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. Daniel says:

    Did the hand washing improve the hospital’s effectiveness?

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  2. 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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  3. 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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  4. 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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  5. 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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  6. 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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  7. 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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  8. 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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