Rewarding Employees for Good Behavior Can Improve Infection Prevention

Everyone likes compliments, whether they acknowledge it or not. Everyone likes rewards, too. There has been some debate in modern business about whether punishment is more effective than reward, but recent studies indicate that rewards may be the way to go if you want to bolster good behavior. For healthcare workers (HCWs) struggling to improve their hand hygiene compliance and general aseptic technique, anything that can reinforce this behavior is a blessing.

Recognizing the Good

"Giving recognition to our coworkers adds value to both the self-motivated and the not-so-self-motivated among us," says Janis Allen, a performance consultant and owner of Performance Leadership Consulting in Brevard, N.C. Allen is the author of "You Made My Day," a book about creating coworker recognition and relationships.

Incentives don’t have to be Rolex watches or Caribbean cruises; inexpensive gifts can reinforce your message without breaking the bank. Even a simple note can serve as a reward. In her book, Allen provides a short note that can be photocopied and used again and again. It says, "I like what you did," and offers space to add your own comments about the positive behavior.

Rewarding good behavior requires more than just being nice all the time, Allen writes. "Positive recognition is pointing out a specific behavior that you like in a person and then telling that person what you like about it. It’s a reaction from you that follows a particular behavior or celebrates its results."

Allen points out that management must be involved in positive recognition, but that coworkers can do it for each other, too. "In my last 10 years of working with organizations, I have encouraged them to use 80 percent of their training and coaching resources with employees instead of with management and supervisors," she writes. "We teach them to develop measures, goals, and daily feedback tools for their own performance."

During that decade, she relates, some employees have suggested their bosses should be doing that instead. This, she stresses, indicates that leaders should be using these tools before they ask their teams.

When you do recognize your staff for doing something right, "Shut up as soon as you finish applauding," Allen advises. "This is not a time to ... set higher goals or assign additional work ... let them savor your positive words without rushing to the next goal."

Finally, she says, it’s important to find a way to phrase things well. Instead of insulting someone by saying, "That stinks," substitute the phrase, "Here’s another way to do this." If people offer good suggestions that seem expensive or out of reach, don’t commit "ideacide," Allen recommends. Instead, "Name what you like (about the idea), and ask for ways to make it work."

Case Study No. 1

To improve compliance with infection-prevention strategies, hospitals can focus on several options: rewards, entertainment or personal fulfillment. All these options require buy-in from the top down. If a department mandates behavior without an investment from the facility’s leadership, the program’s success is doomed. And it helps if the management can create a positive environment so that change can occur in a non-threatening setting.

One hospital, Grays Harbor Community Hospital in Aberdeen, Wash., has managed to improve compliance in many areas of the hospital just by creating a positive environment where employees actually want to come to work. According to John Mitchell, the hospital’s CEO, that requires hard work and a willingness to step outside the traditional style of management. "When I have lunch with new employees every month, I ask them two questions: ‘How many of you have worked someplace where the people in charge said they’d do something to improve your morale?’ Most of them raise their hands. Then I ask, ‘Did it work?’ Most of the hands go down. What I tell them is, ‘The reason it didn’t work is that they told you what they would do; they didn’t ask you what they could do.’

"I cannot manage anybody’s morale at my hospital. No CEO can," he emphasizes. "Everyone here has to manage their own morale. My job is to create an environment where they can do that."

Grays Harbor has created formal and informal teams, each with a different focus. "We have a team, for example, that decides how they’ll assist employees in their personal lives. We have another group of people who are smokers who have their own culture; then they come and tell us what they want to do," he offers. Additionally, a new team will be starting for employees who want to lose weight. The hospital will begin a wellness program, but will ask for employee input in its design.

It’s a given that all hospitals have mission statements or vision statements; the problem is, they’re meaningless if they cannot be implemented. "When I got here, I wanted to develop a mission that was nine words or less," Mitchell says. "We did that with input from staff, the board, and frontline employees, and now our mission is to heal, comfort and serve the community with compassion."

The teams help the hospital accomplish that simple mission, and their projects are not done in a vacuum—before executing a new program, the leadership will request suggestions from employees. "A lot of people think this is touchy-feely, but I knew this type of management would work. If you’re a leader, you have to give up the old command-and-control style, because it won’t work," Mitchell observes.

Now, each hospital department—on every shift—has a five-minute meeting every week. Each meeting has the same script—a "huddle" focusing on a different department or function and why it is important, a quote of the day, and a healthy living tip. Everyone in the hospital becomes aware of every other department’s contribution, and the information in each meeting helps support the year’s strategic goals. "Everything that’s important to hospitals—such as patient satisfaction, core measures, national patient safety goals, finances—can be advocated and advanced using this type of cultural tool," Mitchell adds.

The new strategy has been successful, and the results are tangible. Eighteen months ago, the hospital was next-to-last in the state for quality; in the last year and a half, the hospital has moved into the top third. "When we measure employee satisfaction, we’ve seen a 23 percent increase into the second year," Mitchell says. "Patient satisfaction in the ED and the rest of hospital is up about 20 percent."

The hospital has even successfully negotiated two union contracts without any acrimony, because everyone feels empowered and valued. This type of environment makes it easer for the hospital to focus on techniques like hand hygiene, because employees are open to the idea—they are allowed to offer their own ideas for improvement, and the hospital has a good system in place to track improvement.

Case Study No. 2

Other hospitals have improved compliance with infection-prevention strategies by making work entertaining. "We’ve never done much in the way of punishment, but we make work fun, and encourage and reward people," says Ann Marie Pettis, RN, BSN, CIC, director of infection prevention at Highland Hospital in Rochester, N.Y. "Several years ago, we were struggling with a lot of Clostridium difficile (even before it was getting national attention), so we decided the first thing we needed to look at was hand hygiene, or we were going to go nowhere. We did a study and made 200 observations in medicine and 200 in surgery. We found that overall, the compliance was about 30 percent on medical and surgical floors. At that point, we came up with a lot of things to do over several weeks, so we went around catching people doing the right thing, which was hand hygiene. We had fancy soaps, movie tickets, fanny packs, and gift certificates. As we saw somebody washing their hands, we would give them one of those prizes. We held contests, we provided posters, and we did a fun experiment outside the cafeteria—we cultured people’s hands before they went in to eat. We brought the cultures up to micro; they would plate it and grow whatever they had, and we would show [the staff] the results a couple days later when they were coming into the cafeteria again. After that, unbeknownst to them, we repeated the study and did an additional 200 observations in each area. Our goal had been to double our rate, and indeed, we went up to 64 percent compliance versus 30 percent."

Recently, Pettis began exploring the psychology of punishment versus reward. "From everything I’ve read, either one is effective, but you have to constantly change your strategy, so whether you go with rewards—which most of the writers said (at least in healthcare) was more effective, or punishment—it is only effective to a certain point and you have to constantly change, depending on the groups you are dealing with."

The rewards need to be changed, she points out, because the reward may not always be appropriate for everyone. "Food works with some, but may not work for those on a diet. If you just went to Weight Watchers, I can’t reward you with a pizza party," she says. "On the other hand, if I offer you an extra vacation day, that might reward other folks. Rewards are looked upon more positively, especially when dealing with adults."

Pettis’ research showed her that when punished, adults become angry or frustrated, and the punishment may lose the employee’s loyalty. So while behavior may improve short-term while the employee is being punished, ultimately, if he or she does not "buy in" to the behavior, it stops as soon as you’re not looking. "The whole idea of reward is what you want to go with if you’re trying to increase behavior; punishment is what you go with if you want to decrease behavior, and if you ignore it, you’ll extinguish behavior," she adds.

An article in the September 2006 issue of the American Journal of Infection Control focused on social marketing. The article, ‘Social marketing: a behavior change technology for infection control,’ encouraged managers to look at infection control as if they were trying to sell somebody something. "What you’re really after with healthcare providers is increased cooperation," Pettis says. "It’s not that they don’t know they’re supposed to do this stuff, but you have to give them a lot of different messaging to convince them there’s something in it for them."

Another article Pettis recommends is "Steve’s Primer of Practical Persuasion," on the Web site Healthy Influence. "Operant Conditioning for Me?" discusses the difference between rewards and punishment, and when to use which. To view the article, visit

The author, Steve Booth-Butterfield, writes, "Reinforcement theory boils down to a main point: consequences influence behavior." In this instance, "consequences" doesn’t necessarily represent something bad—Booth-Butterfield simply refers to the fact that an action confers a response, be it positive or negative. And if the consequence is something positive, the employee is more likely to repeat that behavior.

Pettis takes this type of advice to heart. In her facility, new employees undergoing orientation get a bottle of hand hygiene gel, and a clear example of what not to do. "There’s a good video we’ve used here, called ‘Hand Hygiene: Get the Picture?’" The film highlights in red every time someone on screen practices poor hand hygiene.

In addition, Pettis has applied the rewards concept. "It did work, but it only lasts for a short time," she points out. "So you have to constantly come back with additional rewards. I’m at the point now where despite everything I’ve read, I do believe that there have to be consequences for bad behavior. I think you can do a lot of the fun stuff, then you massively campaign this whole social marketing thing, but then that has to be woven into performance indicators. When people don’t do [the desired behavior], and it’s documented, we have to get to a point where we’re willing to fire people for that. That’s why I’m a big proponent for making flu vaccine mandatory. I don’t give a rip about their rights; we can’t be killing people—but that’s what we end up doing."

Pettis references another book she found in her research, "Evidence-based Medicine," which features editorials debunking and slamming healthcare providers for all the things they don’t do right. "It was written with that slant in mind, but it was evidence-based," she says. "One reference was an editorial published in a big medical journal, and it was a physician saying ‘There’s no good evidence that hand hygiene really makes a difference.’ Semmelweiss had to have been turning over in his grave. But this guy actually published this letter because it was so damning—because yes, some physicians do believe they’re somehow immune to germs, and ‘It couldn’t be me contributing to the problem.’ But sadly, I don’t think it’s specific to physicians, and indeed, when we broke down our handwashing data here, nurses were not quite as bad as the doctors, but they were right behind them. The best at hand hygiene were housekeepers, dietary, physical therapists, respiratory therapists. In the psychological studies I read, they mention that if you are fearful for your own self, that is the most motivating thing. If you think about it, the healthcare workers in environmental services have the least knowledge in terms of germ transmission. They’re so afraid that of course they’re going to use the best hand hygiene. What’s in it for them? They’re afraid for their own safety. It makes sense that they’re the best at hand hygiene."

The next question is this: is it best to reward the desired behavior immediately, or is it better to hold a monthly meeting in which employees are recognized for their efforts in front of their peers? "Everything I read said that if you’re going to reward, you have to do it immediately—so the idea of handing a reward to them as you see them do the behavior seemed to be the more effective method," she says.

For some people, peer recognition is motivational, but for other people, it may not be. "It depends on how they feel about you and the organization," she adds. "If they value you, it’s great. If their colleagues then start making fun of them, it can work against you."

Some employees may do better with a tangible reward, such as movie tickets. Others might prefer a handwritten note congratulating their performance. Really, Pettis says, "It depends on the person. They use a teacher as an example. It’s so difficult to be a teacher because the very thing that motivates some students is going to turn others off. Rewards are tough because you have to constantly evaluate them and know your audience, and if the reward is working. It gets tricky, and that’s why sometimes you might end up having to default to punishment."

Some infection control experts want to avoid punishment entirely, but, Pettis says, "I do believe that you have to go there at some point, or people die."

Currently, Pettis’ facility is using stickers on the soap and gel dispensers to monitor use of the products. The hospital then determines how much product is being used per thousand patient encounters. "Right now, we’re in the process of monitoring, and once we get some really good data fed back to the staff, our goal is to reinitiate or reinstitute some sort of program, whether it be rewards or punishment," she says. "Every six months, we’ve done a different campaign, and our most recent was parroting what the Joint Commission did—‘Be your own advocate.’ We offered buttons reading, ‘Ask me if I washed my hands,’ then did surveys with staff."

She says the program was received fairly well, but may have been a little ahead of its time. Pettis’ facility did the program approximately 18 months ago. "Some of the employees were actually insulted by the campaign," she recounts. "I read a study that said if you ask nurses and doctors about their handwashing, they will say ‘Of course I washed my hands.’ Some studies say, nurses and doctors will tell you they do it at least 80 percent to 90 percent, but when you observe them, they fall short of that."

The hospital monitored usage the month before the campaign, as well as the month after, for comparison, and there was a noticeable bump in soap and gel usage during the campaign and the month immediately following. However, it quickly reverted to baseline. "Whatever you do, it tends to be a temporary blip on your compliance chart, and that’s why I say that at some point, it has to be woven into performance monitoring," she says. "If they came to work late all the time, would we not punish them for that? So why do we not punish them for doing things that will kill people? I think we’re heading in that direction, if nothing else, because of all the consumer and legislative pressure."

Case Study No. 3

A hospital in Toronto gave employees tangible rewards: they were given $2 Tim Horton’s gift certificates for washing their hands. It improved hand hygiene in the hospital, but also gained the hospital a great deal of press.

"We got a lot of really negative press and a lot of positive press," says Michael Gardam, MD, director of infection prevention and control at University Health Network in Toronto. "The positive press was ‘Hey, whatever it takes to get this done, go ahead." The negative press focus was twofold—No. 1, we shouldn’t reward people for something they should already be doing, but that attitude is kind of naïve, because change management is never all negative—you always need some positive reinforcement as well. This isn’t a huge piece of positive reinforcement, but it creates a buzz. When I give a gift certificate to an employee for (practicing hand hygiene), the employee goes back to the nurses’ station and says, ‘Can you believe this guy gave me a gift certificate for washing my hands?’ And suddenly you have two healthcare workers talking about hand hygiene.

"The second negative argument was that we are single-handedly contributing to the worldwide epidemic of obesity by rewarding with Tim Horton’s certificates, which I discount. But overall, the response to our campaign has been very positive."

Gardam cannot quantify exactly how much the gift certificates had to do with the overall improvement, because the rewards were only one part of a multi-pronged strategy. "Overall, our compliance is going up, but I can’t tell you what component is doing what," he says. "We’ve developed new buttons and posters; we’ve added point-of-care gel (we introduced a new product) everywhere; we are giving rounds and finding champions, and staff who are consistently noncompliant are getting disciplined."

Although discipline has been avoided by many facilities, it’s now becoming more common. "Recently, in the U.K., there was a story on the BBC Web site about a nurse who was fired for not washing her hands while caring for MRSA patients," he says.

Gardam says the process of installing the new hand hygiene gel is approximately halfway done, and audits of its success have begun. A final audit will be done when the installation is complete. "We’ll do some hand hygiene audits; we’ll measure the amount of gel being used, and—assuming people aren’t drinking it—if the numbers go down, that means they are using it for hand hygiene. We’ll follow our MRSA rates and see if they go down. Our rates have been relatively stable over the last year, and we’ve been measuring for five or six years, so we have a good baseline."

Hand hygiene is not the hospital’s only focus, however; other techniques are also being targeted. "We’re also doing universal admissions screening for MRSA on every new patient," he adds. "The problem with infection control is that to control a problem, you take out a shotgun and blast it, but you don’t know which pellets did what."

The hospital had attempted a hand hygiene campaign immediately after the SARS outbreak in Canada in 2003, but the campaign, he says, "fell flat on its face. It seemed like the right time to do this program, but we underestimated the institutional fatigue there was, so it really didn’t have an effect. Although it had the lip service, it didn’t have solid support. The infection control department at that time didn’t have the necessary staff to drive it, so we talked about it and nothing happened," he recalls.

Now it’s a different story; the department has more staff, and the senior administration is firmly committed to improving the hospital’s aseptic technique. "All the stars are aligned," Gardam says. "There is a Canadian equivalent of the Institute for Healthcare Improvement (IHI)’s 5 Million Lives campaign, with lots of media interest and lots of public interest."

Medicare and insurance companies are also jumping on the punishment bandwagon. If hospitals are not willing to comply with good health standards, and patients suffer a nosocomial infection or other negative result of staff’s negligence, they will no longer be reimbursed for the patient’s treatment for that infection—and they cannot bill the patient, either.

"I’ve used that headline in multiple talks—it’s more evidence that the world is starting to take this seriously; that’s why we’re seeing public reporting of infection rates," Gardam observes. "I think it’s a great idea (non-reimbursement) and I am pushing it for the province of Ontario, but we’re not quite there yet."

However, he adds, the reward system has certainly worked in his setting, not just for hand hygiene, but for influenza shots as well. "We have a high rate for flu vaccination in our hospitals’ employees; I believe that occurs because we have a big campaign, and we pit our hospitals against each other. But the main reason the employees get vaccinated is because we give out 9,000 chocolate bars a year," he explains.

The equation is simple: get a shot, get a candy bar. "It’s called bribing. I don’t care why you got your flu shot—just that you got it," he says. "We tend to be preachy and tell the healthcare workers that ethically, it’s their responsibility to be vaccinated, but nobody responds well to that. But if you offer positive reinforcement, if there’s something good in it for them, they’re more likely to comply. A lot of people tell me the only reason they get vaccinated is because they get a KitKat bar out of it. I’m lucky our administration lets us buy a lot of chocolate bars. But it works."