Hand hygiene (HH) compliance can be improved through appropriate leadership and change agents (CAs). This study describes the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) for HH improvement. Based on the Diffusion of Innovation Theory, it was hypothesised that democratically identified peers will be early-adopters to improve HH through their social network. A randomised-controlled study was conducted at two wards in Malaysia. Wards were randomly assigned to PICAs or MSCAs. Outcomes were: HH compliance; HH knowledge; observations from ward tours; perceived leadership styles of CAs; social network connectedness and communication patterns; HH leadership attributes. Both study arms experienced significant HH improvement and improved HH knowledge. PICAs led by example while MSCAs were authoritative. Organisational culture of both wards was hierarchical. All staff preferred authoritative leadership. PICAs were not inferior to authoritative leaders, they acted as early adopters who facilitated HH improvement through role-modeling and their social network.