Surf and Turf
All-day seminars are often hailed in infomercials as a way to change behavior. But KUNC commentator Dr. Marc Ringel says things like that aren’t enough. For a real breakthrough, we need easy-to-stick-to systems. Although a little bribery to sweeten the deal doesn't hurt...
“Okay. But you’ll have to serve steak and lobster.” That was my response to a request to put on a conference for the medical staff at a hospital where I worked years ago. The Joint Commission on Accreditation, in whose good graces it is imperative every hospital stay, had recently cited ours for poor hand hygiene on the part of the professional staff, especially of the physicians.
So the director of clinical services asked me, director of continuing medical education, to organize a meeting for the doctors on hand washing. I knew there was no way any of my colleagues would attend a presentation on this uninspiring topic unless we offered a gourmet meal to go with it, which is why I asked for surf and turf.
Needless to say, we didn’t hold that meeting. And even if we had, it wouldn’t have done much good. Anyone involved in adult education understands how small is the likelihood that a single hour-long conference will actually alter anyone’s behavior.
So, how do you get people to change? There is a wonderful Gary Larson cartoon that I sometimes use when I give talks about principles of professional education. It shows a hapless guy walking out of a restaurant men’s room. All customer heads are turned toward a sign over the bathroom door that’s flashing “DIDN’T WASH HANDS.” I imagine there’s a buzzer or siren sounding too.
Ridicule and shame are not how you get people to behave better. Education alone is usually not enough either. You need systems.
For example, at my family practice it wasn’t until we put a good flow sheet in every diabetic’s chart on which we recorded foot exams, kidney function, cholesterol, etc., as a reminder to check these items, that we actually improved our adherence to the care standards we all had learned to recite. Something as simple as a single printed sheet of paper, if well conceived and implemented, can be the cornerstone of an effective system.
Gathering and tabulating data from the flow sheets of each practitioner’s diabetic patients and regularly letting us know how we were doing tilted the quality graph of our diabetes care further upward. Which illustrates two other basic principles of adult behavior change, measurement and feedback.
Back to hand washing. Every health care worker knows they should wash their hands before and after every patient encounter. Yet for years professionals’ national rate for cleaning their hands when seeing patients has been around 40 to 50 percent.
Last year my Alma mater, the University of Illinois Medical Center in Chicago, decided to address this problem by installing a system that detects hand washing, provides immediate feedback, and accumulates data about this behavior. It’s called HyGreen, developed by a Florida company, Xhale (spelled with a capital “X”). The technology, originally designed to detect alcohol on people’s breath, is sensitive to alcohol in the hand cleansers and soap that are dispensed in every patient room.
If a person steps within a seven-foot zone of a sensor positioned at the head of a patient’s bed the gizmo detects any trace of alcohol evaporating from freshly cleaned hands. If no alcohol is detected the device sends out a signal that will set the ID badge vibrating if it’s a staff member at the bedside. The vibration is an immediate hand-washing reminder.
If the person doesn’t leave the detection perimeter within ten seconds, presumably to attend to hand hygiene, a negative event is recorded. Three unheeded buzzes and an email message is automatically sent to the hospital’s infection control committee, which has an official, escalating set of warnings and sanctions for dirty-handed scofflaws.
In the 22-bed intensive care unit where the HyGreen system has been piloted, hand-washing compliance has increased from 67% to well over 90%.
Given that unclean hands are a major contributor to the 1.7 million infections acquired in hospitals every year, this new system is hugely good news…to everybody except those who are still holding out for steak and lobster.