Ethics, Accountability Must Drive Healthcare Workers' Handwashing Behavior

A recent headline in the May 28, 2013 issue of The New York Times read: HOSPITALS STRUGGLE TO GET WORKERS TO WASH THEIR HANDS. This is news? It is an age-old problem that no one wants to take on directly. It seems that personal responsibility has taken the last seat in the steerage compartment of the ship when it comes to patient safety and doing what it right.

By John Scherberger, REH, CHESP

A recent headline in the May 28, 2013 issue of The New York Times read: HOSPITALS STRUGGLE TO GET WORKERS TO WASH THEIR HANDS. This is news?

It is an age-old problem that no one wants to take on directly. It seems that personal responsibility has taken the last seat in the steerage compartment of the ship when it comes to patient safety and doing what it right.

Healthcare professionals around the globe have reason after reason for not washing or sanitizing their hands and quite frankly, enough is enough. Why are hospital systems willing to spend hundreds of thousands of dollars to remotely monitor the handwashing practices of their staffs? Why are they willing to invest in cameras made in China, Taiwan, Korea, or some other country to monitor those who chose to ignore established policies and procedures? Why are they willing to pay a company to hire people in India, Pakistan or the Philippines to watch monitors 24/7 to catch those healthcare workers (HCWs) who think they dont have time to properly wash or sanitize their hands?  (Shades of the NSA surveillance!) Why are hospitals investing millions in RFID badges to check HCWs' interaction with soap and hand sanitizer dispensers? They certainly dont show that the HCW is using proper techniques or investing the proper amount of time needed to effectively rid their hands of dangerous microbes and surface dirt and grime.

Why are healthcare systems nationwide willing to spend hundreds of thousands of dollars on lapel pins and buttons to reward a person for doing what is right, for doing their job?  Why are hospitals willing to squander millions of dollars in purchasing and making posters, giving away free meals, free pizza, free coffee?  Why the need to hire handwashing coaches?  Why are coupons for free promotional giveaways, and payroll bonuses given to cajole HCWs to do what is expected of them and what is their ethical and moral duty? Why?  Apparently personal and professional responsibility is no longer important. Why do HCWs have to be constantly reminded that their actions or lack thereof can have serious and deadly consequences?

Using 13-year-old data, the Centers for Disease Control and Prevention (CDC) states that healthcare-acquired infections, those that are the result of medical, surgical, or nursing care, not pre-existing conditions that provoke healthcare encounters (hospitals and other professionals prefer the term healthcare-associated infections for obvious reasons), lead to 100,000 deaths at a cost to hospitals of $30 billion annually. 

A 2012 retrospective metadata study, yet to be released, shows completely different and much more devastating statistics.  When considering direct medical costs, nonmedical costs, and indirect costs the true costs in 2010 dollar values is estimated to range from $100 billion to $151 billion annually. According to the same study, there actually are 1.4 million to 1.6 million hospital-acquired infections annually in the United States.  These HAIs account for and additional 8.9 to 10.2 incremental hospital days per infected patient.

According to The New York article, Studies have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients.  Nurses, physicians, therapists, aides, and other healthcare professionals are held in high regard because of the work they do and the great dedication they show in performing their oftentimes thankless tasks. But they are not God, neither are they to be treated as demigods. They should be held to the same standards everyone else is when they fail to perform their required duties. In healthcare, there are benefits and burdens and risks and rewards. Of this there can be no argument. 

So, I offer the following thoughts: When it comes to the most basic and simplest methods of infection prevention, the healthcare professional must return to the four medical ethics principles:

Respect for Autonomy, Non-malfeasance, Beneficence and Justice. These all have the patient as the focus, not the provider and that is how it should be. Each time a HCW fails to do perform even the simplest of their tasks, handwashing or sanitizing, they are violating these principles and placing the patient in danger.

Physicians have their Hippocratic oath: "First, do no harm." Nurses have their code of conduct. Other licensed healthcare professionals have similar statements to which they subscribe. Nowhere in these oaths, codes, or statements are there qualifying clauses. In no instance will applicable healthcare professionals find qualifying clauses negating responsibility of patient safety unless or until a bonus is forthcoming as is the case of some hospitals, tying handwashing to bonuses. Let me be clear here, they are not stating the foregoing but that is certainly what they are doing.

The allure of bonuses, lapel pins, free food and feel-good posters will lose their glitter and motivation in short time. Unless the culture is changed for the patients sake, progress, advancements, successes, and positive patient outcomes will be short-lived.

Nowhere is any healthcare professional granted license to ignore patient safety just because the required action is considered time-consuming, inconvenient, a low priority, or if the staff member is too busy, has an allergic reaction or intolerance to soap or sanitizing agents.

Let me be very clear here: I have great respect and admiration for most nurses, therapists, doctors and other HCWs.  But I have no tolerance or respect for anyone who, for any reason, will put a patients life in jeopardy. And neither should anyone.

In The New York Times' opinion pages on April 28, 2011, a recently retired physician commented: I can tell you that the main reason I failed to wash my hands on occasion was lack of basic materials to do so. No soap, no towels, and all too often, a sink out of order. Those are excuses, not reasons. And neither excuse nor reason should be acceptable when it comes to the health and safety of patients. Some believe failure to wash ones hands is a lack of leadership from senior medical staff and administration. I wholeheartedly agree with that. Medical staff leadership and administration must lead by example. That means ensuring that the tenets of benefits and burdens be applied universally, with appropriate measures, in a timely manner, and with similar consequences for all. Put very simply on an individual basis: The benefit of washing hands is that one keeps ones job and patients are safe; the burden of not washing ones hands is that one suffers the consequences and patients may die. Hows that?

Lets get to the one simple answer to the why questions presented at the beginning of this article. Very simply, its a lack of leadership and commitment on the part of healthcare to hold people responsible for their actions and inactions. It gets back to the lack of accountability, the refusal to hold others responsible for their actions, the refusal to accept responsibility either corporately or individually, the tendency to seek blame rather than seek to do the right thing, and finally, valuing the physician, nurse, therapist, or other HCW more than the patients. 

Healthcare must get its collective head out of the sand. Yes, there are direct economic consequences of preventing infections. But more than that, there are human costs and consequences affecting patients that must be considered. The Latin word from which we get the term patient means one who suffers, but must the patients suffering be compounded and reinforced due to the inconvenience of proper hand hygiene by HCWs? Must they be made to suffer because of misguided values?  Must staffs need for expediency take precedence over the patients need for healing and a quality outcome? 

We must never forget that the patient was a person before they became a patient. They should have a right to expect healthcare professionals to do what is right, what is medically ethical, each and every time. They also should have a right to expect that those who do not do what is right are deprived the privilege of providing treatment and care for them. Unfortunately, healthcare and the media have made treatment and care synonymous. Care must always accompany treatment and treatment must always accompany care. But they are not the same. Treatment is the application and intervention of a medical process, procedure, or medication. Care is the human contact, the compassionate, empathetic interaction of sharing and touch between one human being with another.  Lets never forget that medical treatment is not always necessary, but caring is always necessary. Care with clean hands, I should add. 

Proper care along with treatment must be a part of healthcares culture. If people do not want to belong to that culture, which includes efficacious hand hygiene, they should move on, either of their own volition of with some help. It is culture that must change, not cash changing hands.

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John Scherberger, REH, CHESP, is president and founder of Healthcare Risk Mitigation, Inc, (HRM).