Mark Graban's leanblog.org - Lean Healthcare, Lean Hospitals, Healthcare Kaizen, Lean Thinking, Lean Manufacturing, Toyota Production System

My Anti-Handwashing-Poster Poster

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Hospital acquired infections continue to be a big problem, one that's often unsolved except for instances like Dr. Rick Shannon's work at West Penn-Allegheny and UPenn and the “checklists” approach used at a number of hospitals around the world.

One approach to infection prevention has been a focus on medical professionals using proper hand hygiene techniques… often done through endless education campaigns and tons of posters. Is the root cause of this problem really lack of education?

I'd propose that if signs and posters were really the solution, then hospitals would have solved hand hygiene and HAI's already. Yet this is still the approach that's often pushed – more signs and more posters, including clever ones or cute ones like this.

There is a good blog and website that I've written about before called HAI Watch. They have a new online community that you can sign up for to discuss these problems and to talk about potential solutions. It's one thing to say it's unacceptable to have infections “on my watch” (as a medical professional), but as Dr. Deming would have asked, “by what method?”

But one feature of the site that I sort of cringed at is the “make your own poster” feature. This might be well intended, but may be ineffective.

Since I have a bit of a subversive streak, I made this “anti-poster poster” that talks about how posters might not really be the right countermeasure… given the chance, this is the poster I'd hang in hospitals:

infection poster anti-poster not on our watch

The link mentioned in the poster is here.

What do you think? Would an anti-poster poster be just as effective as the signs that are normally posted?

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

18 Comments
  1. Michael Lombard
    Michael Lombard says

    Since I began working in healthcare, I’ve definitely noticed an over-reliance on “educational pieces” including training, posters, memos, etc. as countermeasures to poor quality. It’s almost a conditioned response. Instead of asking why and getting to the root cause, we quickly move to address a surface cause with education. Training, posters, memos, etc. are great, but they’re on the extremely weak end of the mistake-proofing spectrum.

    1. Ron K (PT Wonk) says

      I agree. The bedside staff are overloaded with posters, memos, etc. throughout the hospital units. Physically and functionally we could not make it easier for staff to consistently wash their hands. But everyone would admit to occasional lapses – we sometimes have our focus elsewhere.

      Behaviorally, I have seen some staff report their lapse, primarily because it was a patient that noticed it and said “Don’t touch me until you wash your hands!”… but of course, this is shaming to the staff member. Far too many staff interact with the patient in isolation, so there is no other staff member to notice the lapse and gently remind staff to wash or sanitize their hands.

      The most successful campaign I have heard about is a “foam in/foam out” campaign where staff use the hand sanitizer INSIDE the patient’s room before going to the patient’s bedside (so the patient can see the staff do it) and OUTSIDE the patient’s room so other staff can see the staff member do it.

      I think it was in Daniel Pink’s book “Drive” a reference to a study where compliance with dropping a quarter in a jar for coffee in the break room was improved by simply putting up a picture of person that appeared to be looking down at the jar. We are all driven to abide by cultural norms when we know that we are accepted by the culture but also surrounded by it.

      Ron

      1. Mark Graban says

        Ron – Yeah, shaming people isn’t the right way to go. As for patients speaking up, one hospital I worked with years ago did their own survey of patients that showed many patients were afraid to speak up for a number of reasons.

  2. Leslie says

    More handwashing/sanitizer stations in more locations work better than a poster. Making it easy to wash your hands (there should always be a place to clean your hands within sight) is a better motivator than a cheesy tagline on a poster.

    1. Mark Graban says

      Agree with you Leslie, on making it physically easy for people (dispensers everywhere and making sure they’re not empty) but also making sure people aren’t in a hectic environment where it’s too easy to forget to follow hygiene standards. This is a TOUGH nut to crack, or it would have already been solved.

  3. Corey says

    The purpose of the poster is to be an obvious signal that management “did something” about the problem. The real problem, as usual, is poor alignment of the interests of the stakeholders.

    1. Mark Graban says

      Yeah, maybe the posters are just a way to “look good” to visitors and public who might buy the line that posters are a solution??

      1. Corey says

        As a Quality guy, I’d run screaming from the building if I ever saw a poster for basic hygiene hanging on a hospital wall, but I can see how an under-trained manager might see a public relations benefit.

        But I don’t think that’s the motive. I think it’s about plausible deniability and deflecting responsibility back toward the staff without providing any support to act on that responsibility.

  4. Brian Buck says

    Even worse than a poster…”Let’s write a new policy and put it on the SharePoint and tell people to read and follow it”. I wish this was a made up “counter-measure” and not something I have heard discussed before (more than once).

    Ever since I read your outstanding book, I have been trying to spread the message that warning or reminder posters indicate the root cause has not been addressed. Despite the pure logic of this statement, people in hospitals do not usually quickly agree with me!

    1. Mark Graban says

      How do they make the argument that the signs and posters are working or that they are effective? They might argue that the signs are better than nothing? Is that even true?

      1. Brian Buck says

        I am usually told posters keep the issue in front of people to help them stay focused on the change. People are quick to say posters are not the ONLY counter-measure because there is usually training and discussions in meetings which means the posters are a reinforcement. Kind of a “better than nothing argument”.

        I think part of this mentality is old thinking because the normal series of; conduct training, discuss in meetings, put up posters, then move on to the next thing is a pretty common approach in hospitals. Even a hospital on a lean journey may be in this pattern still if the management hasn’t changed yet (leaders using lean terms or wanting lean outcomes for their projects doesn’t always mean they have changed).

  5. Michael Lombard
    Michael Lombard says

    Oh Brian, you understand my dilemma! Policies or posters…which is a more superficial countermeasure?

    Mark, I don’t think they’re analyzing the countermeasure for effectiveness. I think it is just assumed that education is virtuous, therefore anything educational is unquestionably good. Posters, PowerPoints, whatever.

  6. Andrew Cahoon says

    Deming said “Eliminate numerical goals, posters, slogans for the workforce, asking for new levels of productivity without providing methods.”

  7. Jeff Hajek says

    How about a poka yoke in the restroom so the door won’t open until the soap dispenser is pushed?

    Or a big buzzer outside the door with a ‘Contamination’ light that flashes if the soap is not used.

    I’m only half kidding…

  8. Richard Chapman says

    No Jeff, that’s not a bad idea at all. Since washing hands is business-critical, you should not be able to leave the washroom or enter the sensitive areas without it. the ICU at the hospital near me has the dispenser on the door, and (admittedly a sign) that you must open the door with your elbows.

    I think Mark is making the point though about the root cause, and lack of habit. The root cause may be occupational stress.

    If staff ‘feel’ too busy to wash their hands – then we have muri ie they are too busy. If they don’t form the habit, then they haven’t been shown EXACTLY how to do their jobs, only told, or assumed to know. Neither are Lean.

    But certainly a ‘bathroom’ process that is foolproof is what is required. This may sound like Lean = trivial again but in hospital it is critical.

    I don’t object to patients putting the evil glare on staff who don’t wash hands. They are customers = Lean 101 = what they value and it is also a form of ‘pull’.

  9. […] I’ve written about before (“My Anti-Handwashing-Poster Poster“), these signs might be well intended, but I think they miss the point. If signs and […]

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