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. 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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  2. 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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  3. 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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