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Why Don’t Hospital Employees Wash Their Hands?

+ Kari Kohn

“Wash your hands.” It’s is one of the simplest and most important rules in a hospital, yet compliance is notoriously difficult. Social norms about hand-hygiene lead many medical professionals to wash their hands less often than they should. But as a recent Bloomberg article makes clear, the stakes are high:

In the average U.S. hospital, hand- washing compliance rates vary from just one-third of patient encounters to half at best. And hand hygiene is the single-largest contributor — and the most fixable — to the almost 2 million hospital-acquired infections each year that kill 100,000 people in the U.S.

In addition to the human toll, there are monetary costs. Estimates put the cost of these preventable infections at $30 billion each year. What’s more, new federal rules will not allow hospitals to receive Medicare funding for preventable infections. The cost-benefit calculation seems obvious, but the inefficient social norms persist. The New York Times writes:


Technological solutions offer one way to shift norms through more effective enforcement of the rule. Remote video auditingwritstband monitors, and badge tracking systems are among many of the solutions marketed to hospitals. None are perfect and the inefficient equilibrium norm remains difficult to change. The NYT quotes Dr. Elain Larson, a professor in Columbia University’s school of nursing who has made a career out of studying hand-washing:

“People learn to game the system,” she said. “There was one system where the monitoring was waist high, and they learned to crawl under that. Or there are people who will swipe their badges and turn on the water, but not wash their hands. It’s just amazing.”

These are more extreme examples. But as a 2011 article from American Medical News suggests, it’s not always about bad actors:

“Ninety-nine point nine percent of health care workers are not devious. They’re just incredibly busy.”

And in the NYT:

Philip Liang…attributes low compliance to “high cognitive load.”“Nurses have to remember hundreds — thousands — of procedures,” Mr. Liang said. “Take out the catheter; change four medications. It’s really easy to forget the basic tasks. You’re really concentrating on what’s difficult, not on what’s simple.”

Other solutions are more rules-based or education-based. They include issuing red cards (like soccer) for offenders, “infection coaches,” “secret shoppers,” buttons with slogans (“Ask me if I’ve washed my hands”), and infection prevention classes for staff.

If hospitals are serious about this issue, one option is for hospitals to create an independent agency within hospitals similar to Hong Kong’s ICAC unit that was used in the 1970s to eliminate a culture of police corruption. An independent unit would be created with employees recruited from outside the hospital staff who would report directly to the top and have a mandate for education, monitoring, and enforcement. A multi-pronged approach will be necessary to improve the norms of medical professionals when it comes to hand-hygiene.

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