KANSAS CITY, Mo. — Two years ago the "Clean Hands Report Card" gave Americans a grade of C in hand-washing habits. That's hardly a stellar performance considering the risks out there, such as pandemic flu, contagious skin diseases and the annual cold season.

Unfortunately, the hand-washing situation seems to be getting slightly worse. A new report card is out, and our collective grade dropped to C-.

Health experts are adamant that Americans do better.

"We really look at hand washing as being the one key thing that everybody can do not only to keep themselves healthy but to keep from spreading illnesses to others," said Don Pickard, spokesman for the Kansas City Health Department.

The challenge is washing often enough and thoroughly enough to prevent disease. We're falling short in both categories. Here are a few of the findings from a September national survey for the Soap and Detergent Association. The survey prompted the sub-par grade.

• 68 percent of Americans don't wash their hands long enough to remove dirt and germs, higher than the 54 percent in the 2004 survey.

• 36 percent seldom or never wash their hands after coughing or sneezing. This was an improvement over the previous survey.

• 31 percent don't always wash their hands before lunch. The result was about the same as in 2004.

In addition, while 92 percent say they always wash their hands after using the bathroom, an observational study in 2005 by the association and the American Society of Microbiology found the real figure to be 83 percent.

When to washHere are the instances when it's very important to wash:• Before preparing food• Before meals and snacks• After using the restroom• After touching animals or money• When you or someone near you is ill

How to washMany of us need a remedial course in hand washing that works. Here's how to do it right:• Wet hands before soaping up.• Create lather by rubbing hands together away from running water.• Wash for 20 seconds or more. Be sure to get the back of the hands, between the fingers and under the nails.• Rinse under warm, running water.• Dry completely with a clean towel or air dryer.Hand sanitizers and wipes are OK if soap and water aren't available.