On Twitter last week, Tom Peters wrote:
This is the wrong premise – it's not that doctors (and nurses, for that matter) aren't smart or that they haven't been taught that hand hygiene is important. The right question should be why don't they wash their hands consistently enough? Why do so many patients get infections that are, as Atul Gawande said Thursday night in Cambridge, are predominantly caused by hand hygiene problems?Recently, I got an email from Barbara, who told me about a well-intended website from Kimberly-Clark – “HAI Watch News.” There's a lot of good information there.
But there's a video that bothers me, since I don't like the practice of hospitals pressuring patients and families to nag the medical providers to properly wash their hands or use hand sanitizer when they enter the room. I've written about this before (“Why Do Hospitals Have to Rely on Vigilant Patients and Families?“).
The video starts with a silly staged type moment with the doctor who is the CDC host of the video turns from the sink as if to say, “Oh, hi, you caught me washing my hands….”
He tells us that there are more than 1 million infections in hospitals each year…. He reminds (lectures?) the viewers:
“Make sure everyone who touches you, including your doctor, cleanses their hands too.” … “you'll see how easy it is to get involved…”
The next speaker in the video adds:
“[They] know… but sometimes they forget… you can remind them…
You shouldn't feel embarrassed…. they really want to do all they can to prevent you from getting an infection.”
Everything they can do except always washing their hands. Do people forget? Yes, we're human, we forget. That's why, in the Lean philosophy, we design systems that are error proofed, so it's harder for people to forget. That's why hospitals (well, 20% in the U.S.) use surgical checklists so steps aren't forgotten. One hospital did an experiment with error proofing handwashing – ensuring that, except in an emergency, that you have to wash your hands before the tollgate goes up to enter the room (video can be seen here or go here for an interview with the creator of this device).
Why are hand hygiene compliance rates sometimes only 50% or even less? Again, it's not that MDs are dumb. It's not that nurses don't care. If there's “no time” (a common excuse), what's the root cause of not having enough time? Can we eliminate waste to free up time to do the job the right way? If clinicians get distracted, what can we do to reduce distractions? I wrote about this here (“Revisiting Handwashing, Time, Systems, and Blame“).
Back to the video — after the intro, we see some dramatizations of what might happen. At least the acting isn't as bad as some industrial films I've seen.
An MD is asked to wash her hands, and the MD responds “Oh, I washed right before I came in the room.” The woman who is looking after the patient asks her to do it again “in front of me.”
“Sure, no problem,” smiles the MD. OK, that COULD happen. Hooray for the patient standing up for their safety.
The video ends without training you on this: How should you react if a doctor or nurse reacts badly? That's a possibility right? This WHO study (PDF file) found that 31% of surveyed patients (in a small sample of 80) said the doctor got “angry” and 9% refused to wash their hands. Seems that this is the situation to train people for…
I've seen “Crew Resource Management” training for hospital staff (by LifeWings), where techs and nurses are taught how to speak up and express concern to someone with more power – for example, a surgeon. A patient is in a similar low-power position. Patients are often afraid of angering a physician. Even if doctors wear buttons that say “Ask Me,” one hospital I worked with did a patient survey and found that a majority of patients were still afraid to speak up.
Overcoming fears of insulting staff can be a chief challenge, especially among elderly patients, said Dr. Woodruff English, the epidemiologist at St. Vincent's.
“It's a generational thing. We all have our cultural values and the older population is generally respectful of rules and authority,” he said.
McGuckin's research shows that 80 percent of patients will speak up if they're invited, and that when they do, hygiene can improve by as much as 56 percent within weeks. How health-care workers react when they're reminded about hand hygiene is crucial.
The model from LifeWings should probably be taught in the CDC video. From my recollection of the training, they would teach the patient this four part approach:
“Dr. Smith, I am concerned that I didn't see you wash your hands. Would you please wash them in front of me?”
- Address them by their name
- Say “I am concerned” (a statement of fact)
- State why you are concerned
- Make a recommendation for them to follow (although, here, I have the patient asking more so than recommending)
How about some training for what happens if the doctor glares at you or growls at you or refuses? THAT would be good education to provide, don't you think? The video says “they don't mind” being asked — but what if they do?
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