Tying Executive Compensation to Hand Hygiene? Be Careful.

By Clean Hands - Safe Hands

Should nurse managers get a financial bonus if their units achieve excellence in hand hygiene?

Should hospital leaders be penalized if hand hygiene rates remain low?


The current Leapfrog Hand Hygiene survey asks if “senior administrative leadership, physician leadership, and nursing leadership [are] held directly accountable for hand hygiene performance through performance reviews or compensation.” To earn a top Leapfrog Hospital Safety Grade, hospitals can link leaders’ compensation to “meeting targets for hand hygiene compliance rates.”

That sounds like a good idea in theory, but in practice, linking compensation and performance reviews to metrics that leaders can’t directly control is problematic.

Education Tried Holding Teachers Accountable for Student Test Scores. It Didn’t Go Well.

In the early 2000s, education reformers and legislators who wanted to boost student achievement turned their attention to teachers. A 2010 briefing published by the Economic Policy Institute noted that some states were “considering plans that would give as much as 50% of the weight in teacher evaluation and compensation decisions to [student] scores on existing tests of basic skills in math and reading” – and added, “we consider this unwise.”

Despite this warning, in 2012, then-NYC mayor Michael Bloomberg declared that student test scores would be a “deciding factor” in awarding teacher tenure, which directly influences teacher compensation.

By 2021, authors were reporting “many unintended negative effects of outcome-based accountability,” including narrowing of the curriculum, teaching to the test, and cheating. Teacher morale plummeted. As noted in a November 30, 2021 Forbes article, linking educators’ compensation to student test scores “placed teachers in a crazy world where they face the threat of punitive actions over things they cannot control. And it has reduced the attractiveness, the basic appeal, of the profession.”

Meanwhile, student achievement stagnated.

A Better Approach to Hand Hygiene Accountability

Will linking hand hygiene metrics to hospital leaders’ performance reviews or compensation have the same disastrous impact?

It could. We know of a hospital that tied staff bonuses to hand hygiene rates and faced significant pushback. Some employees quit. Eventually, hospital leaders realized that their electronic hand hygiene system wasn’t accurately collecting data. The result? A lawsuit.

Careful implementation of hand hygiene accountability systems can prevent such costly mistakes. We recommend these three steps:

1. Incentivize behaviors that will lead to the desired outcome

Your hospital CEO and nurse managers cannot control whether individual staff members wash or sanitize their hands, so it’s not fair to reward or punish them for something that’s beyond their control. It’s also highly ineffective.

It’s much more effective to tie leaders’ performance reviews and compensation to behaviors they can directly influence, such as the percentage of staff members who regularly wear their electronic badge or twice-weekly discussions of unit hand hygiene data.

2. Don’t immediately tie compensation to performance

Allow time for improvement. It takes time – considerable time – to establish an effective hand hygiene program.

“Don’t start taking money out of people’s paychecks on day one,” advises one SwipeSense exec. “You need to build in a period of time for things to improve – and we’ve learned that period of time is typically much longer than what most organizations expect.” It may take six months or longer to see significant improvements in hand hygiene.

You can achieve a top Leapfrog Safety Grade by outlining a process by which your institution will hold leaders accountable for hand hygiene.  

3. Positively reward performance

Leapfrog’s “intention behind tying hand hygiene to compensation is to emphasize the seriousness of the issue and get people to remain engaged with the data,” Dr. Hermann says. You’ll have the best luck if you reward positive steps forward, rather than penalizing poor performance.

“People get very defensive and upset if you start pulling money out of their paychecks,” Hermann says. Consider financial bonuses for progress toward hand hygiene goals. Some educators eventually realized that it may have been better to reward teachers and schools that demonstrated growth. In many places, though, that realization came too late.

Hospital executives can learn from education reformers. Incentivize behaviors rather than outcomes; allow time for improvement; and positively reward performance.


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