Revisiting Handwashing, Time, Systems, and Blame


I've struck a chord with a few nurses with this post from late last year:

Why Do Hospitals Have to Rely on Vigilant Patients and Families?

I asked:

I've written before about my questions of why so many hospitals abdicate their leadership responsibility for quality and patient safety, or at least offload much of it onto the patients. I think it's wrong to put patients of the position of asking the providers if they've washed their hands. The hospital, the providers, the physician leaders, and the administrators need to take on this challenge. They need to fix processes and put better management systems in place. That's getting closer to fixing the real root cause of these problems instead of asking families to play the role of “quality inspector.”

I had two angry or defensive comments from nurses.

I'd invite you to visit the post and the comments (including my responses). I'm not blaming the nurses as individuals. If proper hand hygiene does not occur, it's not their fault, it's a system problem.

I think some key questions to ask are:

  • If it's “inexcusable” (in the 2nd nurse's words) for errors to occur, why is “we don't have time” an acceptable excuse for not washing your hands enough?
  • If we don't have time, is that end of story or can we do things to improve the process to free up time and take away the excuse?
  • If management has assigned 8 to 10 patients to a nurse and there's “not enough time” to do things the right way, who notices? Do we have data that shows that an RN can really take care of 8 to 10 patients the right way or was that driven by budgets and leaders who don't know the reality of the work? A 6:1 ratio would cost more in the short-term, but what are the long-term costs in terms of infections and patient care/safety?
I don't claim to know all the answers here. I've worked with nurses enough to know they are caring, wonderful people who WANT to do the right thing. I've done enough work with them in process improvement to know that time CAN be freed up in very simple ways (using the Lean concepts of 5S, kanban, and standardized work for example).
Why is “we don't have time” somehow an acceptable excuse? I can't get my mind off of that thought…
Thoughts? Comments? Like I said, please do read the original post and comments and either add your comment there or here.

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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. As an outsider (other than a possible patient), this is all just appalling.

    Who runs these hospitals? Who allows people to work this way?

    I don’t have time? In the ER clip you shared, the jerk surgeon “didn’t have time” to do the checklist and he was called on it (by a peer). He chose not to make the time. Where is management?

    To these nurses who claim “we don’t have time” how much of their day is spent just chatting at the nurses station and not working? You read about nurses who are poking into celeb patient records or doing naughty things on facebook… where do they have time for that?

    Good grief. Where are the managers in these circuses?

    Does a Toyota worker get to say “I didn’t have time to build a quality car today?”

    These hospitals are often life and death with the infection I could pick up or the errors that could occur. From reading blogs like yours, Mark, and Steven Spears book “Chasing the Rabbit”, it really scares me that hospitals seem like poorly managed organizations. I used to think technical errors were the problem… it just all sounds like bad management.

    I guess, as a student of Deming, that shouldn’t be surprising.

    I will go pray now that I don’t get seriously ill or hurt, requiring a hospital trip.


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