The Hawthorne Effect at Work

By Kelly Teal

The medical field has known for almost 200 years that disinfecting hands saves lives by reducing the ability to carry disease. But even in 2016, global hand hygiene compliance remains shockingly low. At any given time, the World Health Organization (WHO) notes the presence of at least 1.4 million healthcare-associated infections (HAIs), even as the nonprofit accreditation body the Joint Commission has dubbed hand hygiene “the most important intervention for preventing HAIs.”

Around the world, a number of studies show hospitals’ hand hygiene compliance rates tend to hover at or below 40 percent, on average. In just the United States, HAIs cost hospitals between $28 billion and $45 billion per year, according to a 2009 whitepaper written by R. Douglas Scott II for the Centers for Disease Control and Prevention (CDC). And that’s merely the financial toll. In that same report, Scott said about 75,000 HAI patients died during their hospitalization.

No question ought to linger, then, about the need to improve hand hygiene compliance. When that happens, fewer people should contract, and die from, HAIs and, as a bonus, hospitals will save money, too. In fact, Scott discovered that prevention reduces hospitals’ collective annual spending on HAIs to a range of about $6 billion to $32 billion. Reaching that target takes buy-in from everyone within that healthcare ecosystem, from the CEO and infection preventionists to the cafeteria worker delivering food. Nonetheless, as the statistics prove, simply teaching healthcare staff of all roles to wash or sanitize their hands still leads to unacceptable consequences. Medical institutions must go beyond basic education and the optimal solution may lie in engaging both people and technology such as real-time locating systems that log and communicate when providers have used, or can use, sanitizing stations.

But that first element, the human factor, is key, as a study from Santa Clara Valley Medical Center (SCVMC) highlights.

About a year ago, the San Jose, Calif.-based institution wanted to ascertain how its staff fared in terms of hand hygiene compliance. Incidentally, the federal government mandates hospitals to track this performance. So, between July and December 2015, SCVMC’s infection prevention department tasked five nurses and 15 hospital volunteers, whom staff did not know, with watching employees’ behavior. All told, the division collected 4,640 observations.

And what leaders unearthed from those six months was startling.

When staff did not know they were under observation, many succumbed to the impulse to cut corners, for various reasons. However, if they identified the auditors, they did a more thorough job with hand hygiene, reflecting a phenomenon known as the Hawthorne Effect, whereupon people modify their actions because they know others are watching them.

The Hawthorne Effect earned its name from a nine-year project carried out by Harvard researcher Elton Mayo at Western Electric’s Haw-thorne plant. He at first intended to measure the impact of physical conditions on workers. Along the way, his work morphed into an explora-tion of workplace motivation and industries of all kinds continue to use his breakthrough to their benefit. It all started when Mayo increased the lighting for one set of workers while making no change for another. The workers with more light showed greater productivity. Other positive tweaks, such as adding breaks or reducing hours, also fomented increased output. Mayo ended up concluding that higher productivity was tied to knowing observers were present.

Healthcare stands among the professions that have adopted the technique of direct observation because it tends to reveal unexpected or even undesirable behaviors. Indeed, Nancy Johnson, MSN, CIC, infection prevention manager at SCVMC, calls direct observation “the gold standard” for measuring hand hygiene compliance. To that point, during the six-month period, SCVMC workers were twice as likely to devote attention to hand washing when they knew someone was looking. The overall disparity amounted to 30 percent. “This was not a result that we expected to see,” Johnson said during a presentation of SCVMC's study data at the 43rd annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC) this past June. Maricris Niles, MA, an infection prevention analyst at SCVMC, agreed with Johnson, calling the outcome “surprising.”

Johnson says the explanations for low compliance included availability of resources such as soap or sanitization dispensers; glove-use education;  irritated or allergic skin reaction to cleansers; awareness through performance feedback; and sporadic conformance to WHO’s “Five Moments” guidelines.
Since conducting its 2015 experiment, SCVMC has put in place procedures and safeguards to ensure greater hand hygiene conformity. Yet the hospital is not alone in discovering that people tended to skip steps when they thought no one would notice. The Joint Commission encountered the same issue, as it discussed in the January 2015 edition of the Journal on Quality and Patient Safety. From December 2008 to September 2010, authors Mark R. Chassin and Klaus Nether tallying hand hygiene events at eight major hospitals, recording, in no particular order, these causes for non-compliance:
• Health care worker forgot
• Ineffective or inconvenient placement of hand rub dispenser or sink
• Dispenser or sink broken
• No hand rub in dispenser, no soap at sink
• Health care worker was distracted
• Perception that wearing gloves negated need for hand hygiene
• Proper use of gloves (for example, changing between rooms) slows down work process
• Ineffective or incomplete education
• Inadequate safety culture that does not stress importance of hand hygiene for all caregivers regardless of role
• Caregiver’s hands were full (holding medications, supplies, lin¬ens, food trays); no convenient place to put supplies to facilitate hand hygiene
• Lack of accountability: staff do not remind each other to clean hands
• Isolation area: special circumstances related to gowning and gloving
• Skin irritation from hand cleaning product
• Lotion dispenser used instead of soap
• Following another person into or out of a patient room
• Equipment sharing between rooms requires frequent entry and exit from room
• Bedside procedure or treatment requires frequent entry to and exit from patient room
• Hand hygiene compliance data are not collected, are inaccurate, or reported infrequently
• Admitting or discharging patients requires frequent entry and exit from patient room
• Perception that excessive hand cleaning is required
• Hand cleaning product perceived as feeling unpleasant
• Health care worker was too busy
• Emergency situation
• Workflow not conducive to consistent hand hygiene

Pertinent to SCVMC’s understanding that it needed to devote more focus on gloves’ ability to transfer germs, Chassin and Nether, as well, found that caregivers in six of the eight hospitals “had the mistaken opinion that hand hygiene was not necessary if they were wearing gloves.” This underscores a crucial reality: Direct observation gives hospitals a chance not just to spot problems but to figure out why they occur. “[I]t allows us to observe quality compliance-possible barriers to hand hygiene – such things as thoroughness of cleansing, use of gloves and, most importantly, who is compliant with hand hygiene,” Johnson said. When infection preventionists are armed with information, they can go about correcting the problems. SCVMC is doing that, as the above list attests. And it is maintaining dependence on direct observation and subsequent on-the-spot intervention as it makes hand hygiene a key operational priority for 2017. “Literature does demonstrate that real-time education is very effective and we do implement it,” Johnson noted.

Of interest, staff awareness of the possibility of direct observation already seems to have led to a 40 percent increase in compliance, Johnson said. “Throughout this process it became apparent that healthcare providers really want to enact principles of care to prevent the spread of disease,” she said. “However, organisms are invisible and they become abstract in the theory of hand hygiene. We aim to continue to identify strong motivators that will create new habits and make hand hygiene rote.”

As it pinpoints those areas, SCVMC further has launched initiatives to help create a more holistic hand hygiene framework. This list lays out those specific new tactics:
1. Added hand hygiene to risk assessment.
2. Created a Hand Hygiene Quality Assurance Performance Improvement (QAPI) committee with a charter; members are made up of key re-source staff and decision-makers.
3. Performed a gap analysis and policy review.
4. Validated current hand hygiene auditing (self-audits) to assess accuracy and identify the true starting point.
5. Presented findings with data reports and gap analysis and now continuously send performance data to the various departments and lead-ers.
6. Implemented changes that aim for successful promotion of the hand hygiene plan.
7. Updated hand hygiene policy to reflect current CDC guidelines.
8. Added the “Five Moments” and annual e-learning to its education platform.
9. Conducted a resources and engineering assessment to increase easy and convenient access to product and materials.
10. Ongoing focus on patient and staff education using videos and posters that proclaim, “It’s OK to Ask.”
11. Developed hand hygiene champion posters/screensavers depicting staff and physicians who work on the unit as reminders. Another tool relies on a screensaver hand hygiene message, which changes periodically, on all unit computer monitors.
12. Developed a patient/visitor hand hygiene education/awareness plan to include in the admissions packet.
13. Give awards for the highest-performing units, participation in meetings.
14. Continued focus on improving the facility’s safety climate and integrating hand hygiene into the patient experience program.

“The goal is to get everyone (patients, staff, and visitors) to be aware and monitor each other,” Johnson said.

Certainly that’s the hard part. As anyone familiar with human nature can attest, “this culture is the most difficult to change,” says Johnson.

Thus, SCVMC may incorporate automated hand hygiene-compliance systems into its strategy as a way of strengthening its results. Johnson would not reveal details on this front but did say SCVMC is exploring different types of products and their reliability. She also said that “group approach monitoring could be an excellent way to monitor opportunities and we would continue to use direct observation for the quality assurance of hand hygiene.” To be sure, technology could provide that extra defense hospitals need to strengthen hand hygiene compliance and to lower HAI rates. In 2011, Ellingson, Polgreen, Schneider, et al. wrote in Infection Control & Hospital Epidemiology that “Automated oversight technologies mitigate the behavioral biases inherent in direct observation, and they offer a source of constant oversight that is impossible to achieve with direct observation.” And while they don’t come cheap, recall Scott’s estimated cost of prevention versus reactive treatment.

Again, though, no machine seems able to replace human influence. As such, pairing direct observation and ongoing education with proven smart hand-hygiene systems could encompass the most effective way to reduce HAIs. Attaining such an objective will not happen without dedicated effort and spending, and perhaps SCVMC’s Johnson summed up the matter most succinctly. “It is clear that with hand hygiene improvement, there is no easy, immediate fix,” she says. “For improvements to occur and be sustained, a culture of safety needs to be adopted and be part of the operational priorities of every hospital.” As SCVMC acts on its own findings and advice over the coming year, it will be compelling to learn how that beefed-up enforcement, especially through direct observation, translates into higher instances of hand hygiene compliance. 

Kelly Teal is a Phoenix-based freelance writer.