Thoughts on Handwashing in Healthcare from David Mann


Some good discussion was raised in my original post, where I was thinking out loud about what Lean management methods you should use to get clinical healthcare providers to wash their hands 100% of the time, in the name of patient safety.

Here are some thoughts from an email exchange with David Mann, author of the excellent book Creating A Lean Culture: Tools To Sustain Lean Conversions (used with his express permission). I was curious about his general model for solving the “how do I get compliance?” problem.

Some thoughts based on a simple model of learning: knowledge, practice, feedback:

1. Are there visuals at the point of use (where handwashing occurs) based on, for example, time sample observations, that show percentage compliance versus the 100% goal? This feedback would be the equivalent of posting lean assessment scores or 6-S audit results.

1a. Is there something like a 6-S audit in which this practice is simply one of those explicitly expected and audited? If not, seems like it might be good to start.

2. Is there a method for reporting failures to comply. These could be anonymous (initially); the object is to provide feedback on daily or weekly (for example) performance which virtually all in the health care setting would agree (I'm assuming) is important.

3. Is knowledge of the situation widely disseminated? Are findings from consequences made visible, in incidence percentage (PPM?) and counts based on root cause analysis of the subject infections, plus those resulting in death? Are the data widely visible? Visuals raise the level of accountability and disseminate responsibility. Are there only a few with the data doing all the worrying? It wouldn't be unusual if that were the case.

4. Is there the equivalent of a stand-up meeting at some frequency where this subject and results (as from 1- 3 above) could be touched on? Counting on good habits to persist without reinforcement, measurement, and reminders isn't a robust strategy. As you've said, hope isn't a plan – unless you're the chaplain!

5. Following a month or a quarter of implementing some or all of the above steps, consider converting step 2 from anonymous as to reporter and reported to the mode where the reported are identified by name and followed up by whatever authority with disciplinary action with the appropriate progressive steps. Or, begin random observation schedules by those in a position to initiate disciplinary action (progressively, of course) based on what they see.

In lean implementations, noncompliant individuals present themselves to be made examples of, part of their testing the system. The same will happen here, whether among staff or physicians. When it happens, it's important to act. It's often the case that the miscreant lets others know what happened: “You wouldn't believe what they did to me!”, helping to spread the word. Organizations have discipline systems for good reason.

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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. Good post! I know that you are focusing on the delivery end, but this is a huge problem for the manufacturing end as well. In the U.S. about 83%of the population wash their hands after using the toilet. (My informal observing says that it is less.) In clean room manufacturing the incidence of hand transmitted fecal coliforms is a significant problem. Hygiene is important.

    For clean manufacturing operations the introduction of coliforms into the process is like pouring a glass of sewage into a barrel of wine. It becomes a barrel of sewage.

  2. I dont know where to start.

    I’ve been in 30+ hospitals both in the UK and US.

    In the UK signs, visual information are readily available on the impact of not washing, where one should and should not wash and the requirements to wash.

    Information on washing compliance is discussed at every level from Trust Boards and Clinical Governance all the way down through Nursing and Management.

    Audit results are well circulated from Board level down. Compliance levels are well known.

    Root cause analysis is far trickier. It would be virtually impossible to attribute a HCAI death directly to an individual failing to wash their hands. Was it one of the 4 Consultants, 5 juniors, 20+ nurses, support staff, visitors, cleaners, physio’s, OT’s or someone else?

    This would be even trickier to find out given that up to 30% of the population carry MRSA with no symptoms whatsoever.

    One of the problems is there is no downside to a clinician not washing their hands. You can not discipline or otherwise castigate an individual that does not work for you. You can not prevent them from practicing medicine. If a nurse does it you could take them through a disciplinary on jeopardizing patient safety but for MD’s you cant.

    Naming and shaming will not happen, not with front line staff who behave in a subjugated role to MD’s and Surgeons. They will not stick their head above the proverbial parapet to get it blown off.

    Discipline systems work but when they are not applicable they are irrelevant and when dealing with Clinicians hospital disciplinary processes are irrelevant as most MD’s do not work for the hospital. (In the UK this is almost entirely the case)

  3. Thanks for your thoughts, anonymous.

    So if all of this discussion about hand washing is taking place, why the disconnect where we don’t have anything close to 100% compliance?

    Sure it’s impossible to attribute a death to a single person not washing hands, but is that the point? Washing hands certainly can’t hurt, can it? Well if it does hurt the hand washer through dry chapped hands, the hospital should make good hand lotions available through wall dispensers (and many do).

    I’ve seen studies that say over 60% of us carry MRSA around.

    “No downside” to not washing…. other than knowing that you’re helping to spread germs around???

    I agree that there seem to be many organizational cultural barriers that get in the way of good systems to ensure 100% hygiene.

    We can’t just throw up our arms and say “oh well.” We have to try to do better.

  4. Here’s a news story that shows how at least one Dentist doesn’t have common sense or common decency.

    Yahoo news story:

    “A British dentist was found guilty Thursday of urinating in his surgery sink and using dental tools meant for patients to clean his fingernails and ears.

    A medical tribunal said it was satisfied the evidence showed 51-year-old Alan Hutchinson, who “routinely” did not wear gloves or wash his hands, had risked the health of “himself, staff and patients” for more than 28 years.

    A dental nurse who worked for Hutchinson for 16 years said she had caught him urinating in the sink more than once.

    “He was tucking something into his trousers before zipping them up hastily. I walked over and I was behind him. He moved to the left and I could smell urine,” the nurse told the tribunal.

    A later hearing will decide if the dentist’s unhygienic habits impaired his ability to treat patients, and if so, whether he should banned from practicing.”

    I’m not going to panic and assume ALL dentists are doing this. But still…. how does this happen in a case like this? I’m sure his staff KNEW he wasn’t wearing gloves…. I guess if they reported him, he’d get shut down and they’d lose jobs??


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