Read the title above, again, please. It sounds like something we’d have told our kids as soon as they could understand basic language and then later played their first team sports – soccer, baseball, football. But those two simple messages are not being either effectively communicated or understood in many levels throughout our healthcare system. The results are unnecessary harm, complications and fatalities – all shocking and unacceptable in light of our national, economic and physical health not to mention the value we put on life and safety.
Within the past few weeks, I’ve read two articles in the New York Times dealing with the harm infections cause by healthcare workers’, including physicians, nurses and other staff members, failing to repetitively and habitually wash their hands. One estimate is that “it is rare to find a hospital that has been able to keep the hand washing rate above 50 percent.” According to the same article, 2 million hospital infections occur every year affecting roughly one in 20 patients leading to 100,000 fatalities. The cost to our healthcare system is estimated to be between $30 and $40 billion per year. A few days later, I read New York Times article entitled, “Physician Heel Thy Self.” It explained how unprofessional team behavior – sometimes blatant bullying, sometimes subtler actions (failing to return calls, unwillingness to answer questions, condescending and sarcastic interactions) – can likewise cause complications as well as fatalities. This story suggests that such conduct may be contributing to a rise in avoidable medical errors which, in total, may be causing potentially 200,000 deaths a year. Add the two estimates together and the point is that such improper practices and conduct may be contributing in some measure to 300,000 needless deaths per year.
These issues are not new; in healthcare, both have been the focus of major professional and academic studies. Both are caused by a culture that needs to be changed. The primary focus needs to be to prevent, rather than just detect or correct, harmful behaviors through “ritualized” standards of conduct.
As to bullying and uncivil behavior, there are interventions for physicians and others, complaint processes, administrative procedures and penalties. Those can be useful but, largely, they’re directed at addressing problems after they’ve needlessly occurred. Likewise new technologies are being developed to determine whether individual healthcare workers, including physicians and nurses, washed their hands after visiting patient’s rooms and other treatment areas. The cost of such devices is currently estimated at $1,500 – $2,000 per patient bed. This equipment may be useful but surely there must be some more basic behavioral changes put in place first, as the author also notes.
In my view, the most cost-effective and long-term fix is to address healthcare culture which in essence says, by tolerance rather than direct statement, it’s ok not to wash your hands, and it’s ok [at least in some circumstances and for some leaders] to bully others. If both practices were seen as direct threats to patient care and the cause of massive wasteful costs, they’d be addressed. So why is dealing with them so difficult? My answer is that for too long these forms of behavior have become accepted practices unconnected to their impact. Physicians and others learn on the job; they watch their leaders act and they absorb habits the same way they learn clinical skills. In the words of medical education, they “see it, do it, teach it.” That’s the way we learn most of our workplace lessons and pass them on to others.
Ultimately, the vision should be that hand washing and professional, civil behavior are routine, intuitive, and natural with breaches being a rare, unacceptable deviation rather than a fairly routine and pervasive problem. In other areas of healthcare, it’s obvious that “behavioral” protocols are strictly followed as a matter of habit. For example, it’s impossible to imagine that an operation could get underway without the team scrubbing in and donning masks and gowns. Likewise, it’s beyond belief to imagine a transfusion being administered without a process being followed to make sure that the right blood is being delivered to the patient. Both, by the way, are governed by the kinds of “checklists” that originate as process and evolve to become routine ways of performing to minimize risk and errors. If the steps aren’t followed, something “feels” wrong and it’s time to stop and regroup.
Workplace conduct and hand washing need to move in this way. Technological changes and reactive disciplinary systems may be necessary but they are costly, burdensome and should be a second line of defense.
Here’s my prescription:
- Set clear standards of conduct regarding team behavior and hand washing practices
- Make sure leaders adhere to these standards and regularly remind others to follow them
- Leaders need to step in immediately when they deviate from these standards and explain that failure to act in line with standards is a form of technical deficiency – if abusive behavior or failure to wash hands routinely causes harm, as both do, that’s what failure to follow basic standards is.
- Finally, patients, their family members and staff should be encouraged to speak up when they see healthcare workers failing to wash their hands when they treat them. There needs to be a campaign to encourage them to ask this question before they are treated or examined: “Excuse me, when I was admitted, I was told to ask you — did you wash your hands?” This sounds basic but it would have a quick impact on daily practice, especially if a failure to do so or a failure to answer were reported to institutional representatives. Similarly, when witnessing improper behavior, other team members should be taught and encouraged to speak up about, and if necessary, report offending parties.
- As to hand washing and conduct, we need, then, to hold those accountable for their conduct.
After all, it’s a matter of life and death.
