The Top 5 Real (and Surprising) Reasons Clinicians Don’t Clean Their Hands

Hand hygiene continues to be a challenge for nearly all healthcare organizations. On the surface, it seems like a pretty simple concept, but once you really understand the complexity and variability of the clinical reality, it quickly becomes massively complex. The Joint Commission just raised the standards for hand hygiene, and, as of last week, clinicians have to perform hand hygiene or risk a citation.

Hand hygiene is performed correctly 30-40% of the time on average, and some organizations have actual hand hygiene rates below 20%. Why is this?

The initial reaction we commonly hear is that clinicians need more education, they just need to “buck up” and wash their hands, or we should just fire them if they don’t somehow magically start to do it.

Are clinicians lazy, uneducated or uncaring? No! As a group, they are some of the most hard-working, well educated and highly compassionate people out there. The real reasons they struggle are nearly always not their fault.

We went back and analyzed data from over 10 million hand hygiene opportunities from hospitals of different sizes, types, and locations to identify the top 5 reasons that clinicians fail to perform hand hygiene.

1. Clinicians are very busy and they sometimes forget. This is by far the most common reason, and fortunately, it can easily be addressed. Many healthcare providers are expected to clean their hands over 250 times per shift, and they have many other things on their mind. The research collaboration that established the foundation for our company came together to develop a reminder for hand hygiene. We have been continually amazed how a simple Real-Time Voice Reminder™ can help improve and sustain behavior change.
2. Often, it’s a non-obvious educational issue. You’d be surprised how much confusion there can be about a hospital’s hand hygiene protocols, even among the most experienced clinicians. Our system uses a voice reminder that is configured to match the expected behavior and allows us to identify these opportunities for improvement. In nearly every case, these are not the basics of hand hygiene that are covered in hand hygiene class or moments that can put on a poster, but the real-world reality that happens during the complexity of acute care.  I recently met with a very senior physician, one who’s consistently ranked a “Top 100” doctor and who sits on the hospital’s quality committee. He was asking me why he heard our voice reminder every time he left isolation rooms after taking his gloves off. He didn’t know he had to clean his hands after removing gloves. The IP manager then politely explained why this was important and the problem was solved.
3. Unit cultures are all different, and some are more attuned to hand hygiene than others. We’ve seen an individual clinician move from a unit with high hand hygiene performance to one with low performance, and even that individual’s performance declined. We are all influenced by our surroundings, for better or for worse. That’s one reason our process incorporates group competitions. These fun activities get units to pull together as a team, and positively influences each unit’s culture.
4. There can be unintended workflow issues that make it harder for clinicians to clean their hands. We see a very consistent point of diminishing return around hand hygiene. Simply put, there is a point where all clinicians become disorganized in their ability to provide care, and, as a result, hand hygiene suffers. In many cases, there are simple answers to these challenges. For example, one hospital partner of ours had central line supply carts that were too big to fit inside patient rooms, which meant clinicians were running back and forth out of the room. We’ve also seen glove boxes installed in an inconvenient place, as well as hand hygiene rates changing depending on how close a patient room was to the supply closet. We partner with hospital organizations to shed light on these kinds of logistical details and, in addition to improving hand hygiene, it can actually make the hospital more efficient.
5. Finally, there are occasionally what we call “Conscientious Objectors.” These are clinicians that understand the protocols and simply choose to ignore them. While people assume this is the main reason people fail to sanitize, it truly isn’t. The vast majority of clinicians are intelligent, empathetic, hard-working people who just need a reminder, education, or an improvement in culture or systems. There are really just a small minority of Conscientious Objectors. Fortunately, our system can easily identify them so managers can focus on working with them rather than having to spend their time focusing on all clinicians.

Now that The Joint Commission is citing hospitals if they see an individual provider fail to clean their hands one time, hospitals are even more concerned than they were before about improving hand hygiene performance across the board. Understanding the reasons that clinicians sometimes don’t sanitize is the first step in solving the problem.