negate the need for qualitative assessment of HH practices (e.g. targeted DO audits). Using the Hy-genie system, organisations use a computer interface to set staff a personalised HH improvement target (e.g. 20% increase in HH activity) based on an individual’s