Second Opinion: Organisational culture has the upper hand over hygiene

Beaumont Hospital is going to appoint "hand-hygiene champions" in the hope that they will improve doctors' abysmal hand- hygiene practices. They will not.

Changing bad habits and even reckless behaviour needs a total organisation response.

Champions, no matter how persuasive, are not going to change deep-rooted attitudes and behaviours. Intense and frequent training in hand-washing techniques will not work either. Irish hospital culture must change if patients are to be touched by clean hands at each and every healthcare encounter.

A 40-year old research paper, The Myth of the Hero-Innovator and Alternative Strategies for Organizational Change, by Nicholas Georgiades and Lynda Phillimore, and still relevant today, explores the overreliance of most organisations on training and innovators, or champions, to bring about changes in worker behaviour.

“The fact of the matter is that organisations such as schools and hospitals will, like dragons, eat hero-innovators for breakfast.” The authors emphasise the immense influence of organisation culture.

“Behaviour patterns are part of and are moulded by the culture of the work situation.” Even first-class training has little influence on how people behave when back at work if their supervisors behave differently.

“If the old way of doing things is still the shortest path to approval by the boss”, then that is what happens.

Hand hygiene is recognised internationally as the single most important preventative measure in the transmission of healthcare-associated infections.

The World Health Organisation specifies "Five Moments for Hand Hygiene": before touching a patient, including shaking hands; before a clean/aseptic procedure, such as taking a blood sample; after body fluid exposure risk, like removing a dressing; after touching a patient, even patting someone's arm; and after touching patient surroundings, such as curtains, chairs or tables.

Unannounced visit
According to the Health Information and Quality Authority (HIQA), "it is essential that a culture of hand-hygiene practice is embedded in every service at all levels".

HIQA’s unannounced visit to Beaumont Hospital found that “while a few doctors were compliant with hand-hygiene best practice, most were not”. Out of 60 hand- hygiene opportunities throughout the monitoring assessment, only 28 were taken (45 per cent).

HIQA’s report concluded that a culture of hand hygiene was not embedded in Beaumont Hospital. None of the four other hospitals which had unannounced visits met the HSE’s 2013 National Service Plan target of 90 per cent hand-hygiene compliance.

Even the Lourdes Orthopaedic Hospital, Kilkenny, which was judged to have an embedded culture of hand hygiene, scored 86 per cent, below the 90 per cent target.

The latest report from the Health Protection Surveillance Centre (HPSC), published in March 2013 and based on an audit carried out in October 2012, shows that other hospitals are not much better.

Only six of the 44 hospitals included in this report met the HSE’s 90 per cent target. Nurses achieved the best compliance rates (89 per cent), doctors the worst (71 per cent).

The report stressed the importance of hand-hygiene education for medical staff in particular, a strategy which is obviously not working.

Various commentators, who clearly know very little about the influence of organisation culture on behaviour, have suggested ways of improving hand hygiene in Irish hospitals.

Most of these would not work in practice, and would actually make the problem worse. It is not a patient’s responsibility to ask healthcare workers if their hands are clean. Gloves are out.

The same amount of hand hygiene is needed when using gloves as without them and they are an extra major risk for germ transmission.
Disciplinary procedures
Invoking disciplinary procedures would be a disproportionate response, using a sledgehammer to crack a nut, and a waste of everyone's time and energy. Things are hard enough for HSE employees, who are already under great pressure, than being fearful about disciplinary action. Criminalising healthcare workers is not the answer either.

A 1947 Health Act allows for the imposition of a £50 fine – equivalent to €6,000 in today’s money – if a person, who knows he is a probable source of infection, does not take reasonable precautions to prevent his infecting others.

What is needed is quite simple. Hospital managers, every consultant, top nurses, and all supervisors must model best practice hand-hygiene behaviour and expect their peers and colleagues to follow suit.

Reminders should be issued in front of patients if necessary. Modelling changes hospital culture quicker than anything else, including training and champions. Guaranteed.

Dr Jacky Jones is a former HSE regional manager of health promotion
drjackyjones@gmail.com