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Background: High hand hygiene (HH) workload is a commonly cited barrier to optimal HH performance. The objective of this study was to assess trends of HH workload as defined by HH opportunities (HHO) and performance rates over different timescales using automated HH monitoring system data., Methods: This multiyear retrospective observational study was conducted in 58 inpatient units located in 10 North American hospitals. HHO and HH rates were analyzed by time series mixed effects general additive model., Results: Median HH rates peaked at 50.0 between 6 and 7 AM with a trough of 38.2 at 5 PM. HHO over hours in a day were the highest at 184 per hospital unit per hour at 10 AM with a trough of 49.0 between 2 and 3 AM. Median rates for day and night shifts were 40.8 and 45.5, respectively (P = .078). Weekend day shift had the lowest median rate (39.4) compared with any other 12-hour shift (P < .1018). The median rates and HHO varied little across days in a week and months., Conclusions: HH workload and performance rates were negatively correlated and changed drastically over hours in a day. Hospitals should consider HH workload in the development and timely delivery of improvement interventions., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)