Applied Psychology Improves Hand Hygiene in Hospitals


According to a recent New York Times report, hand-hygiene compliance in hospitals can be as low as 30%, with serious implications regarding hospital-acquired infections.1 While many initiatives have employed secret observers, vibrating badges, or hand-washing coaches, a Research, Innovations, and Clinical Vignettes (RIV) poster at HM13 outlined how a multidisciplinary committee at University of Colorado Hospital in Aurora applied principles of psychology to the challenge of compliance.2

The initiative focused on behavioral changes: surreptitiously auditing staff behaviors, real-time feedback, and immediate public corrections for observed nonadherence on the test unit from an infection-control champion. The study randomly assigned daily auditing responsibilities across all members of the nursing staff, including aides. Taking a page from soccer referees, auditors handed out red tickets to hygiene violators—and individually wrapped Life Savers to reinforce adherence.

When unprofessional behavior is the response to a verbal correction, leadership has to be prepared to act, explains hospitalist and lead author Ethan Cumbler, MD, FACP.

“We need to stop thinking about hospital staff and physicians as rational actors when it comes to hand hygiene, but as social animals who will respond to positive and negative reinforcements and group culture,” he says.

Noncompliant hand hygiene is largely unconscious behavior that needs to be brought to conscious attention but is amenable to change, Dr. Cumbler says, adding that “unit leadership steps in for repeated nonadherence or an unprofessional response to correction. We have never needed to intervene more than once with the same person.”

Hand-hygiene adherence reached 97% on the pilot unit in the second quarter of 2012 and has remained at that level, Dr. Cumbler says. Additionally, iatrogenic infections dropped to zero from 4.8 per 1,000 urinary catheter days, with bloodstream infections falling at a similar rate.

Similar results with hand-hygiene compliance have been reported at St. Mary’s Health Center in St. Louis, which has been testing a system that reminds nurses to wash their hands at various checkpoints in the hospital, tracking their compliance with a badge that turns green when registering the presence of hand sanitizer, thereby informing patients that the nurse’s hands are clean.

The system, developed by Biovigil Hygiene Technologies of Ann Arbor, Mich., started on two pilot units last year, where compliance has grown to 97% and 99%, respectively. System set-up can cost about $2,000 per patient room, plus monthly subscriptions per employee, but more hospitals in the system could sign on next year, reports the St. Louis Post-Dispatch.3

Larry Beresford is a freelance writer in San Francisco.


  1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
  2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
  3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
  4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
  5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
  6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

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