(original article - Medscape : http://boards.medscape.com/forums?128@659.WQ45aiaDlWk@.29f8f873!comment=1
by Leslie Kane, Other, 10:10AM Jan 14, 2010
Hospitals and healthcare organizations have made it a major goal to get physicians (and other health workers) to wash their hands more frequently, in order to prevent cross-contamination. While there are pockets of success, most efforts have been as useful as warning teenagers to put down the cell phone while driving.
Despite conveniently-placed sinks, admonishing signs, and rewards such as free movie tickets for best compliance, doctors still wash their hands as little as one-third to one-half times as often as they should, said Atul Gawande, MD, surgeon at Brigham Women's Hospital in Boston, in a New Yorker magazine article.
To promote hand washing, most health organizations use educational tactics, but the campaigns aren't working. Some executives say nothing will change unless non-compliance brings penalties. So the tactics are escalating.
Several tactics are being tested, sometimes together.
Interestingly, they hinge on different views of human nature. The positive approaches (education, rewards) assume that doctors will do what's right if they learn why it's important; the avoidance approach (penalties, fines) assume that people won't change a comfortable behavior (especially one that crops up all day long) unless they're trying to avoid a Skinnerian shock of electricity; the neutral approach (system) bypasses motivation and instead seeks to change the environment so that hand washing is unthinkingly routine.
In escalating order of punitiveness, here are some of the current options being used, and I'm sure there are many others.
1) More education and motivation, such as reminders, announcements, signage. This does help improve the situation, but in most cases it doesn't seem to get the compliance percentages where they need to be.
2) Rewards and incentives. Give unit heads performance goals and bonuses to improve the hand washing rate in their units. This is the time-tested (and typically effective) route to compliance among most corporations. Or, offer rewards to individuals who show improvement.
3) Systemic approaches, such as checklists and technology. Unfortunately, checklists aren't quite appropriate for an activity performed dozens (or many more) times each day, often on the run. Several systemic changes have been implemented to promote hand washing, with mixed success.
4) Harness peer pressure. Martin Kane, MD, from Altamonte Springs, FL (full disclosure = my brother) suggested using an automatic sink faucet that emits a tone or a light goes on when washing commences and stays on for the recommended hand washing time. If a doctor leaves the sink before the light or tone stops, it would be obvious to passersby, and peer pressure would promote more extensive hand washing.
5) Enlist staff members as whistleblowers. Some hospitals already ask the infection control staff to report doctors who don't wash when appropriate. Another suggestion is to have a phone number for anonymous tipsters to use. The notion of snitching in pursuit of the greater good has evoked anger from some people.
6) Caught on camera! Robert Wachter, MD, professor and associate chairman at the University of California San Francisco Medical Center, and a leader in patient safety and healthcare quality, once suggested the use of video monitoring, and the idea has gained momentum. Arrowsight Medical, Mt. Kisco, NY, a company that does video monitoring and feedback for various industries, ran a pilot program in a Georgia surgical center and saw hand washing increase from 30 percent to 90 percent.
Still, in our new YouTube culture where almost any video could end up on the web, this idea makes folks shudder.
7) Penalize the offenders. Let's say the non-hand-washers can be identified and they make only cursory efforts to wash more frequently. What's an appropriate penalty?
In some hospitals and health organizations, repeat culprits are called in for a chat with the head of the medical staff or the hospital CEO. (Some doctors are undaunted, others say it's like being called to the principal's office and they're not happy about it).
As far as actual penalties, if hospital officials feel a doctor is truly endangering patients, they want to take some action. Still, the situation is so widespread, might there be too many fish caught in the net? Also, I can't see a hospital - at least one that competes for doctors' services - creating such bad will with its physicians.
Not all doctors are convinced that the focus on hand washing is necessary. One physician recently told me that this is just another annoying thing that doctors are being pummeled for, and the link between hand washing and most nosocomial infections is not as strong as many would have us believe.
--
Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre
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