Changing the culture of hand hygiene compliance using a bundle that includes a violation letter.

Hand hygiene is the best method of preventing transmission of infections in health care, but compliance is usually suboptimal. In one hospital, compliance with hand hygiene was improved and sustained using a multifaceted bundle approach. A unique aspect of the bundle was the creation of a violation letter that was sent to and enforced by managers of noncompliant personnel. The letter appeared to be the major factor in raising the hand hygiene compliance rate from 34% to >90% in a 2-year period.