Should Efforts to Improve Hand-Washing Include Posting Names?

We’ve all heard about efforts by hospitals to reduce infection rates by having employees wash their hands more often. But what are the best tactics for achieving that goal?

A recent article by Health Leaders Media describes the techniques used at Barnes-Jewish St. Peters Hospital (BJSPH) in St. Peters, MO. They succeeded in getting more people to wash their hands regularly. But I have mixed feelings about how they did it.

Basically, they used a carrot-and-stick approach: They praised people who had good hygiene and criticized those who didn’t – privately at first, then publicly.

The first efforts involved handing out “You’ve been spotted” cards.

For positive reinforcement, some of the cards were flagged for incidents where the receiver has been spotted using good hand-hygiene practices. These cards includes a $2 coupon good in the hospital cafeteria or gift shop—enough for a cup of coffee or candy bar, or they can be saved up to buy lunch. Funding for these coupons came from the infection prevention budget.

And then there are the other cards, which read, "We are putting you on the spot for not using hand hygiene."

The reason the cards look nearly identical is to prevent any sort of embarrassing scene for the people involved. It's impossible to tell from a few feet away whether you've received a positive card or negative.

This approach worked, but not as well as officials hoped. So they took it a step further by posting names of all spotted employees – the good and the bad.

To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH added an additional, and very public, way of rewarding those who were spotted using proper hand-hygiene processes.

"Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a 'hand hygiene hero' drawn in the cafeteria," says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH.

The cafeteria is shared by staff and guests alike, so the congratulatory ceremony—including Bonnie Tyler's 1980s hit "Holding Out for a Hero" playing loud and clear—can be witnessed not only by staff, but also the people using the hospital and their visitors. There's a gift involved for the winner of the drawing as well (a $25 gift certificate) and, in months where the goal is exceeded, multiple names are drawn.

Winners' pictures are taken and posted throughout the building—even built into screen savers on hospital computers.

One could argue that we’re talking about changing behavior rather than improving a process, but I can’t accept that. Yes, we are talking about changing behavior, but hand-washing is also a step in hospital processes.

Is BJSPH using a lean approach? I wonder, because they are using after-the-fact feedback to achieve change rather than seeking to ensure that hand-washing occurs in the first place. Does this approach show respect for people? Are there other, better ways of making hand-washing an integral part of processes?

I’ve never been involved in process improvement in a hospital, so I can’t say. If any of you have thoughts on this, please add your comments below.


Mark Welch said...

I'm a Lean Facilitator in a hospital and was once a Human Resources Manager, so I have some thoughts...

This is an interesting approach. I applaud their active management of hand hygiene, which would be considered Lean, but in my humble opinion, the public noting of those who had failed at compliance falls short of the "Respect for People" aspect. It's a blame and shame approach. Yes, these people may have failed, at times, with their hand hygiene, but a good Lean manager would be asking, "What were the circumstances that led to the failed compliance? What were the barriers? How can we remove them?" I hope they are doing this.

Also, the old axiom of "Praise in public, criticize in private" should be held to. Public humiliation in a workplace will lead to fear, which causes people to hide problems rather than surface them, which is what Lean seeks to do.

Brian Buck said...

I am a Lean Faciltator at a hospital as well. From a Lean perspective, I think it should always be about the process and not the person. However, I frequently get data requests to be broken down by provider instead of min, avg, median, and max time for diagnosis or procedure.

The reason I am given why they want to single out the best and the worst is because Doctors are competitive. Mangement has used data publically to show which providers are not as fast/compliant, etc in order to motivate those falling behind the norm.

This appears to be a long-standing cultural issue. In private, it may be worth seeing who is the fastest and replicate how they do the work (provided they are doing everything without cutting corners), but I think the carrot and stick appraoch is more harmful in the long run.

Tim McMahon said...

I agree with the others on this issue. Positive feedback is much more effective than negative feedback. But this is not a cultural issue to wash hands. Hand washing in this case is more a process issue. How do they go about enusring employees wash hands? What is available to empployees for supplies? If they can notice that another employee did not wash their hands why not support them by encouraging them to do so. Why do they need so many referees to in the game. Get people to play the game to win.

Jason Yip said...

Why don't employees wash their hands?