100% is the Only Goal for Hospital Hand Hygiene


Ledger-Enquirer | 03/27/2007 | Campaign's goal is to reduce infections

To those who might have thought I overstated the situation with hand washing in hospitals, here's another article about maintaining proper hygiene among hospital staff and caregivers.

One particular risk is the bacteria Methicillin-resistant Staphylococcus aureus, or MRSA.

Susan Harp, M(ASCP), CIC, Columbus Regional infection control coordinator, says 40 to 60 percent of the population carries Staphylococcus in their nose.

“It lives there happily and many people can have staph and never have a day's problem,” she explained.

The problem is that many of us carry this around and we're OK, but when it's passed to someone who is susceptible, it can be deadly.

Karen Williams director of infection control at Hughston Orthopedic Hospital likens a hospital to a Petri dish with bugs moving around in a rich culture. That can cause bacteria and infections to spread.

The problem of drug-resistant bacteria is blamed on overuse of antibiotics…. a form of “overprocessing” in the Lean terminology (the “waste of overprocessing,” or doing more than is required to add value for the customer).

One “best practice” that helps stop the spread of MRSA — basic hygiene, such as washing hands with soap or using alcohol-based cleaning gels.

The problem is getting caregivers to wash their hands. As I highlighted in my earlier essay, the lack of hand washing is a real problem. Although caregivers report higher numbers, hospitals that do direct observation often find that the compliance rate can be under 50%. Washing hands saves lives, pure and simple. But hospitals often lament, “how do we get people to wash their hands?”

Well, how does a factory get employees to follow safety practices, such as wearing safety glasses?

  1. Leadership — set an example, a visible example?
  2. Explain Why — employees should be reminded that proper safety measures are not optional and are not secondary to quality or speed.
  3. Take Action — you need to observe to see if “standard work” is being followed. Hope is not a strategy. There have to be consequences for people not following the standard work safety practices.

Ideally, we, as leaders, need to treat people as adults, trust them to do the right thing. But, if that's not happening… you have to fall back on your formal power… the power to discipline employees.

This happens in good factories every day…. if someone's not wearing their glasses, they're reminded and probably threatened with punishment or discipline, if need be.

Here's a case where “lean leadership” isn't “nice” — you have to be tough when safety is involved. You can't just wait for someone to lose an eye before reacting and re-emphasizing safety glasses.

So why do hospitals find it so difficult to get compliance with hand washing standard work?

  1. Doctors are usually not employees. There is a different dynamic involved. Hospital administrators don't hold the same kind of authority over doctors that a plant manager might have over a supervisor or an assembly worker. Hospitals rely on doctors to bring patients (and therefore revenue), so it's common for administration to not hold MD's accountable for following a standard process (whether it's washing hands or filling out post-op paperwork in a timely manner).
  2. It's impossible to observe 100%. We can't possibly observe every MD every second of the day. I suppose the medical profession itself has to take this on, with colleagues pressuring or shaming their peers into handwashing compliance.
  3. Patients are often afraid to speak up. Many patient safety experts are urging patients to speak up, to keep giant Purell bottles by their bedside, and to insist that your caregivers wash/clean their hands in front of you. If your MD or RN is offended, that's probably a bad sign.

In the article, they talk about using “secret observers” to look for compliance:

“You have to be consistent and conscientious,” Harp said. She reports that at Columbus Regional they have secret surveyors, who watch for compliance.

“They look for opportunities when an employee should have washed, and then they see if they do,” she explained.

But what when they see these opportunities? Are they collecting data or driving improvement? Is anyone being punished for NOT washing properly?

I can't believe we're even spending time discussing something like this. You'd think basic hygiene would be “a given.”

One hospital mentioned in the article set a goal of “100%.” That's a good start. Safety goals need to be in absolute terms. Factory safety goals need to be “zero injuries.” Forget what people say is “impossible.” Setting a goal other than perfect sends a horrible message that it's “OK” for a certain number of injuries or deaths. At least the hospital execs aren't setting goals of “75% handwashing compliance.”

But setting the goal is just one part. Leadership and getting compliance to standard work is the ongoing challenge. Sad.

What advice would you give our healthcare leaders? Click “comments” to chime in.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Secret observers?! Sounds like inspection waste of the worst kind.

    I’m certainly no expert in this, but it seems that hospitals might consider asking “Why” a few more times, to get to some better root causes. The 3 reasons you state are a good start, but given the magnitude and potential impact of the problem, there must be some other more basic reasons. Since hygiene is normally a personal habit, it would seem that the reasons for non-compliance would be largely personal as well, and getting to the root of that will require careful questioning and respect.

    My wife, who works in medicine, can add one more reason: washing her hands all of the time dries them out and causes the skin to crack, which is painful (it also increases the places for bacteria to flourish). Maybe hospitals should dispense with hand washing and insist on frequent glove changes?

  2. Infection control is a vexing issue, for many of the reasons Mark stated in his blog. We’re addressing it by frequent reminders, placing hand-washing stations and/or gel stations (gel is actually better than washing with soap and water) in more convenient places, and raising awareness of the ways infections are spread. One of the biggest reasons for not washing that we’ve heard is time – being in a hurry to get to the next patient or the next case. It’s a tough issue, but it’s one that’s essential, and we’re using our Lean knowledge to help.

  3. Read the TWI article below, and try TWI.

    We can not assume that everyone knows and understands the rules unless they have been properly trained. Yelling at employees and putting posters in the hallway is not training.

    Good training starts with a clear standard, and requires one-on-one instruction until you know the person understands.

    If the person hasn’t learned, the instructor hasn’t taught!

  4. I appreciate the comments, plus another real helpful email I received (checking to see if I can share).

    I think:

    1) Not starting by yelling and threatening punishment is the right start.

    2) Having a “tip line” to report the bad practice and tracking the # of reports (without punishing violators) would be a good start

    3) Education and constant reminders must be key

    The thing I have trouble getting my head around… do we really have to educate MD’s that washing hands is good?

    Hate to be cynical, but maybe insurers and payers should make “hand washing” a chargeable task.

    When a factory talks about “True North” and not cutting corners in quality or safety in the name of getting the production numbers, shouldn’t we expect the same of MD’s?

    “Not having time” rings really hollow and it would piss me off to hear it from a doc.

    I’m trying to exercise my “respect for people” chops, but if a caregiver isn’t following proper hygiene (and this includes OR dress and behavior), my patience and respect runs thin.

    What about respect for the patient? That should come first.

  5. I work for a pediatric teaching hospital who wrestles with this very issue.

    We’ve made some gains over the years, but it really is vexing that we can’t achieve 100% compliance. We’ve approached this problem from several angles: every patient room has a wall mounted purell dispenser, we have reminder stickers in every bathroom (and many other places), and we address this topic frequently in our internal communications.

    I’ll bet that the secret surveyors weren’t expected to intervene when they observed a non-washing incident. While that would have been ideal, especially considering that patients lives are at stake, thre is commonly a large cultural divide between physicians and hospital staff, and most staff wouldn’t feel comfortable intervening. I’m not saying that’s ideal, but it’s the probable reality.

    Unfortunately, there is often a delicate genius mentality among physicians: their time and attention is thought too precious to focus on mundane hospital initiatives. We’ve spent years working to shift this mindset, and we’re making progress.

  6. Healthcare leaders should open meetings with a hand washing excersize or demonstration. When people see the boss washing his hands, they’ll be more likely to do it too.


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