SECOND OPINION:Everyone has bad habits – even healthcare organisations, writes JACKY JONES
SINCE I retired, I have a habit of rising about an hour later each day. I’ve noticed the days pass more quickly and the morning porridge is barely digested, the papers read, and the dog walked, before I’m thinking about what to have for dinner. The cue for getting up pre-retirement was the 8 o’clock news; now it’s The John Murray Show. This is a habit I need to change or it will permeate every aspect of my life, according to Charles Duhigg, author of The Power of Habit: Why We Do What We Do and How to Change.
All habits have three elements, forming “habit loops” which start with a “cue”, followed by a “routine”, then a “reward”. People who want to change a habit must change the routine that goes with it. Changing the cue or reward will not work. Keystone habits influence all aspects of life. Changing one keystone habit sets up a chain reaction that affects everything else.
Identifying your keystone habit can be tricky and is based on the concept of small wins and not changing too many things at once. This is different to quick fixes, such as going to a gym, dieting and giving up smoking, all at the same time. Such approaches, favoured by TV programmes such as Operation Transformation, invariably fail, and most people go back to their old habits within a short space of time.
Duhigg argues that organisations also have keystone habits and changing one of these changes the whole organisation. He uses the example of US aluminium company Alcoa to illustrate his point. The new chief executive announced at his first board meeting that the priority was worker safety and zero injuries. He then pointed out the safety exits in the room to the bemused executives who expected to hear about how he was going to increase their profits. The members went away complaining about the “crazy hippie now in charge” and worrying about the future of the company. Within a year Alcoa’s profits hit a record high and the company also became one of the safest places to work in the US. He did this by attacking one habit and watching other changes ripple throughout the organisation. Almost everything about the company had to change in order to accommodate the safety programme. Specifically, communication routines had to change because the chief executive wanted to personally hear about all accidents within 24 hours.
The theory of changing one keystone habit can be applied to the HSE and the hand-washing habits of healthcare workers. The World Health Organisation (WHO) specifies five hand-washing moments: before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. The latest report from the Health Protection Surveillance Centre (HPSC) shows that many healthcare workers do not wash their hands. Doctors are the least likely to wash their hands, with nearly one-third not complying with WHO standards. Health professionals such as physiotherapists and midwives have the best hand-washing habits, with 84 per cent compliance.
The target is 90 per cent compliance by 2013. Why not 100 per cent, or zero tolerance for health workers who don’t wash their hands?
Nearly seven million citizens avail of hospital services every year and it does not seem too much to ask that these services comply with WHO hygiene standards. Some may think hand-washing is a trivial matter, but is it? A 90 per cent target means it is okay for 700,000 people to receive services from dirty hands.
The HPSC found that health workers are most likely to wash their hands after body fluid exposure risk and touching patients. This suggests that they care more about protecting themselves from infection than they do about having clean hands before touching a patient or carrying out a procedure. A policy of 100 per cent compliance would bring about a huge cultural shift. First, it would create a habit of excellence and say in unequivocal terms that the patient comes first. Secondly, hand-washing routines would have to change. Currently, patients are encouraged to remind workers about washing their hands. This is fiddling with the “cue” and will not work. Instead, colleagues should do the reminding as part of normal practice, and do it in front of the patient. This is guaranteed to work spectacularly. In the meantime, I will get up an hour earlier.
Dr Jacky Jones is a former regional manager of health promotion with the HSE