by David Maxfield and David Dull, MD

The Centers for Disease Control and Prevention reports that in the United States, two million people suffer each year from hospital-acquired infections (HAI).¹ Of these patients, some experts estimate that as many as 90,000 die annually. Leading researchers and industry regulators have long established that the most effective way to combat HAIs is for healthcare professionals to wash their hands.² However, getting staff, nurses and physicians to practice impeccable hand hygiene has proven far more difficult than expected. Despite implementing a wide variety of interventions, most hospitals have seen little improvement. On a national average, hand hygiene compliance rates remain stalled below 60 percent.³

Over the years, leaders at Spectrum Health, the largest not-for-profit healthcare system in West Michigan, also implemented a variety of hand hygiene initiatives—each one producing small gains but falling short of expectations. Despite the interventions, Spectrum could not move the needle on its compliance rates which hovered just above 60 percent—slightly higher than the national average.

In 2009, infection control leaders at Spectrum partnered with researchers at VitalSmarts, a corporate training company, to apply a unique change-management model to improve hand hygiene compliance systemwide. The VitalSmarts Influencer model was recognized as the Change Management Approach of the Year by MIT Sloan Management Review due to its multifaceted approach to securing change.⁴ The model is based on more than 50 years of social science research combined with case studies of current, successful change initiatives—including IHI President and CEO, Don Berwick’s, 100,000 Lives campaign to reduce patient injuries.

Research behind the Influencer model reveals that successful change is not predicted by how critical the change is to the organization’s long-term success, but rather by the number of influence strategies aimed at a single behavior. The following will outline how Spectrum Health embraced this change model to bring about unprecedented improvements in their hand hygiene compliance.

Determine Results

The first challenge Spectrum leaders faced was to clarify the measurable results they ultimately wanted to achieve. Leaders made a strategic decision to focus on improving compliance rates rather than infection rates. While reducing infection rates is the ultimate measure of success, the links between hand hygiene and infection rates prove too complex to measure: dozens of strains of infections exist; multiple ways to check for each strain exist; and HAIs are rarely reported to the hospital following discharge.

As a result, leaders determined success would be measured by improvements in systemwide hand washing compliance.

Identify Vital Behaviors

The premise of the Influencer model is that the solution to most problems—even persistent and resistant problems like getting every hospital employee to always wash his or her hands—is driven by a small handful of behaviors. To uncover the vital behaviors that would lead to improved hand hygiene, Spectrum leaders examined successful outliers among other healthcare facilities, combed through research released by international governing bodies, and studied positive behaviors in their own culture. Leaders asked, “What are the minimum behaviors that, if practiced, would achieve our goal to improve compliance?” Based on their positive deviant research, they identified and adopted the following three vital behaviors:

1. WIWO. Wash in and wash out every time staff enters a patient’s room—regardless of whether or not care is provided during the encounter. This behavior was taken from the Michigan Health and Hospital Association. It is also consistent with the WHO and CDC hand hygiene recommendations.
2. 200 Percent Accountability. Each staff member is 100 percent accountable for his or her own behavior as well as 100 percent accountable for the hand washing behavior of his or her coworkers.
3. Say “Thank You.” When a staff member is reminded to wash his or her hands (even if he or she has just washed) he or she is to say “thank you for reminding me” and wash again. Staff members are not to get defensive but to make it safe and easy for others to remind one another.

Spectrum leaders believed if staff adopted these three behaviors, they would successfully change hand washing compliance systemwide.

Consider Six Sources of Influence

Influencers succeed at managing systemwide change because they “overdetermine” success. They combine a critical mass of different strategies to make change inevitable. The Influencer model organizes influence strategies into six sources that both motivate and enable people to change through personal, social, and structural forces. The researchers behind the Influencer model studied thousands of leaders who were engaged in executing more than 100 mission critical initiatives to uncover a formula behind successful change management. They found that when initiatives combine at least four sources of influence, they are 10 times more likely to succeed than those that utilize less than four sources.⁵

Spectrum leaders recognized that when implementing these vital behaviors, each unit would face unique challenges and would need a customized influence strategy. They also knew the staff and physicians would need to take ownership in the initiative to achieve the level of success they were hoping for. To transfer ownership, leaders provided staff with the six-source model of influence and asked them to identify and implement the appropriate strategies in each of the different sources. Each strategy was closely monitored, measured, and modified as needed to ensure it created the desired behavior. While leaders provided coaching and support, the staff took the lead and identified the following strategies as they relate to the six sources of influence.

Source 1, Personal Motivation

The goal of this source is to ignite every person’s passion for hand hygiene—to cause every person to see the three vital behaviors as “the right thing to do.” The most powerful way to build personal motivation is to use personal experience and moving stories. Below are a few of the methods the units used to build personal motivation.

1.      Link to a personal experience. Staff members were asked to share their personal experiences related to HAIs. The most effective stories came from physicians. These physician champions caused staff to reflect on the impact of poor hand hygiene as well as revealed the physicians’ personal passion for hand hygiene. Personal stories reinforced that WIWO was the right thing to do—not just a rule to follow. Units also worked through the Patient and Family Council to find former patients who had suffered from an HAI. They invited the patient to meet with their unit and tell their story. Perform germ powder demonstrations. One unit created a dramatic personal experience by using an invisible powder. They spread the powder around the room, simulating the spread of pathogens around a patient’s room, and asked staff and physicians to perform routine chores. They then used an ultraviolet light to reveal the powder staff had accumulated on their hands. This exercise dispelled a common belief that as long as staff members don’t touch patients, they won’t pick up any germs.

2.      Link to an experience in the news.  Some units used a local news story to focus on the importance of hand hygiene. Hope College suffered a norovirus outbreak spread by poor hand hygiene that was so severe, the college had to shut down for a week. More than 400 staff and students were racked with vomiting and diarrhea that lasted up to 48 hours. Many staff had children or friends who were affected by this outbreak. Teams discussed the outbreak and made the link to hand hygiene.

3.      Teach the skills to others. Spectrum Health encouraged staff to participate in community-education experiences. Several units volunteered in the Children’s Hospital and in local schools to educate children about hand hygiene. As a result of leading these discussions in local schools, the staff came to “own” hand hygiene as a personal mission.

4.      Become your patient’s advocate. Leaders, staff, and physicians tapped into staff members’ initial motivation for entering healthcare. Most had the goal to improve the health of patients and take on the role of patient advocate. In the hierarchical culture of healthcare, the advocate role can seem subversive. It was therefore effective for staff to hear from their peers, managers, and physicians that everyone wanted them to play this patient advocate role.

5.      Connect with purpose. Staff members were asked to sign commitment boards that asked for formal commitment to upholding the three vital behaviors.

Source 2, Personal Ability

Even the most motivated staff members will fail to change their behavior if they don’t know how to adopt the new skills. As a result, the units implemented strategies that ensured every staff member felt competent and comfortable performing the vital behaviors, including  holding each other accountable for appropriate hand hygiene and making sure everyone understood the whens, whys, and hows of washing in and out.

1.      Provide formal training. Spectrum Health employees were trained in Relationship-Based Care and Crucial Conversations. Staff members were encouraged to utilize skills learned in these training programs to hold others accountable for hand hygiene.

2.      Create scripts. Each unit created sample scripts for reminding someone to wash their hands, for responding to a reminder, and for pushing a bit harder if they met resistance from their colleague. The goal was to keep the scripts brief, nonjudgmental, and friendly. It’s rare to know for certain whether a person is noncompliant with WIWO, so the reminders and responses include an element of tentativeness (“I know you might have just done this but …”).

3.      Conduct role plays. Staff members practiced the scripts until they felt comfortable speaking up on their own. Physicians participated in practice sessions as often as possible which helped convince nurses and staff that physicians wanted and valued reminders.

4.      Deal with difficult doctors. Initially, a few physicians had concerns about the WIWO policy. These physicians were identified and carefully approached by a physician leader. To get their support, leaders presented them with the logic related to a “safety culture” as well as high-reliability science. Several of these physicians later became passionate supporters.

Sources 3, Social Motivation

Social motivation strategies were designed to make sure all staff members knew their leaders, peers, and the physicians on their units supported adopting the vital behaviors. It was vital that staff members were rewarded and not punished by the people around them.

1.      Demonstrate support from senior leaders. Senior leaders, including the hospital president, spoke out and wrote memos supporting the hand hygiene initiative. They provided the team that led the initiative with access to consultants and other resources, and they demanded improvements. Managers across the organization saw that this was an initiative their leaders valued.

2.      Recruit managers and physicians. It was essential to have the unit managers and key physicians actively support the initiative. Each unit had a manager and a respected physician champion the practice. These managers and physicians made a point of asking staff to remind them when they forgot to wash their hands. They also had many other opportunities to demonstrate their passion for hand hygiene—transforming the initiative from an imposition into a commitment, and even a moral imperative.

3.      Work through opinion leaders. Many units had frontline staff members who worked alongside managers to lead the unit. We asked these informal leaders to lead the way in practicing perfect hand hygiene and to remind others when they made behavioral oversights.

4.      Showcase public commitments and permissions. Colorful and signed commitment posters were placed in public places, for the staff, physicians, and even patients and family members to see. Leaders also created posters that featured prominent Spectrum Health physicians saying, “Remind me to wash my hands.”

5.      Make it fun. Confronting others can be stressful, so staff and physicians found ways to lower the pressure. A staff member in the ER dressed as a clown with her oversized pockets full of mini-Purell dispensers. A physician named herself the “queen of clean” and wore a plastic gold tiara. These extra steps helped to communicate that any staff member can hold others accountable without ruining relationships.

Source 4, Social Ability

The purpose of social ability is to create a team approach—giving any individual the support required to wash up and remind others to wash.

1.      Everyone reminds everyone, regardless of role or position. This essential strategy doubled as the second vital behavior. Every staff member agreed that while they always intend to wash their hands, circumstances arise that lead them to forget on occasion. As a result, whenever someone saw them forget to wash, they would greatly appreciate being reminded.

2.      Use opinion leaders to convert skeptics. Unfortunately, some people did object to being held accountable. The physician and manager champions took time to speak with these people and gain their support.

3.      Make the infection control team a resource and partner. It’s easy for units to see the hospital’s infection control team as enforcers, rather than as resources. The infection control team took great care to be helpful by arranging resources for the units and meeting frequently to learn about each unit’s needs.

Source 5, Structural Motivation

Structural motivation creates incentives and rewards for acting on the vital behaviors. These rewards are most effective when used in moderation and in ways that enhance personal and social motivation.

1.      Use individual rewards. Stickers and gift certificates were used to visually reward and recognize early adopters.

2.      Celebrate success together. Parties were held to reward consistently high performance.

3.      Offer a grace period. Before the vital behaviors became a part of staff members’ performance report, a grace period was implemented by each unit. Only now is Spectrum Health in the process of including hand hygiene compliance in the key performance measures for managers and directors. Additionally, some medical staff departments are incorporating physician-specific hand hygiene compliance into their ongoing professional practice evaluation metrics.

Source 6, Structural Ability

Structural ability includes changes in the physical environment to make hand hygiene more convenient, easier to remember, and easier to track.

1.      Ensure access to hand hygiene dispensers.  Hand sanitizer dispensers were placed just inside and outside of every patient room, every meeting room, and every manager’s office.

2.      Use reminder cards. Staff members created pocket cards that served as reminders to practice perfect hand hygiene. If they didn’t feel it was appropriate to remind a person verbally, they could hand them a reminder card.

3.      Have units track performance. Each unit became responsible for measuring and tracking their own hand hygiene performance. Staff members rotated into the observer role and were asked to make several observations each week. Units had immediate access to their data. It was placed in a very public area, and they took ownership over the numbers.

4.      Use visual cues. Signs and posters were placed in every unit, and screen savers were installed on most computers. These were friendly and colorful reminders. One example was a large poster and Purell dispenser that greets every patient and visitor at the hospital’s main entrance.

5.      Conduct a PR campaign. Spectrum Health initiated a community hand hygiene education program complete with news releases, interviews with local media, and public educational materials in their outpatient and urgent care clinics.

Lasting Impact of Hand Hygiene Intervention

As units began acting on the three vital behaviors and implementing their custom six-source plans, Spectrum Health realized rapid and sustained improvements. Tracking within the first two months showed improvements of 90 percent compliance. And these improvements continue. A year later, Spectrum reported a compliance rate approaching an unprecedented 95 percent.

But the value of this initiative goes much further. Resounding evidence of behavior change is evident in the way the staff members confront and have the right conversations with one another. Remarkably, staff members speak up and confront physicians who may be perceived as intimidating or powerful when the physician fails to comply with the behaviors outlined in Spectrum’s influence initiative.

Spectrum’s Vice President of Innovation and Patient Affairs shares a telling experience. An executive was participating in rounds and entered a patient’s room without washing his hands. While the physician was unlikely to touch anything, he was violating the wash in wash out policy—the vital behavior every employee had worked hard to adopt. A staff nurse who observed the violation spoke up and reminded the executive to wash his hands—all of this in front of patients.

As a result of the numerical data and anecdotal evidence, leaders at Spectrum Health came to see hand hygiene as the perfect microcosm for developing the skills and norms required for a highly reliable patient safety culture. The hallmarks of a safety culture include: 1) anyone who has a concern is expected to speak up immediately and others are expected to listen; and 2) everyone holds everyone accountable for safe practices, regardless of their role or position. Through the Influencer model, Spectrum Health has accomplished both of these hallmarks within the area of hand hygiene and is beginning to see changes in all other areas of performance.

Matt Van Vranken, president of Spectrum Health explains, “As people have learned to hold each other accountable for something as simple as hand hygiene, they’ve learned skills they’re using to hold each other accountable for other outcomes that are expected: patient safety, quality, and efficiency. The hand hygiene initiative has provided us with a cultural framework to drive high performance broadly within the organization.”

About Spectrum Health

Spectrum Health is the largest not-for-profit healthcare system in West Michigan with seven hospitals, more than 140 service sites and 2,000 beds systemwide. It has the largest children’s hospital in West Michigan, Helen DeVos Children’s Hospital, and the largest adult open heart program in the state. It is the largest regional provider of cancer care and has one of the top joint replacement programs in the nation. The service area covers Michigan with 500,000 Priority Health plan members and more than 8,000 employers.

References

1. CDC. Public health focus: surveillance, prevention and control of nosocomial infections. MMWR 1992;41:783-7.
2. WHO. WHO Guidelines on Hand Hygiene in Healthcare. First Global Patient Safety Challenge Clean Care is Safer Care. WHO 2009; 24-25. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
3. WHO. WHO Guidelines on Hand Hygiene in Healthcare. First Global Patient Safety Challenge Clean Care is Safer Care. WHO 2009; 159. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf 
4.  MIT. MIT Sloan Management Review. The Richard Beckhard Memorial Prize. July 1, 2009. http://sloanreview.mit.edu/the-magazine/articles/2009/summer/50499/the-richard-beckhard-memorialprize/
5. MIT. MIT Sloan Management Review. “How to Have Influence” by Joseph Grenny and David Maxfield. October 1, 2008. http://sloanreview.mit.edu/the-magazine/articles/2008/fall/50113/how-to-have-influence/

David L. Dull, MD, is the vice president of quality for Spectrum Health Grand Rapids. He received his medical degree from Wayne State University School of Medicine in Detroit, Mich. and did his residency and fellowship at the University of Iowa Hospital and Clinics in Iowa City, Iowa. Dr. Dull leads the strategic planning and coordination of tactical implementation of the clinical quality and safety initiatives at Spectrum Health Butterworth Hospital, Spectrum Health Blodgett Hospital and Helen DeVos Children’s Hospital.

David Maxfield is the vice president of research for VitalSmarts, where he is leading a series of consulting and research projects on the role influence plays in initiating and sustaining change in organizations. He is also the coauthor of the New York Times bestseller, Influencer: The Power to Change Anything. Maxfield did his doctoral work in psychology at Stanford University, where he studied personality theory and interpersonal-skill development. He develops training for VitalSmarts, an innovator in corporate training and organizational performance. www.vitalsmarts.com.