Wednesday, February 8, 2012

Hand Washing,Teamwork, and Professional Ideals

Hand washing protects hospital patients from healthcare-associated infections. But on average, adherence to hand hygeine standards is under 40%.

In June, 2008, Northshore Hospital on Long Island started an experiment. It installed motion detectors in the doorways of ICU rooms to monitor entrance of staff, and installed cameras focused on the sink and hand sanitizer dispenser. Video auditors (in India) scored each event. The intervention tested the impact of (a) installing cameras and (b) feedback of results. No individuals were identified. Results were only reported in aggregate form.

In the 16 week prefeedback period, hand hygiene rates were under 10%! At that point, electronic boards were installed in the ICU hallway. Results were given on each shift. To my eye, the board looks cheerful. It shows the date, the target rate (>95%) and gives an electronic pep talk ("Sanitize Hands Upon Entry/Exit of Rooms!"). On May 17, 2010, the day displayed in the photo, it tells the staff: "GREAT SHIFT!!" and gives results for physicians and other health professionals.

Once electronic reporting of aggregate performance was given, adherence jumped from under 10% to the mid 80s. The results were sustained for two years.

The report in Clinical Infectious Disease doesn't speculate on what drove the change. There were no financial incentives and no monitoring of individual performance.

So what happened?

Here's my guess. Very few hospital workers doubt the importance of hand hygiene. But resolving to do better is like our New Year resolutions to lose weight or improve ourselves in other ways - easy to vocalize but hard to carry out.

The cameras without feedback accomplished nothing. But daily feedback reminded staff of where it stood relative to its ideals. And the aggregate reporting told staff that everyone was on board. In other words - an experience of unity in relation to professional ideals.

That's like the congregation singing a hymn together and praising the God they adhere to! The electronic board wasn't a voice from heaven, but it spoke to the flock every day on every shift. On a bad day it must have been like the chorus from Messiah - "All we like sheep have gone astray."

I hope a journalist or a qualitative researcher delves into the human side of the statistical story the article tells. We might learn important lessons about what helps us put our healthcare ideals into action.


Bose said...

Hay Jim, your 50 years of experience shows with the great articles here, this is my first visit and a doctor from India. I do agree that hand wash is most important then any, you normally do every activity with hands and having them cleaned after every work so important, many infant baby's have habit of putting there fingers in mouth, which the mother should be very careful. When we are very hungry we forget most of the time washing hands. I almost advice all my patience to keep this practice. Thanks so much for the helpful pack of article and am have bookmarked..Keep them coming Jim,


Jim Sabin said...

Hello Bose -

Thank you for your visit to the site and your comment. I'm especially happy to have readers from India. Both my wife and I have done research in India. We have visited India many times and treasure our friends there.

Your point is excellent. Hand washing is a very basic human function. When I was a child polio was still an epidemic, and I remember how strict my parents were about hand washing. In U.S. health facilities now it's common to have signs that emphasize how washing hands can decrease the spread of influenza.



Jdoc said...

Very interesting study. We have a system of anonymous monitoring and interestingly, our handwashing monitors are always reporting close to 100% compliance which I highly doubt. I would gues advertising the results may play a bigger role than the actual policing. People don't realize how often we forget to wash hands even when we believe it is effective. You have to make people realize how bad we really are or advertise how bad we really are. Not sure which component makes people improve...

Jim Sabin said...

Hi Jdoc -

I'm also not sure what component elicited the improvement, but it wasn't policing individuals. It looks to me as if the key factors were (a) focusing attention and then (b) building on success, which I speculate (c) reinforced motivation through pride in meeting ideals and the sense of solidarity from doing it as a team.