Error Proofing Handwashing?

by Mark Graban on February 18, 2009 · 5 comments

Hand washing and proper hand hygiene is a big concern at most hospitals — thankfully so, since hand hygiene and other basic infection control measures can save lives, preventing or slowing the spread of harmful bugs like MRSA and C-Diff, bugs that can be acquired during a hospital stay.

This article talks about how MRSA cases have been reduced in ICU’s through better prevention.

“The risk of bloodstream infections caused by MRSA that are associated with the use of central line catheters has dramatically declined by 50 to 70 percent since 2001, in all types of adult ICUs,” said lead researcher Dr. Deron C. Burton, associate director of CDC’s Health Equity National Center for Health Marketing.

The drop in these infections is largely due to better procedures that have improved the safety of catheters, Burton said. “There has been improvement in the sterility of how they are inserted and how they are cared for while they are in the patient,” he explained.

This article talks about how soap and water can help slow c-diff. Basic “blocking and tackling”, eh? Getting 100% compliance with proper hand hygiene proves easier said than done, unfortunately. Hospitals often rely on signs that lecture, I mean remind, staff or rely on hospital visitors (or patients) to ask their caregivers if they’ve washed their hands. This can be an awkward exchange, on many levels, and many patients are afraid to speak up.


The basic Lean concept of Error Proofing is interesting to through around in this context. How CAN we error proof proper hand hygiene? We can do spot checks, but we can’t watch people constantly, it seems. We can make it easy to do the right thing — eliminating systemic barriers that would make it hard to clean your hands. Hospitals can put gel dispensers everywhere and can make sure carts are available so staff members can keep their hands free to be able to clean up.

I was really intrigued by this article and the accompanying YouTube video:

MetroWest Medical Center – MetroWest Medical Center Boasts Innovation

The one-of-a-kind device, which looks something like a toll-gate, was developed by Lean Process Manager Kevin Frieswick, and works by wiring the dispensers to an arm which blocks access to a room, and only goes up once someone has activated the dispenser.

Staff need only stick their hand under the dispenser to receive a shot of sanitizer, raising the barrier. A motion sensor then waits until the door is clear to lower the barrier.

“I made it out of Radio Shack and Home Depot parts,” said Frieswick, who wired the one-of-a-kind device together. “You’re not getting in this room without making a conscious effort to ignore this.” Hospital officials are contemplating whether to pursue a patent for the device, which is being piloted in one unit and may someday be outside every patient room.

What are your thoughts on this? What do you think the pro’s and con’s are of a method like this — both in theory and in practice?

Subscribe via RSS | Lean Blog Main Page | Podcast | Twitter @leanblog

  • Share/Bookmark

{ 5 comments… read them below or add one }

1 Anonymous February 18, 2009 at 1:15 pm

As a prototype I think it is a good idea. I do have some questions about the room enter-exit sensor.

My big concern of hand washing in hospitals is visiting families. If the first person washes their hands can the rest of the visitors pile in the room. I know limiting the number of visitors in a room at once is common practice however I see this rule broken very often for the very sick.

Like or Dislike: Thumb up 0 Thumb down 0

2 rearden215 February 19, 2009 at 7:37 pm

This seems like something straight out of ‘Shockwave Rider’.

Although the intention is good, the implementation treats us like we are not too smart.

Like or Dislike: Thumb up 0 Thumb down 0

3 Mark Graban February 20, 2009 at 9:18 am

Rearden – how does this error proofing treat people as stupid? They aren’t like Frederick Taylor, calling workers stupid and ox-like.

People in hospitals are very smart… yet hand hygiene practices aren’t followed 100%. It’s not a matter of smart or dumb… it’s about making it hard for smart people to make mistakes. People forget… we’re not perfect (plus management isn’t paying close attention to the hygiene issue typically). A device like this helps, does it not?

Like or Dislike: Thumb up 0 Thumb down 0

4 rearden215 February 20, 2009 at 9:41 am

Mark, I was referring to the tollgate-styled dispenser which blocks access until one places a hand under the dispenser.

This seems like yet another example of the dumbing down or ’sailor proofing’ of a task which takes away one’s sense of personal accomplishment through accountability. And, yes, 100% compliance is too dependent upon humans to be realistic.

If we are too overzealous in sailor-proofing we risk becoming a dystopia.

I would hope that healthcare folks would be diligent in this matter.

Like or Dislike: Thumb up 0 Thumb down 0

5 Anonymous February 23, 2009 at 11:56 am

Is there any risk that a member of the hospital staff would not get to a patient fast enough because of this device? Would there need to be an override? Would the nurse/doctor arriving to administer cpr to a patient in cardiac arrest have to rub in the gel or foam before attempting to save the patients life? Just a thought.

Like or Dislike: Thumb up 0 Thumb down 0

Leave a Comment

You can use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Get a link back to a recent blog post:

Previous post:

Next post: