How Has Dr. Jack Billi Achieved 100% Hand Hygiene Compliance Since 2008?


billiThanks to my friends in the Michigan Quality System group, the internal Lean group at the University of Michigan Health System.

They shared a video that was put together by Dr. Jack Billi, a long-time student of Lean and advocate for Lean healthcare.  You can listen to my podcast with him from 2011.

My contact in the MQS team says the video “is also an excellent example of standard work, PDCA, visual management, and a blame free culture.”   

In the video, Jack talks about his own efforts to achieve 100% hand hygiene compliance when entering and leaving patient exam rooms.

He tried a method that worked… except when it didn't. That's because the method relied on a reminder that was easy to miss. It wasn't perfectly effective mistake proofing.

So, in the spirit of PDSA, he tried something else, but solving one problem created a different problem.

How did he eventually tweak his approach?

See here in the video:

Jack says he has been 100% compliant since 2008. It took him four weeks to experiment and develop a system that works for him.

“Vigilance is not a system,” he says. I agree.

My question would be about how to spread that method to other physicians in his group. Do they do the same thing? Or, do they get the same results through a different method?

How can we move beyond an approach that relies on posters, reminders, “be carefuls,” and such? Doctors and nurses know they are supposed to clean their hands, so it's not an awareness or education issue (but hospitals seem to treat it like an education issue, but more posters don't solve this problem).

Vigilance is not a system, says Dr. Jack Billi, about hand hygiene Share on X

How can we fix the system so we make it easier for people to the right things the right way?

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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. Wonderful, Mark! “Vigilance is not a system” is something for all managers and leaders to inculcate. But wouldn’t it have been so much easier if the medical centre CEO just told Dr. Billi that he (the doctor) was “accountable” for clean hands!

  2. From a friend on Facebook:

    “That’s great for Jack, but how about the other 26,000 people that work at the U? (Especially the ones that aren’t as passionate as Jack about hand washing?) It’s a tough nut to crack at every hospital.”

  3. Another good practice of Dr. Billi’s is his insistence on the “elbow bump” as a way of greeting instead of a handshake… not sure if he does that with patients, but I bet he does. I know he does the elbow bump in other settings.

  4. Interesting headline from the Detroit News about the University of Michigan Health System:

    UM among worst area hospitals on infections

    The University of Michigan and Henry Ford health systems are among nine local hospitals that got poor ratings in a new report that looks at hospital-acquired infections among patients, with UM scoring among the worst

    And my favorite empty-words expression comes up from Henry Ford:

    The safety of our patients is our top priority and we have in place initiatives aimed at reducing infections,” said Dave Olejarz, spokesman for Henry Ford.

    Top priority? I guess not?


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