What Do You Think of This Sign?

A reader sent this picture from a hospital restroom. I'm not sure if the reader is a patient parent or a hospital employee. They asked, “Why are we putting it on the parents to remind doctors to wash their hands? We have enough to worry about, our kid is sick. Who really does this??”

I'd absolutely agree. I've seen tons of signs in hospitals about handwashing and proper hand hygiene. Some are serious, some are cute. If hanging signs worked, we wouldn't have such low hand hygiene adherence. Different studies put the number at roughly 50%, as I've blogged about before. This isn't in the context of before surgery, rather this is about hand hygiene between patient encounters.

As we discussed before (and also here), signs and admonishment don't work. You need to ask “why?” Are people too busy to wash their hands? Are managers not observing the process to see if standard work is being followed? Are managers not holding people accountable? Are co-workers not holding each other accountable?

There are many many root causes for which we can develop countermeasures. I'd argue it IS wholly unfair to ask parents to nag the caregivers. Honestly, I'd be embarrassed to put up a sign like this… it's an abdication of the hospital's responsibility for safety patient care. That's my opinion. What's yours?

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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. One hospital did an internal study (non-published) that indicated that patients and families were scared to speak up about handwashing (and the hospital had an active “remind your caregivers” campaign).

    People are afraid of retribution or that the nurse or doctor will hold a grudge against them. Sad.

  2. We need signs that say “Dear Passengers, ask your pilot if your airline has done all of their proper maintenance. Proper maintenance can help prevent firey crashes.”

    Good lord.

  3. 1. A father with his young son in the men’s room of a local big-box store reading the sign aloud that says “Wash Your Hands, It’s The Law,” and telling his son, “see, I told you you could get into serious trouble for not washing your hands.” Obviously the sign had an impact not intended, but possibly effective.

    2. Washing hands between patient encounters seems very inconvenient and could generate a lot of waste. How about having caregivers carry packets of antibiotic hand wipes with them and use them between patients? Same effect, but less hassle usually equals greater compliance.

  4. Mike – you’re on the right track with point #2. Washing hands is “inconvenient” but better hand hygiene correlates with fewer infections for patients.

    Making it EASIER is key. Many hospitals have installed gel dispensers where you almost can’t turn without hitting one.

    But, hospital people are often pressed for time, or they have their hands full (literally). We have to address those root causes rather than just nagging. Building time to wash hands into someone’s standardized work (and then staffing accordingly) would be a good idea, I’d argue.

  5. I can tell you why I didn’t wash my hands between every patient.

    By far the most important reason is:

    #1 reason: Gloves. Healthcare providers are required to use “universal precautions” with all patients. Most of them don’t — but I did, I never touched a patient without gloves on. But it’s not just that I figure the gloves should be doing their job, it’s also that washing your hands or using the alcohol foam makes it nearly impossible to don your gloves afterwards (try it sometime, wet hands and vinyl/nitrile/latex). You have two steps in the process back to back that are like oil & water. That accounts for about 80% of the reason by itself.

    #2: Yeah, I was in a hurry too. My manager (who was the worst manager I’ve ever seen in any business, and was ultimately fired) do frequent audits to see how many exams we were doing and pushing us to do more.

    #3 is that I wasn’t wholly convinced that it a reasonable expectation to wash hands as frequently as they say. It’s not just in between patients. It’s anytime you touch something after washing your hands basically. So if you went from the patient to pull the blinds and then back to the patient you’re supposed to wash your hands.

    All of that being said, I did wash my hands a lot. I always did when I was in surgery and always before and after patients with high risk infections (MRSA, VRE, etc.) and cancer patients. But if you’re an otherwise healthy 40 year old with leg pain for 1 week? Iffy.

    Anyway that’s why I got out of medicine — it’s a system that is setup to fail.


  6. A loved one almost died of a pulmonary embolism. Spent 8 days in the hospital. Fortunately survived. 10 days later was back in the hospital with hospital acquired pneumonia. Almost died again (40 yo mother of 4). Asked to talk to risk management and they said it wasn’t the hospital’s fault because patient originally admitted with a compromised health condition. Don’t know if it was handwashing problem or not.

    If hospitals had to pay $10,000 for every hospital acquired infection then handwashing compliance would go 3 sigma overnight. Can’t wait for the day!

  7. Fantastic post Mark. D – There are always excuses but with alcohol based washed outside every room it’s hard to justify any of them to a HCP given the current evidence.

    That sign is fantastic. Why? Because I can’t think of anything more embarrassing than having to have a patient ask me to wash my hands. One of the most profound “motivators” I’ve ever seen but I don’t think I’d ever hang it in my office because of Neutron Jerk’s comment. The onus shouldn’t be on the patient for me to wash my hands.

  8. #1 cited reason: Time.

    That is not to say that it is the root cause.

    If properly followed, the guideline is to wash hands with antibacterial soap and warm water for 20-30 seconds. Has must be washed before and after patient contact. This adds about 1.5 to 2 minutes to the visit (or 2 hrs for a doctor that does 60-70 exams). Frequent washing with soap causes dryness. Dry hands harbor more bacteria.

    Many hospitals have started using alcohol based hand sanitizers. These take only about 15 seconds per visit, and have been proven to actually cause less dryness.

    Habits are hard to unlearn. It is sometimes simply a matter of dilligence.

  9. Yes, soap and water washing dries your skin. I heard someone explain that when people claim that the alcohol cleanser stings, it’s not the alcohol as root cause.

    Alternating between soap/water and alcohol does it. Dried hands (due to soap/water) dry and crack, creating the openings that sting with alcohol.

    If you use gel 100% of the time, the stinging won’t happen.

    I agree “lack of time” is not an excuse, nor is it a root cause. It’s management’s job to improve the system to eliminate the root causes of “lack of time.”

  10. From a pragmatic perspective I think this sign is an excellent idea.

    We all acknowledge that hand washing/sanitation is a problem and one that has various root causes and possible solutions. It isn’t going to go away immediately and it does have serious negative effects.
    This sign simply empowers the individual with the most invested (parents) to feel comfortable asserting proper procedure.

    Is it a long term solution? No, it doesn’t come close to addressing the serious underlying problems. But, as a pragmatic step towards increasing immediate safety, I think it’s a good idea.

  11. Mistake Proof??

    If the wash station is located outside every room, and every room has an entrance, the entrance could trigger a pleasant sound (reminder) every time someone went through it.

    The dispenser could be rigged to disable the sound for one ‘entrance.’

    If they used the dispenser before going in, there would be no reminder. Anyone who didn’t remember to use the cleanser would have an reminder upon entrance, and if they missed the reminder it would be evident to anyone else in the audible area.

    And is it possible to wear gloves and wash one’s hands while wearing them, to reduce drying the skin with soap & water?

  12. Hey Mark, have you heard about
    this one?

    Is it the hospital who performs the procedure?

    Jurevicius becomes sixth Cleveland player to contract staph
    Associated Press

    {comment republished by Mark – please use HTML tags when posting links}

    CLEVELAND — Browns wide receiver Joe Jurevicius contracted a staph infection following knee surgery, becoming the sixth Cleveland player in four years to suffer from staph.


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