Preventing Infection

“Thanks for reminding me”- The cultural change in hand hygiene

In a stressful working day, healthcare professionals might forget to clean their hands every time it is necessary. By encouraging patients to remind nurses and doctors of their hand hygiene, compliance rates increase, which results in a decrease in infection rates. Although campaigns such as these may initially seem intimidating, they are bringing about a positive cultural change.

It’s six p.m. when the late-visitation round is coming to an end. A doctor and a nurse open the door, and greet the patient resting in his bed. They shake hands, and keep chatting while the doctor adjusts the patient’s infusion that is hanging on a stand next to the bed. By this time, dangerous bacteria and other germs might have already been transmitted into the patient’s body – because the healthcare professionals forgot to clean their hands.

"It is a typical scene I have seen many times," says Dr. Arjun Srinivasan, an expert for hygiene, "It’s not that healthcare professionals don’t know about proper hand hygiene. The challenge is that they have to do it a lot, and have to remember it every time, even in stressful and emergency situations." Srinivasan works as Associate Director of Healthcare Associated Infection Prevention Programs at the US Centers for Disease Prevention and Control (CDC). "We don’t have to convince people that disinfecting hands is important – they generally agree. Instead, we try to find ways to help professionals remember it every time."


"A cultural change in hand hygiene has begun on both sides. We have to empower patients to ask, and also help our healthcare team to react to it."

Dr. Arjun Srinivasan, Centers for Disease Prevention and Control


"There is no guideline for changing behaviour"

The introduction and implementation of alcohol-based hand rubs “really has been transformational in helping people to keep their hands clean,” says Srinivasan. In addition, institutions such as the CDC continually work on guidelines and recommendations for hand hygiene. “As valuable as guidelines might be for identifying evidence-based practices, they are sometimes ineffective in directly changing behaviour.” For example, one working group studied 1 the diffusion, implementation, and impact of the revised CDC hand hygiene guidelines on practice in 40 National Nosocomial Infections Surveillance system hospitals. They found that hospital staff were well aware of the guidelines, and that structural changes had been made to implement new policies, and ensure that products were available to staff. However, there was no difference in the process of hand hygiene, or on the outcome of infection rates when comparing hospitals with high and low guideline implementation scores.2

“You need to understand the psychology that leads to a change in behaviour,” says Srinivasan. Various theoretical models and improvement strategies exist, but sometimes interventions that work well in one organization will not work in another. Experts suggest that interventions often fail to improve staff practice because they are not customized to specific problem areas within an organization. “We have often seen the importance of leadership. The senior-most position in a team is a role model. If the leader of a team demonstrates good hand cleaning practice, the rest of the team in the room will do the same. Unfortunately, the reverse holds true as well,” Srinivasan explains. This is why the CDC tailors certain messages to senior physicians, to make them aware of their influence in the effectiveness of hand hygiene practices.

What is the CDC?

The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States. The CDC is a United States federal agency under the Department of Health and Human Services, headquartered near Atlanta, Georgia. Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability in the US and internationally. The CDC focuses national attention on developing and applying disease control and prevention.

Involving patients for better hygiene

Another powerful way is to involve patients and their families in the process. With informational brochures, and clearly visible signs next to sinks or hand rub dispensers, medical facilities raise awareness on the topic of hand hygiene. “In the US, another form of campaign has become popular in the past few years, because it is effective – and cheap,” says Sriniviasan. He is referring to buttons and badges for medical professionals that say something like ‘Ask me if I’ve cleaned my hands.’ These encourage patients and visitors to remind their nurses and doctors of proper hand hygiene practices, without transferring responsibility from healthcare workers to patients and visitors3. “Mostly patients will hear ‘Yes, I have done it, but I’m happy to do it again in front of you.’ This reinforcement will increase confidence and trust. Making the patient feel more comfortable is just one result of such campaigns4.

“There have been a number of studies that have shown a couple of things. One is that with hand hygiene campaigns, compliance rates have gone up from 50% to well over 90%. At the same time, infection rates go down,” explains Srinivasan. Healthcare–associated infections (HAIs) are a major burden to the US health care system. The CDC estimates that on any given day, about one in 25 hospital patients has at least one HAI, with close to 75,000 of these patients dying annually. A 2013 JAMA Internal Medicine article projected the annual costs of five major HAIs add up to $9.8 billion5. Organizations participating in campaigns run by the Joint Commission’s Center saved up to $2.8 million dollars in direct medical costs by targeting effective hand hygiene.6

A cultural change for better health

“Of course, the buttons can be intimidating for patients and healthcare professionals alike. But there has been a transformation in overcoming historical norms. Before such encouragement, people would never have dared to ask their doctor or nurse if they have cleaned their hands,” says Srinivasan. Although today many healthcare professionals participate in button campaigns, Dr. Srinivasan understands the obstacles. “I would never trivialize how hard it is for patients to ask. It is hard for me to remind colleagues – and they all know what I do for a living.”

For him, a positive development is taking place in the US. “A cultural change has begun on both sides. We have to empower patients to ask, but we also have to help our healthcare team to react properly to it.” Dr. Srinivasan always wears the blue-and-white button on his coat. “I admit that even as an expert in healthcare-associated infections and hygiene, there have been situations when a patient asked me – and I had to say, ‘You know what? I forgot,” says Srinivasan. “‘Thanks for reminding me!’”

Further information

  1. Dissemination of the CDC’s Hand Hygiene Guideline and impact on infection rates, Larson EL et al., Am J Infect Control.

  2. Measuring Hand Hygiene Adherence: Overcoming the challenges, The Joint Commission

  3. A Quick Guide to Just Clean Your Hands – Ontario’s Evidence-based Hand Hygiene Program for Hospitals, Public Health Ontario (PHO)

  4. Patient empowerment and hand hygiene, 1997-2012., McGuckin M, Govednik J, J Hosp Infect.

  5. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system, Zimlichman E et al., JAMA Intern Med.

  6. Hand Hygiene Buttons and Stickers, Joint Commission International







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