Wednesday, June 10, 2009

Hand Washing in Hospitals (Part I)

One of the greatest struggles of any change leader is process discipline. That's a fancy term for good old fashioned behavioral compliance! Doing what is right! Simply doing what you're told! There are few things more frustrating than establishing an improved process or policy, training everyone in your organization to understand its importance, and then having constant issues with the process or policy not being followed by those same people! A recent case study I read in Gawande's "Better" highlights this all too common frustration.

According to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand will die of that infection. By comparison, in 2005 just over forty five thousand people died in vehicle accidents in America! This makes the hospital one of the most dangerous places in America! Yet health care studies show that the number one preventative measure for hospital infections, hand washing, is only accomplished one half to one third as often as it should be to prevent these infections. Surely doctors, nurses, therapists, and other care givers understand the importance of hand washing. They would almost all acknowledge the importance of following hand washing standards and guidelines. And yet half of the time they choose not to, potentially spreading infections that take the lives of tens of thousands of people.

Deborah Yokoe is an infectious disease specialist at a major American hospital. Her full time job is to stop the spread of infection in the hospital. She has tried everything you can imagine to increase hand washing compliance. Threatening signs. Repositioned sinks. Additional sinks wherever they may be needed. Establishing "precaution carts" with everything needed for washing up, gloving, and gowning. She's given away movie tickets as positive reinforcement. She has stood guard at sinks and confronted doctors and nurses when they bypass the standards. She has issued hygiene report cards and assessments. And yet infectious rates at her hospital has not decreased. Care givers are still passing infections from patient to patient.

One barrier to good hand washing discipline is the time it takes to follow the strict procedure. If you're really interested in this topic you can go to http://www.cdc.gov/handhygiene/ to read the 56 page procedure and even take an online training course. If you are a health care provider who is planning to do surgery on me it is required reading! By the way, almost nobody actually adheres to this procedure. Why? Even if you could get the procedure down to one minute per hand washing, doing so between each patient could consume a third of a care giver's time! Doing so this frequently can also irritate the skin and cause dermatitis which, of course, increases bacterial counts on hands. That is probably why your doctor has another patient's pus under her fingernails when she is checking your incision for signs of infection.

If you were hired as a hospital administrator or infectious disease specialist and you were serious about being a change agent to save lives, how would you approach this challenge? In my next post I'll detail the approach this hospital took and the results it produced...

4 comments:

Chris Young said...

I think that this is a great illustration of the difficulty we've all experienced with a process or procedure not being followed as it was intended. I believe it was Jon Rohn who said, "Discipline is the bridge between goals and accomplishments." It is one thing to create a process (goal); it is an entirely different thing to follow the process (accomplishment). Yet, as important as it is for doctors and staff to adhere to the simple task of washing their hands, one could easily access that the discipline isn't there. Why is the accountability so invisible?

The Change Freak said...

Great quote Chris! I hope you don't mind if I add it to the freakin' good quotes section. The real trick as an agent of change is how do you drive the discipline necessary to produce accomplishment? The hospital took an approach that I would be a advocate of, with rather surprising results...

Kevin D. Baskin said...

I can understand alot from this situation. I wonder if the procedure was written by the operators (clinical folks) or administrative folks. My wife is currently in the medical field. Believe it or not i asked her to do some data analyis for me. I JUST CANT help it. She took eight folks in her area and over a month took cycle times to wash their hands. Not to instill any type of "freakish" reaction but some folks cycle times were, zero. OUCH!. Anyway....my original point. Monitor the process, assess the USL and LSL, find out where your process distribution. As my favorite engineer said.

"Talk to the parts; they are smarter than the engineers. Dorian Shainin

The Change Freak said...

I love it Kevin! Thanks for the great comment!