I've written before about how handwashing by medical care workers is one of the most well-documented preventable causes of death and disease in health care settings. One hospital CEO, for example, told me that he wore a button that said "It is OK to Ask," to encourage patients to ask doctors if they had washed their hands -- a practice the doctors didn't like, but that did have positive effects. Last Sunday's New York Time Magazine had a splendid article by Dubner and Levitt called "Selling Soap." The story contains many lessons that go far beyond hand-washing and have implications for evidence-based management on many other things. Consider four:
1. Self-report data can be worse than useless. They describe an Australian study where 73% of doctors reported washing their hands, but when the docs were observed by a researcher only 9% were seen washing their hands. The lesson is that you need to check out what people say, interviewing the people you are trying to help and change produces very suspect data.
2. The story focuses on Cedars-Sinai Medical Center and efforts to get physicians to wash their hands. Nagging doctors with emails and posters didn't work. But the Hand Hygiene Safety Posse did -- they roamed the halls and when they saw a doctor washing his or her hands, they handed out a small reward on the spot, a $10 Starbucks gift certificate. This had substantial effects, getting compliance up to 80% from 65% -- but they were aiming to hit 90% for a pending inspection.
3. The way they finally got compliance up to nearly 100% was to have a group of the hospitals more influential doctors each press their palms on plates that were cultured and photographed, which resulted in images that "were disgusting and and striking, with gobs of colonies of bacteria." One of these was used as a screen saver that was placed on every computer in the hospital. The power of this last intervention not only provides lessons about hospitals, it is a lesson about how to implement any other change that people "know" is good, but aren't doing:
A. They started by changing some of the most powerful and persuasive people in the system -- opinion leaders and people with high status are important for sparking change.
B. They spread the information to everyone in the system, so they could all keep an eye on each other. This made the norm open and easy to monitor -- and vivid.
C. They made the dry statistical information very vivid. The disgusting picture is the perfect kind of image that sticks in people's minds -- check out Heath and Heath's Made to Stick. This is one of their kep principles.
D. Finally, they created the kind of social pressure where if people did not follow the norm, it would lead to loss of face. Economists and psychologists like financial rewards, and as this tale shows, incentives are effective to a point. But if you can find ways that people feel compelled to follow the evidence, or they will suffer humilation in the eyes of the people around them, that is even more effective. It is a lot easier to measure and dispense financial rewards, but if you want to change human behavior, it is hard to beat pride and shame -- as sociologists including Erving Goffman have demonstrated.
Finally, this story, to me, is another sign that focusing on managing the system is more important than devoting excessive energy to bringing in star talent -- that the law of crappy systems trumps the law of crappy people. This hospital clearly has many smart and well-meaning people. But the compliance rate was only about 65% until management started changing the system, first through rewards (which got them up to 80%), and then through those disgusting pictures (which pushed them to close to %100). These are all the same people, they were just managed differently.
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