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?“).
Watch this video from the site (done by the CDC) and let's see if we see it the same way. It's a video designed to be shown to patients and families on admission – has anyone ever been shown this?
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.
This article puts the “afraid to speak up” number at 20% and says:
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?
What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.
Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.
Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:
If you ask your doctor to wash his hands and they refuse, you need to find another doctor.
Mike, that won’t work if you’re, say, in the emergency department or in Day 1 of a planned 4-day hospital stay. Not necessarily practical to “fire” your doctor.
That’s one reason people are afraid to speak up – if they make the MD mad (you have a 30% chance, that study shows) then they’ll somehow give you worse treatment or care over time.
I don’t think that the patient should have to be the final stopgap to make sure that doctors have washed their hands. We need to continue to push for mistake-proof solutions.
On the other hand, I think that you have to remember that you are the customer and you are primarily responsible for your own care. If you are not satisfied with the care you are receiving, you need to make it known and switch doctors, if necessary.
Mike – YES! I agree that it is absolutely dreadful and inexcusable to ask the patients to play the role of process inspector. That’s leadership’s responsibility abdicated to the patient/customer. Very sad.
One issue is respect for process.
I worked in the military aircraft business where we had mechanics who barely graduated from high school who performed highly complex processes flawlessly every single time because they knew that a process error could result in a catastrophic failure.
Skipping steps in healthcare rarely results in an attributable failure and rarer still will it have negative consequences. Providers know this and know what they can get away with.
The second issue is providing time to do things right. This is the system issue. Many providers make constant decisions about how much is enough and when they get behind it is easy to rationalize deviating from standard. Initiatives like TCAB are an obvious response to improve the time available to provide the right amount of care.
Anon – thanks for your comments. You’re spot on that we have to look at freeing up time and eliminating waste. I tried to make that point in this post:
https://www.leanblog.org/2009/04/revisiting-handwashing-time-systems-and/
We can’t just beat up on the docs and nurses for being lazy for not caring. That’s usually not the case at all. We have to put our lean hat on and ask “why?” What are the barriers that prevent proper hand hygiene?
As I mention in my book, one hospital found a simple lack of carts meant that nurses and staff were often carrying linens or such out of room meant their hands/arms were full and they couldn’t stop to gel up. That was one easy barrier to eliminate, much more effective than lecturing people I think.
I think we should be trying any number of methods to get all healthcare workers/providers to have newly-cleaned hands when preparing to touch a patient (and in so many other scenarios). No idea should be tossed on its head without discussion and, if feasible, trial.
Trish – I’m all for experimenting, but I’m curious if we’ve though through all of the likely scenarios. Are any hospitals coaching patients on how to handle it if a doc gets made when they’re asked or requested to wash hands.
Is there evidence that the asking leads to significantly better hand hygiene? I agree that data and reflection should be part of the PDSA cycle.
[…] 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 […]