We examined hand hygiene practices in surgical wards in 9 countries in Europe and Israel through direct practice observation. There was marked interhospital variation in hand hygiene compliance (range, 14%-76%), as well as glove and alcohol-based handrub use. After multivariable analysis, surgical subspecialty, professional category, type of care activity, and workload were independently associated with compliance. Hand hygiene practices are influenced by numerous factors, and a tailored approach may be required to improve practices.