Cold, Hard Cash as a Handwashing Incentive

Whenever you write a book, it’s interesting to see which parts of it people respond to en masse. With SuperFreakonomics, the global-warming chapter has certainly gotten its fair share of attention, and Levitt noted a lot of feedback about the perils of drunk walking.

But there’s a third strong contender: hand hygiene, or the lack thereof, especially in hospitals. Here’s one fascinating reply from Jeffrey R. Starke, a physician in Houston:

I am in charge of infection control at Texas Children’s Hospital in Houston, the largest children’s hospital in the U.S., and am on the faculty of Baylor College of Medicine. We also had difficulty getting hand hygiene rates where we want them to be. We tried all the usual methods that you mention in the book, and a few others, but had a difficult time getting the rates above 70 percent. (We measure rates by use of a “secret shopper,” an expert in infection control from outside the institution who observes the actual hand hygiene behavior of the workers.)

We decided to use a more direct incentive. Our employees participate in a bonus program called P3. Previously, all the required performance measures were financial. However, we made hand hygiene rates part of the program; employees had to achieve and sustain >96 percent compliance with hand hygiene to get their full bonus. (This is a pooled bonus plan — either everyone gets it or no one gets it.) We did much better, but still not quite good enough until we hit on a second idea: we made the hand-hygiene performance part of the hospital executives’ performance bonus, even though they don’t care for patients. Magically, we have attained and sustained a rate of hand hygiene >98 percent, and won a national award for quality improvement from the Children’s Hospitals Corporation of America. Equally interesting is that the rate of hand hygiene among physicians, who are not hospital employees and do not participate in any performance bonus program, also has a sustained rate >98 percent. I guess this is a positive externality, perhaps pressure from employees on physicians to make everyone look good.

Starke added a note about the general use of statistics in SuperFreak:

It is a real problem in modern society that most folks don’t understand statistics at all, and they are used to scare folks all the time. (Mark Twain was right that there are lies, damned lies, and statistics.) My favorite recent example is the H1N1 influenza virus. I lecture quite a bit about this to both medical and lay groups. My standard beginning is the following: “If I told you that 99.9 percent of people who get the H1N1 influenza will suffer no significant complications, would that make you feel better?” (Almost everyone says, “Yes.”) “If I told you that 1 million people in Houston will get the H1N1 influenza, and 1,000 of them will suffer significant complications, would that make you feel better?” (Almost everyone says, “No.”) Of course, both examples are the same number expressed in different ways. These are difficult concepts for most folks to grasp, and so many “experts” take advantage of this.

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  1. Brian says:

    They’re not the same number. 99.9 percent doesn’t give me a sample size.

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  2. Julianne says:

    The H1N1 examples aren’t exactly the same. The percentage is the same, but the scenario is not. They are only comparable if when considering the first example, you think the contagion rate will be high enough to hit 1 million cases in Houston. That contagion rate is guaranteed in the second example–which would in itself be enough to give me pause.

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  3. Joe says:

    The point is that both are *accurate* statistics if used in describing the same phenomenon. Including the contagion rate is a strategic decision – if you are trying to downplay the risks of H1N1, you would say “99.9% do not suffer complications”. If you’re trying to do the opposite, you’d mention both the 1,000,000 number, and the 1,000 number.

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  4. Bennett says:

    Brian, the percentage is the same in each scenario.

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  5. Dr. Manak says:

    Did the hospital execs cheat? That is the play I would expect coming from the standard CEO playbook.

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  6. Jeffrey Starke says:

    Dr. Manek, there is no cheating. The measurement of hand hygiene is blinded to all hospital workers and administrators, and is performed independently by persons from outside the institution who are unknown to the employees. The data are fed back to everyone. Our administration is very supportive of this, especially after seeing the results.

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  7. William G says:

    I have an idea to encourage hand washing, since financial incentives are on the table:

    When someone successfully washes their hands, a dollar bill is dispensed from the sink, and the person who washed their hands can immediately take it.

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  8. di says:

    Right up there with telling you something increases breast cancer rates by 30%. That means from 10% lifetime risk to 13%, if you live to be 90 years old, but saying 30% makes it sound more threatening.

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  9. Joey says:

    Hopefully you’re familiar with — it’s hard to achieve hygiene success when regulatory groups actively fight against it.

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  10. Cmor says:

    @ #7…with what’s found on a dollar bill, that would actually defeat the purpose.

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  11. Brad says:

    William G: How filthy is the dollar bill? :)

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  12. Leland Witter says:

    William G (#7) – That dollar bill had better be disinfected, since paper money is (widely presumed to be) filthy with “germs”.

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  13. Mark S. says:

    “I have an idea to encourage hand washing, since financial incentives are on the table:

    When someone successfully washes their hands, a dollar bill is dispensed from the sink, and the person who washed their hands can immediately take it.”

    Coins would be better, they are easier to sterilize w/o destroying them. Someone even found that the high nickel content euro coins are very nearly sterile in every day use.

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  14. John says:

    “A judicious man looks on statistics not to get knowledge, but to save himself from having ignorance foisted on him.” Thomas Carlyle

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  15. ww3 says:

    Now if only you could apply the concept to restaurants, there would be a lot less food borne illnesses….

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  16. Sally says:

    Number 7 is quite funny. You are giving them the dirtiest thing I can think of as a reward for washing up.

    I face palmed.

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  17. Daniel says:

    Did the hand washing improve the hospital’s effectiveness?

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  18. Gary says:

    The problem with the H1N1 example is that the numbers express the situation as a positive (99.9% are Ok) and a negative (1000 suffer significant complications). It’s not just a misunderstanding of the numbers that’s causing the the differing responses of concern; it’s the sign. It would be interesting to do an experiment to see how much ignorance of statistics and phraseology each contribute to the response.

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  19. sinyc says:

    man who washes hands after passing (sterile!) urine may be touching a tap touched by faeces contaminated finger of previous toilet user.

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  20. mannyv says:

    In almost every case, making executives part of the incentive program is the path to success. Maybe we can incentivize our elected leaders at all levels the same way?

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  21. Mike M says:

    Put the hospital executives pay on the line and magically the compliance rate is >98% even with physicians not in the program? Sounds like cheating.

    Put a sign in each patients room. “If the doctor doesn’t wash his/her hands upon entering inform the billing department for a $100 reward.” Then just fine the doc $100. If you’re afraid of too many false positives attach a time stamp machine to the soap dispenser.

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  22. Christopher Strom says:

    Culture, attitudes, and priorities in a workplace are driven from the top. Unfortunately, most people in executive positions believe they can effect changes in their subordinates’ behavior without altering their own, and they are almost always puzzled by the resulting failure of their efforts. So I find the significant improvements when executive bonuses were tied to handwashing to be unsurprising.

    I have spent most of my career in manufacturing process improvement, and I find that getting leadership to truly embrace (and engage in) the changes they desire is the most difficult challenge in process improvement. Often it feels like an exercise in “belling the cat.”

    I offer my congratulations on getting buy-in from the executives. I am sure that it was quite a challenge to convince executives to risk some of their money on someone else’s behavior.

    “Give me a lever long enough and a place to stand and I can move the Earth” – Archimedes

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  23. matt says:

    ‘it turns out humans’ innate skill with numbers isn’t much better than that of rats and dolphins. “we are systematically slower to compute, say, 4+5 than 2+3,” writes Dehaene. And just as animals have to slow down and think to discriminate between close quantities such as 7 and 8, “it takes us longer to decide that 9 is larger than 8 than to make the same decision for 9 versus 2.” Of course humans also have the capacity to move beyond this stage, but the struggle every schoolchild has learning the multiplication tables is a reminder of the natural grasp of numbers,” writes Dehaene, “and it takes considerable effort to become numerate.”-Stanislas Dehaene

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  24. JohnJay60 says:

    The secret shoppers are hired by management – who are incented to received a good number.

    But actually I’m wondering about the statistics behind using a secret-shopper approach to compliance. To consistently obtain a number capable of distinguishing 96% from 98%, on a Doctor by Doctor basis, requires an astounding amount of sampling and the secret shopper could no longer be secret when making so many observations.

    The entire premise at this Hospital for measuring compliance seems flawed, although the article is about the downstream compensation for such compliance.

    Why not have a system, like night watchmen use in making the rounds, that require Doctors to periodically clean their hands by inserting them in a disinfecting unit that recognizes their unique code from an RFID tag on their badge?

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  25. Steve says:

    In the 99.9% case, most people have a prior that < 50% escape without significant complications. Now you tell them to revise that upward to 99.9%–that’s good. In the 1 million people case, most people have a prior that the virus will not effect that many people in the city. So it’s bad news–tons more people are getting sick! People don’t work out what they now expect the total number of complications to be, but it’s probably gone up so feeling down makes sense. It’s just not a good example. It does expose a psychological bias but its not a great demonstration because its so hard to understand it.

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  26. Avi says:

    I’m wondering HOW the executives got that high a compliance rate. What did they do to change everyone else’s behavior? Did they lurk in bathrooms or check hands randomly?

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  27. Mark S. says:

    #15: food borne illnesses come from our agri-business risk management procedures (or lack thereof). Hemorrhagic E.coli is not native to beef cattle. It enters the food chain in corn feed lots and stays in the food chain in industrial slaughter houses. Of course if you like sushi you may want to reconsider eating at a place where the sushi chef is coughing and wheezing in his sleeve.

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  28. Mark S. says:

    “Put a sign in each patients room. “If the doctor doesn’t wash his/her hands upon entering inform the billing department for a $100 reward.” Then just fine the doc $100. If you’re afraid of too many false positives attach a time stamp machine to the soap dispenser.”

    Better yet, use soap with a purple non-toxic dye in it. If your doctor’s hands don’t have a purple tinge, beware.

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  29. alex says:

    “Why not have a system, like night watchmen use in making the rounds, that require Doctors to periodically clean their hands by inserting them in a disinfecting unit that recognizes their unique code from an RFID tag on their badge?”

    Patient in cardiac arrest in room 412! Let me in!
    Error: Hands not washed. Please wash hands and try again.

    More seriously, the ridiculousness of these proposals is limited to the amount of arm twisting the executives can do to the doctors. At Big Academic Medical Center where doctors are interchangeable parts they do a lot. At the places where the other 90% of health care happens (i.e., the community), things like “We’re hiring fake patients to report on you to us” tend to result in “I’ll be admitting all my patients to the hospital across town from now on”.

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  30. Darren Carpenter says:

    #21 – I think your idea to improve the success rate would be effective, but would create unwanted consequences. I also doubt that there would be the same “by-product type” success found in the bonus compensation program. The bonus program creates a common goal amongst docs/employees/execs. This reinforces a team mentality and builds moral. The “fine per non-compliance program” would not builld positive moral; quite the opposite I suppose.

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  31. Christopher Strom says:

    @ Avi (#26)

    Hospital administrators’ bonuses are a very significant part of their compensation. If that is at risk over handwashing compliance of their staff, and if the compliance is being judged by a neutral third party, they will bring an enormous pressure to bear on their staff in the form of additional training, frequent reminders, possibly a reward system, and the threat of disciplinary action (including termination) for non-compliance.

    To ensure that handwashing behavior is actually changing, a clever administrator would set up his own “secret shopper” system – and not informing the staff – relying on trusted staff members (toadies are everywhere) to monitor compliance ahead of the outside monitor.

    If an administrator is asked to improve his staff’s handwashing compliance, he will issue a memo and have someone buy some posters. Link tens of thousands of dollars of his compensation to his staff’s compliance, and he will see the job done.

    Put another way – People don’t change because they see the light. They change because they feel the heat.

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  32. Mike says:

    This may sound odd, but isn’t washing hands in a hospital seem quite…..manual? I will be in airports this week, and will use hands-free machines to get automatic paper-towel dispensers and newly-installed Dyson “blade” hand driers.

    Extend this concept, with significant upgrades, to the hospitals. I expect it is simply a matter of time before someone creates, and commercializes, a low-effort hand sanitation system which immediately cleans hands, and perhaps is even integrated with a medical workflow capability which would monitor physician hand cleanliness and link into carrots (bonuses) or sticks (some externally-visible penalty).

    Pilots use a stop watch to monitor de-icing efficacy. Public restrooms are investing in hands-free systems (rudimentary though they may be). This whole issue will likely undergo significant innovation. It is ripe for it.

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  33. Tarak says:

    The key question is does going from 96% to 99% make the hospital safer or more dangerous? In making every physician, nures, aide, food worker, janitor… in the hospital wash there hands so much are they taking away from patient care. If a physicain and nurse has to wash there hands 50-100 times per day (mabey even more for the nurses) at 30 sec per wash you are taking away a lot of time from patient care and may delay care at a critical time.

    If the morbidity and mortality outcomes along with the rates of antibitoic resistance do not differ then it is a waste of time and money to achieve such a high percentage. I hope that they can do a follow-up in the next book in comparing patient outcomes at hospitals that are taking these initiatives versus those that do not.

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  34. Chris says:

    Providing the executives and non-treatment employees an incentive to wash their hands helps the doctors wash their hands because you cannot walk out of the restroom without washing your hands if someone else is washing their hands. Shame is a powerful incentive (i.e. late parents to school).

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  35. Jane Farmer says:

    Disallowing the use of paper or coin money in hospitals by employees and replacing all sink knobs with foot controls hospital wide may help. In prisons carrying money is commonly forbidden by both employees and prisoners, so this is not asking too much of people. Hospital issued temporary and permanent free debit cards could be issued for use hospital wide at all vendors and vending machines. Placing these ATM like conversion machines near all hospital entrances to add money (and remove money when leaving) would promote this policy. Hand sanitizers and face mask dispensers located near these machines, as well as being placed copiously throughout the facility, could be helpful as well. Debit cards could be made disposable or require reactivation every 24 hours whereby the machines could sanitize the cards in some inexpensive and quick manner. Although this may be a more expensive option, requiring the cards to be inserted to operate sinks and sanitizers in public areas would force employees to use the cards, and would also allow the hospital to track how often hands are being sanitized. A system like this would be expensive, but would eliminate a bonus system apt to become corrupt. –just my 2 (quick and dirty) cents

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  36. Eric M. Jones says:

    How about–wash your hands and keep your job…Video cameras in the bathroom of hospitals and restaurants seems justified.


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  37. Kyle says:

    I recently just got the H1N1 vaccine because I had to. It was a direct order for I am in the military. I am extremely disappointed and mad because I heard no one stand up for the military in regards if we could at least have a choice. There are so many rumors going around and looking at this article they make me skeptical even more that that vaccine does nothing and it will more than likely hurt you then cure you. I need some insight and honesty. Who could I talk to about this to get the point across?

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  38. Debbie says:

    My CEO may be interested in doing something similar. Can you tell me what dollar amount each employee received?

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  39. Colleen says:

    I am an RN and the upper management attitude has everything in the world to do with handwashing habits on the floor. When I was in nursing school handwashing was beaten into our heads with a crowbar! Wash between every patient, every procedure, every time! We did it without questioning. Then we graduate and go to the floor and whoops- it’s the real world! Some of us whet to facilities that are lax- where you see doctors performing aspirations without gloves,medical staff wearing stethoscopes around their necks and the same lab coat all week, only medical staff using gloves- not dietary or housekeeping, and patient ratios that keep you jumping for 12 straight hours. Slowly, the well learned habits from nursing school slip away.
    Tarak makes a great point- proper hygiene takes time. It is not uncommon to have several patients with hygiene standards- N95 respirator, gown and gloves for patients with TB, full body gown and gloves and mask for MRSA or VRE, positive pressure rooms with double entry- all adds time to your careplan. If you work in a facility that fights you and considers that all “lost time” you learn to cut corners.
    And Joey- luckily, in when the FDA heard about the problems with the checklist they overturned the decision!

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  40. Colleen says:

    I think the problem with the 99.9% verses 1,000 is that in the real world you never know about the 999,999 that didn’t get sick. Who comes into work and tells everyone “Hey, I didn’t come down with the flu this weekend!” All you hear about is the 1,000 that did.

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  41. Abby says:

    JohnJay60, Mike and others — RFID hand hygiene monitoring devices do exist and come with the additional functionality to offer communications and other compliance monitoring. Health care, especially quality improvement in health care, lag greatly behind other industries. However, the times are changing!

    Another important factor to realize is that the CDC mandates hand hygiene before and after entering a patient room AT A MINIMUM, not to mention other requirements for contact with the patient or certain devices. That’s a lot of handwashing and a lot of potential for corner-cutting. Unfortunately, one missed washing can be deadly for a patient. Did Texas Children’s see any changes in nosocomial infection rates following the improvement? Also did see any changes in visitor hand hygiene compliance?

    I question the accuracy of the secret-shopper type of monitoring but this doesn’t diminish the improvement made by Texas Children’s Hospital. Kudos for involving all levels in the quality improvement effort too!

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  42. Michelle H says:

    Jeffrey Starke,
    Have you discovered any further insight into the increase in the physician’s hand hygiene compliance, in spite of their excemption from the incentive program?

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  43. Deepa says:

    I’m a nurse and I can tell you there are 3 big problems that I see daily with this–

    1. There is constant pressure to do so much so fast that taking the time to wash your hands is sometimes frowned upon. Literally, your boss will frown at you, because she perceives you are wasting time at the sink. Money is more important than quality of care. This is what is addressed by giving executives bonuses, so that handwashing can be encouraged all down the line rather than seen as a waste. Nobody sees it as a waste before going into an operating room, but before going into a patient’s room they do.

    2. There are lots of soap dispensers out of soap, sinks where the water isn’t working, and paper towel dispensers either out of paper towels, or jammed so full of them that it’s really difficult and time-consuming to get one out.

    3. Lots of hospitals are encouraging people to use alcohol hand rub instead because it is quicker. They justify this by saying that a hand that has just been rubbed with alcohol can be cultured, and fewer bacteria grow out than from a hand that has just been washed. But this ignores the fact that you are always touching things and picking up new bacteria on the hand. It’s better to wash off any you’ve recently collected and leave your normal flora than to kill off as much of your normal flora as possible and then pick up some MRSA from the outside of an IV bag or whatever you happen to touch in caring for the patient.

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