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Handwashing: Technology Adds a Measure of Management

To reduce incidences of foodborne illness, E&S channel partners need to ensure that end-users understand that operations planning, facility design, handwashing equipment and supplies, and hygiene education are all interrelated safety components.

Date marking. Time clocks. Temperature recording. Measuring is an established practice for all important processes in foodservice. Except when it comes to measuring one of the critical interventions against foodborne illness, handwashing. It is not surprising to find that both operators and regulators agree that handwashing frequency is about half of what it should be in foodservice operations, even in schools and hospitals. What isn't measured is rarely managed well. Daily measurement can be a daily reminder of a strategic priority. Potentially helpful industry programs such as Quality Circles, Continuous Improvement and even HACCP are starved by the current lack of handwashing data and process controls. The problem is left unresolved, fortifying the failed and dangerous behavior pattern.

The Fecal-Hand-Oral Reality The Centers for Disease Control (CDC) has stated that, "Handwashing is the single most important means of preventing the spread of infection." The centers' estimate suggests that post-restroom handwashing is often not done and that a Norwalk-like virus (NLV) is by far the leading cause of foodborne illness. The most common way for foodservice customers to acquire this disease is ingesting the human feces of an infected person, fecal-hand-oral. Does anyone have any further questions on why handwashing is important in the food industry? Toilet paper poke-through, explosive diarrhea and toilet bowl splash-back are daily events which can start a seemingly unending chain of contamination and cross-contamination. See chart below. A worker may bring the virus from home, perhaps by not washing his or her hands after changing a diaper. Initial entering of a kitchen and re-entering must be accompanied by thorough handwashing, preferably using a nailbrush.

Who is accountable for hand hygiene? The ownership/executive management of a foodservice establishment is often unaware of the rising risks associated with the lack of handwashing. Operations managers are typically first concerned with productivity. Risk management usually focuses first on slip/fall cases and Worker's Compensation issues. Design and construction managers are more likely to be rewarded for getting by with a minimal number of hand sinks, as they take up otherwise productive space in a kitchen facility. Quality Assurance (QA) measures the quality of the food, monitors the process and alerts operations when deviations occur. If QA personnel had a handwashing process to monitor, perhaps their role in handwashing would be greater.

Other departments that have an impact are training and human resources, as they respond to high staff turnover and a multilingual workforce. Once trained and given appropriate follow-up, production staff - prep-line, servers and warewashers - should be accountable for proper handwashing and know the reasons behind it. Too often, workers either don't have easily accessible facilities, the time or the will to wash their hands frequently. Without management follow-up, they are immersed in a bad example that goes unchecked.

I repeat ... who's in charge of solving the handwashing issue?

The departments with the best measures of success are management and operations. Most of the measurements they share are solid after-the-fact real numbers - sales, costs and productivity. Real numbers trump estimated risk. Should management and operations wait for an outbreak and the lawyers to help measure the value of preventive actions?

Diffused responsibilities in a foodservice add to the lack of handwashing measurement. This creates a critical gap in food safety. Measuring handwashing can help clarify accountabilities.

Active Management Control/Active Hand HygieneThe strengths of HACCP can best be applied to hand hygiene within the context of an Active Management Control (AMC) program. The FDA, one of the principals in writing and promoting the Food Code, has developed its Voluntary National Retail Food Regulatory Program Standards. The driving principle behind the Program Standards concept is the Active Management Control of all of the CDC-identified risk factors that are known to cause foodborne illness. This principle provides the overall measurement structure.

Active Management Control is the implementation of food safety practices to control risk factors by the person-in-charge (PIC), 24/7. This person can best control the number-one risk factor, the lack of handwashing, when he or she understands the planning process and is equipped to validate actual compliance. We refer to this improved process control as Active Hand Hygiene. It is a risk-control plan based on HACCP principles designed to control the specific dangers caused by poor hand hygiene.

An Active Hand Hygiene Process makes more handwashing happen by the design of the kitchen, by an integrated process and by this daily tracking of success. Corrective actions can now be taken in real time.

Choosing Kitchen StandardsMaking choices in selecting the standards by which to build a professional kitchen must have input from those in executive offices. It is at this level that an organization's tolerance for risk can be expressed. For example, the best standard for hand sink location is not one of maximum distance but, rather, based on a workflow pattern that will encourage use. The test of a good design is not the approved floorplan but rather the reduced risk resulting from more handwashing. See comparative designs (chart, page 41).

Convenience goes beyond hand sink location. A "hand sink" must become a Hand Hygiene Station, continuously re-stocked with easily accessed supplies. An Active Hand Hygiene Station is one equipped with a measurement device to track that the actual handwashing rate is within the range estimated in the planning process. This, together with the understanding of the process, gives the person-in-charge an objective standard and point of control.

Quality is the most pervasive of standards to be included in planning any kitchen designed to serve safe food. It first comes from a review of hiring practices to get people that match-up with a program mission statement and vision. Equipment reliability is a major driver of quality standards, as it impacts frequent use by those workers trying to do the right thing. Attractive, well-lighted and easy-to-use hand hygiene stations are important factors that encourage food worker handwashing.

Active Hand Hygiene StationAn Active Hand Hygiene Station includes: (See photo below.)

  • A dedicated stainless-steel hand sink with good depth and width to minimize the need for splashguards. A fast dry bowl design avoids standing germ-laden water.
  • A faucet capable of delivering a minimum of a 2-gallon per minute flow of tempered water. An automatic faucet is preferred for its hygiene, water/energy savings, user friendliness and, in at least one version, for its measurement of usage. One model offers tracking software on a Personal Digital Assistant (PDA).
  • Hot water and a mixing valve capable of delivering tempered water at least 100 °F. (38 °C., per 2001 Food Code).
  • Soap dispenser - dual never-out dispensers are preferred. A digital counting device can be added to a dispenser to record team usage.
  • Nail brush - preferably with fused soft bristles.
  • Hand-drying supplies - single-use paper towels are preferred for hygiene, effectiveness and speed. Automated and other no-touch dispensers are available.
  • Waste receptacle.
  • Sanitizer dispenser.
  • Single-use glove dispenser. Management of glove changes is improved by establishing a factor relative to documented handwash frequency.


One manufacturer has developed another version of the Active Hand Hygiene Station. Its solution is based on scanning technology that lets workers be individually rewarded for keeping pace with required handwashing frequency. Each worker wears a programmed badge. A screen positioned just above a hand sink displays the operator's step-by-step preferred handwashing process in their native language. The worker is then guided through the stages of wetting hands, applying soap and a minimum scrub time set by the individual operator. Congratulations!  ¡Felicitaciones! ... and the wash is recorded and time-stamped.

The Written Process An integrated hand hygiene solution is best achieved by recording it in writing. With or without the help of automation, documenting a hand hygiene process helps provide a span of commitment across departments, across the spectrum of design-build-equip-supply-operate. It also facilitates employee training and integrates each job with the extended process. The written process captures why components were selected at the design phase, protecting them from the sharp pencils of future, perhaps uninformed, administrators. The costs of handwashing are easy to measure. The risks of not washing are not.

This written process also helps any new health inspectors understand the whole hand hygiene picture. One document can serve as the common guide for three types of inspections - those by operator staff, contract auditors and local regulators.

Its custom-fit nature drives its effectiveness. The Active Hand Hygiene Process changes behaviors by incorporating management values, a specific customer profile, the menu, the facilities and staff.

Prep And Server Motivation Much of the frustration surrounding today's hand hygiene practices in professional kitchens can be removed by including a step to gain commitment from the workers themselves. It is a lot easier to achieve good handwashing frequency when workers understand the reason why ... and want to wash. This was demonstrated in recent research funded by the FDA in Minnesota's Brown-Nicollet County Health Department. They found they could increase handwashing frequency by 25% to 100% using a Pledge of Professionalism and a language-free handwashing training video that is focused on the worker rather than those centered on the trainer. More information on this research and the video program, "Handwashing For LifeTM — The Why, The When & The How," is available from The Handwashing Leadership Forum,

Measuring And ManagingThe quality of a handwash can be periodically measured by use of a disclosing agent - similar to what some dentists do to demonstrate areas frequently missed during toothbrushing. One type of lotion is rubbed into the hands, and then washed off. Areas missed are illuminated under ultraviolet light. This way, a food worker now sees his own personal world of germs and experiences the risk with an impact greater than words alone can provide. This step is valuable in creating worker understanding and commitment.

The Active Hand Hygiene Process is best maintained with a quarterly review. Menus change, new information becomes available and processes can be adapted. Updated local and regional hepatitis A rates are available from the CDC. An operator may choose to manage this particular risk via a vaccination program, particularly in endemic areas. This is appropriately part of the Active Hand Hygiene Process. Hep A is very infectious and its presence puts an even greater requirement on good handwashing, though the added vaccine intervention makes the inevitable missed handwashes less dangerous.

Process control over hand hygiene offers an additional operator incentive. It is a solution that keeps accountabilities clearly defined. It can be used to establish variances in those jurisdictions promoting the no bare-hand contact with ready-to-eat food alternative.

An integrated hand hygiene process lowers risk by aligning and leveraging the operator's entire body of knowledge. It uses technology to give the process synergy and transparency. It converts the wisdom from a strategic plan into meaningful and measurable daily actions.

Handwashing measurement adds the power of good management practices and protects the value of foodservice brands. This outlined Active Hand Hygiene Process makes it easier to manage hand hygiene with the same degree of professionalism witnessed throughout the rest of a successful organization. It makes it easier for the staff to do the right thing, day after day, shift after shift, 24/7. With numbers we can have records and winners. We can celebrate success.