One the challenges in making operations run right is actually getting people to follow the “official” process. Our students sometimes have trouble appreciating that even though a large number of them have never managed to fill out an expense form correctly. Often, the issue is that what is the official process is rather ill-defined or subject to interpretation or seems to be filled with pointless minutia. What is a little more surprising is that dedicated, conscientious workers might ignore the proper process even when the basic process is pretty simple with clear benefits. Take doctors and nurses washing their hands at a hospital. That seems pretty basic. But NPR reports that compliance rates for hand washing are typically on the order of 40% (Catching Hospital Workers Dirty-Handed, Jan 31). Enter a high tech solution:
The standard protocol in hospitals is for doctors and nurses to wash their hands on the way in to see a patient, and on the way out. But that doesn’t always happen — they get busy; they forget. In fact, studies show that only about 40 percent of health care workers in the United States wash their hands as often as they should. So some hospitals are trying to monitor just how regularly their employees are washing up — by testing out new surveillance technologies.
[Lindsey Ann Stone, a nurse at Baptist Princeton Hospital in Birmingham, Ala.] says she washes her hands a lot; she guesses at least 100 times a day. But her hospital’s administrators aren’t guessing — they have installed new devices to keep track. With information transmitted wirelessly through a special badge Stone wears, the hospital can tell when she entered a patient’s room, whether she washed her hands and whether she washed again on the way out. The information is sent to hospital officials, including the CEO.
There is an off-putting, Big Brother aspect to this. I can easily see that if you are supposed wash your hands both on the way in and out a room that compliance can easily slip but this seems a heavy-handed way to assure compliance. On the other hand, it is fairly standard practice in manufacturing to have guides or automatic checks in place so that a work piece cannot move on unless it has been properly processed. Philosophically, there is not much difference between that and monitoring hand washing. It seems the real difference is whether you view nurses as professionals and knowledge workers as opposed to wrench-turners on the assembly line. There is also an issue of how the hospital use the information. On the assembly line, not completing the process correctly is as much about training and whether the process is unnecessarily difficult to carry out. The hospital claims that it uses the system to nudge those who fail to comply (as opposed to firing folks). Hopefully, it becomes a way to monitor and remind rather than unduly discipline.
For what its worth, it should be noted that there may be a cheaper way to increase compliance than a full-blown IT monitoring system. UCLA Medical Center apparently has been able to boost hand-washing compliance from 50 to 93% by having undergrad volunteers track staff (How Undergrads Make Doctors Wash Their Hands, Wall Street Journal, Nov 25 2009):
By the time the undergrad program launched about five years ago, UCLA had been trying to improve hand-washing adherence for a while, with mixed results. A program that enlisted nursing staff to conduct peer audits of hand washing led to reports of 100% compliance — despite the fact that “feedback from patients and their family members, as well as from the staff and physicians who had been patients, indicated that not all staff members adhered to the standards.”
About 20 students per year are selected for the undergrad program, and they record 700 to 800 observations per month. They look for compliance with hand-washing guidelines, as well as adherence to rules for giving medication and handing-off a patient for surgery (adherence to those measures have improved sharply as well since the program launched).
I am curious about what drives better performance, an automated system that the CEO may (or may not) be checking or a sophomore with a clipboard and a disparaging smirk.
Finally, one has to note that there is (as with virtually all thing medical) a cultural angle to this. Back in October, the Wall Street Journal had an interview with Peter Pronovost, a Johns Hopkins doctor who is a big proponent of forcing caregivers to stick with established checklists and processes. He had the following observation (As Easy as 1-2-3? Oct 27, 2009):
Can we get the nurses to ensure that the doctors actually follow the items on the checklist? When I said that, you would have thought I was causing World War III. That’s where the culture came into it.
The nurses said, “That’s not my job to police the doctor, and if I do I’m going to get my head bit off.” And the doctors said, “There is no way I can have a nurse second-guess me in public. It will make me look like I don’t know something.”
But nobody was debating the evidence. What they were debating was power and politics and hierarchy.
I pulled everyone together and said, “Would you harm patients?” Everyone said no. Then I said, “Well, how is it possible that you as a nurse would see someone not washing their hands and keep silent? You know they’re increasing the risk of being harmed; we need you to speak up.”
So then we say to the docs, “If the nurses say these things, they need to know that they’re not going to get their head bit off.”
When it was presented as a patient area rather than power or hierarchy, conflict melted away.
This split in the power structure between doctors and nurses is probably relevant at Baptist Princeton, the hospital in the NPR story. I would guess that the nurses wear tags and get tracks while MDs coming in for rounds do not have anyone looking over their shoulder.