Sunday, July 8, 2012

Quality killers - Absence of personal commitment

This may seem to be a departure into new territory and topics, but it is very much related to health care Quality and Error.

This was an interesting week in clinical microbiology and infectious diseases and infection control, all topics that are still near top of my heart and mind.  This week there was news about a new antibiotic available to treat severe diarrhoea caused by the bacterium Clostridium difficile.  Another new antibiotic that will inevitably follow the familiar path of use then over-use then abuse, then antibiotic resistance and then discard, with little more than a momentary and passing impact on the course of disease.  

What is so needless and so tragic here is that this treatment cycle is required because this bacterial pathogen is passed from person-to-person, usually in  medical treatment facilities either directly from a contaminated environment or indirectly via contact with healthcare workers' poop-contaminated hands.  

Basically this is an infection that does not need to occur if we could keep hospitals and clinics as clean as we expect diners and restaurants instead of like road-side portable toilets.

For a service sector that wraps itself in history and tradition, there are two traditions that healthcare has studiously ignored for well over 100 years, the first is handwashing and the second is Quality Management.  One has to ask “why?”

In 1841 (171 years ago) Ignaz Semmelweis, a physician working in Vienna established after 6 years of definitive scientific method that hand washing could prevent infection.    The concept of hand washing was generally accepted as fact by 1850.  By 1865 Florence Nightingale had introduced strict hygiene as an essential component of nursing education and practice.  For the last at least 80 years it has been part of the curriculum of every medical and nursing school in the world.  It was and continues to be the right thing to do.  

But virtually every place that studies health practices in health care facilities today sees that hand washing is completed no more that 10-20 percent  of appropriate times and in-hospital spread of infection happens all the time and everywhere.  Millions of dollars are frittered away addressing building restructuring and administration and cajoling because health care workers are too self-absorbed to wash their hands.   

In that same perspective, the story of modern Quality Management can be traced back to Frederick Taylor in the 1890s.  It has been adopted in virtually every service and manufacturing sector with the exception of government and healthcare.  Again you have to ask “why?”

Well I can tell you why.

It would be easy to put it down to slips and distractions, and systemic errors due to overwork, or healthcare buildings making sink access inconvenient, but that may account for 1-5 percent, probably less.  

Largely it comes down to an absence of personal commitment along with a distorted sense of professional arrogance.  As in “I know what they say about dirty hands, but I don’t want to handwash because it hurts my hands, and besides I personally have never spread an infection.  And besides I am a too busy professional”.  

What nonsense.

So instead of reducing human suffering by spending 10 seconds at a near-by sink with simple running water and some soap, the healthcare professionals demand the construction of more single rooms (costing a fortune) and the availability more new antibiotics.   And here’s why, construction and purchasing is done with OPM (other people’s money) but handwashing consumes MY time.  
And it is the same story when it comes to Quality Management.  Most healthcare workers would rather spend OPM for software and EMRs (electronic medical records), than be engaged in any commitment to personally do something active to reduce error.  

It is not just sad, it is tragic.

Message: the next time you read about a new miracle antibiotic to cure some horrible infection, ask yourself what are the root causes of the infection in the first place.


  1. Good read and eye opening since I thought it was only the food industry where getting employees to wash their hands was a daily challenge.

  2. A while ago, the baby toe of my right foot became infected after stubbing it on a doorframe in the middle of the night. After a very anxious bus ride I arrived at a local clinic at 4:30 on a Friday night. I was instructed to remove my shoe and sock and wait for the doctor to arrive.

    "What's the problem?"
    "I have an infected toe"
    Doc looks for a long time and says, "I don't see anything"
    "It's the little one"
    "Wow, that looks nasty. Can I touch it?"
    "Only if you wash your hands first"
    Scowls, washes, examines (without gloves), writes Rx. (No culture request). Documents whatever it is he documents in 12 seconds in "my file". Gets up. Picks up next chart. Makes like he's going to next exam room.
    "Um, don't you think you should wash your hands?"
    Scowls, shoots me a look of nastiness and goes into next room.

    I never went back. I suspect things will never get better until someone dictates hands must be washed in front of the patient, prior to patient contact, and patients are informed that that have a right to demand this.

    Relating this back to quality management, we should demand that organizations make sure the basics are covered before more expensive solutions are implemented. What I see, and fear is that organizations don't believe in the basics anymore. Let's put in document control software even though we don't have adequate procedures, and even though staff don't understand the basics. Let's implement this point of care testing even though no one who wants this testing knows if it's the right test at the right time for these patients. After all the manufacturer tells us we don't need all that fancy QC and PT stuff....

  3. Negligence isn't malice. The assumption that you draw about individuals not washing their hands is downright cynical. There is a problem. That problem is a lack of education about the seriousness of that problem. Since handwashing was introduced, we take for granted, like most things in life, that it is so simple, effective, and wasn't as "common sense" as we think now. Professionals do what people in general do best: Treat the symptom and not the problem. When new professionals are starting out, present them with studies citing the importance of handwashing. Impart upon them the how-to and why. When they are doing clinicals, rounds, or tours preceptors/guides should lead by example.

    1. With respect Brandon, I have to disagree. When university trained health professionals don't know enough or have enough sense of professional duty and responsibility to wash their hands to prevent transmission of infection, that is not a problem of lack of education. Healthcare professionals get this information early and regularly and often. They choose to ignore it.

      It is one of the most significant examples of non-professionalism that I can think of. In terms of risk potential is certainly right up their with working while intoxicated.

      Not cleaning your hands risks other people's health and livelihood and resources, and potentially their lives.

      And that unfortunately is an undeniable truth.

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