Moving Through Hospitals: Designing Handwashing
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Images and Article by Rachel Lehrer
In October, 2008, Medicare—the United States’ government program that pays 40% of the nation’s hospital bills—decided to stop covering hospital failures. This meant that a litany of preventable mistakes, including treatments resulting from surgical errors, patient accidents and infections, were now the financial responsibility of the hospital. As a result, medical accidents went from being a source of hospital revenue to a massive financial drain. The good news is that medical institutions were finally forced into the business of disease prevention, at least once people were in their care.
What can be done to prevent costly medical mistakes? The hospital reform with the greatest potential is also the easiest to implement, at least in theory. According to the Committee to Reduce Infection Deaths statistics, hospital acquired infections kill more people in America than AIDS, breast cancer and auto accidents combined. Furthermore, the vast majority of the patients that acquire such infections in hospitals—and more than 5 percent of patients do—get them from the hands of health care providers. Thankfully, hospitals have become increasingly concerned with hand hygiene. The dirty hands of doctors and nurses aren’t just gross—they are an extremely expensive and potentially fatal act of carelessness. Hospital staffers, in order to follow protocol, need to wash their hands hundreds of times a day. Their failure to follow protocol perfectly is their personal responsibility but non-compliance on such a broad scale is also a failure of the medical system that creates the rules and environment that lead non-compliance.
The medical industry’s acknowledgment of hand hygiene as a systemic problem has led to the establishment and growing influence of Infection Control and Prevention Units. For Infection Control and Prevention, solving handwashing takes the form of cheeky posters of doctors reminding everyone to wash their hands, developing inane training videos demonstrating how to properly wash your hands and implementing incentive programs where health care workers reward each other with certificates when they observe a co-workers consistent compliance. In the hospital where I have focused my research, these certificates were returned unused.
One increasingly popular but misguided program has to been to implement paternalistic monitoring of nurses and other providers, who are forced to undergo increasing levels of surveillance. Whether it is video monitoring systems borrowed from meat manufacturing plants or sensor systems that read the alcohol content on hands, staff are cajoled into changing their behavior by receiving real time feedback combined with their fear that their personal compliance level is now public knowledge. There is no carrot—there is only a stick.
Despite growing desperation, few designers have bothered to do much of anything that might make washing or sanitizing hands more appealing. A recent scientific study pointed to “perceived busyness” as one of the primary deterrents to compliance. But this only demonstrates the silliness of current reforms. After all, if followed literally, the prescribed protocol for hand cleaning would require so much of the health care workers time that they wouldn’t actually be able to perform the rest of their job. During a recent observation, nurses were consistently walking from supply closets to narcotic storage bins to patients rooms with their hands full. How, then, can they follow protocol and wash their hands correctly when they enter the room? Are monitoring systems supposed to solve these problems? Or are we merely putting increased strain on an already stressed population without offering any design solutions?
