Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

I started telling him how health care is different, how patients are sick and complicated, how medical practice must be nuanced to individual patients’ needs. But as I was talking, I realized how foolish I must have sounded, how I was making the same excuses that our industry has made for decades, excuses that likely explain why we have not made progress in reducing preventable harm despite a decade of trying.

I paused and shamefully said, "We do not hold people accountable." While physicians have profound individual accountability, we have not made clinicians answerable for the care they provide to populations of patients. If we did, we would not have some units with 30 percent compliance with hand hygiene while other units have 100 percent compliance. (To be fair, our hospital uses a stringent hand-hygiene surveillance process using trained "secret shoppers," who obtain a representative sample from each unit. When this method is used, many hospitals are shown to have compliance rates of 30 percent to 40 percent.)

A true accountability system would require three things. First, we would need to ensure that every unit and department has staff with time devoted to improving quality. Second, we need to ensure that leaders at every level have the appropriate skills and resources to improve. Very few of the people working in quality have training in implementation or improvement science, few are trained in evaluation to know whether care is getting better, few are trained in leading complex change efforts, and few have access to data to evaluate performance.

Third, staff at each level needs to hold the lower level accountable. Health system leaders must set the goals, hospital leaders must hold department leaders accountable for those goals, department leaders must hold unit leaders responsible and so on, creating a chain of accountability. This system could include a formal and structured review process—and real consequences—when the unit fails to achieve performance goals.

Hospitals are collecting an ever-increasing number of performance measures. Now they need to create an accountability system to ensure high performance. Leaders in departments and units, those with the clinical expertise who deliver care, must answer for their results. It is time we as clinicians and managers own the problem and improve. And no more excuses.

We need more than top-down accountability. In 1908 Teddy Roosevelt, reflecting on some unscrupulous business practices, stated, “laws and the enforcement of laws can never substitute for the character of the citizen himself.” The same is true in health care. If we are to improve the quality of care, the values and social norms of clinicians must lead the way. We will know that we have arrived when clinicians routinely remind each other to wash their hands, when they can raise concerns about a patient’s plan of care without fear of reproach, and when clinicians heed such concerns. Organizational accountability must supplement, not supplant, professional norms.

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