This document summarizes strategies for improving physician compliance with hand hygiene recommendations. It begins by noting the typically low rates of compliance in Dutch hospitals and outlines factors that may contribute to non-compliance. These include perceptions that guidelines are too complex, that one's own situation is different, or simply not caring. The document then provides suggestions for addressing non-compliance, such as having repeated face-to-face conversations to emphasize evidence that non-compliance harms patients, limiting guidelines to one or two clear options to avoid decision paralysis, and appealing to peer pressure by emphasizing consistency with other institutions. The goal is to overcome barriers to compliance through effective communication and engagement strategies.

1. 17-­‐07-­‐15
1
Andreas
Voss
Andreas
Widmer
Sbarbaro
Clin
Infect
Dis
2001,33:S240
Changing
physicians
behavior
is
considered
by
many
to
be
an
exercise
in
fuHlity
–
an
unaJainable
goal
intended
only
to
produce
premature
aging
in
those
seeking
the
change.
The
more
opHmisHc
might
describe
the
process
as
uniquely
challenging.
=
coordinated
set
of
acHviHes
designed
to
change
specified
behavior
paJern
…
and
that
you
are
Dutch
Lets
assume
that
you
are
interested
in
hand
hygiene
…
By
far
the
lowest
observed
%
published
compliance
with
HH
¤ 24
hospitals
in
the
NL
(ICUs
&
surgery)
¤ 19%
overall
compliance
² 3%
before
² 22%
a]er
¤ No
difference
between
RN
en
MD
¤ Smaller
hospitals
beJer
than
bigger
Vicky
Erasmus
Inf
Control
Hosp
Epidemiol
2009
The
Lowlands
(NL)
21%
The
Honestlands
50-­‐70%
The
Lielands
80-­‐95%
The
Rest
of
the
World

2. 17-­‐07-­‐15
2
hJp://www.hha.org.au/LatestNaHonalData.aspx
¤
We
look,
others
don’t
…
¤
Our
surveillance
is
too
good
(no
Hawthorne
effect)
…
¤
No
one
can
do
beJer
…
¤
Five
indicaHons
are
(two)
too
many
…
¤
Handhygiene
is
only
one
of
the
measures
…
¤
EducaHon
¤
IncenHves
for
appropriate
behaviour
¤
Penalise
inappropriate
behaviour
¤
….
¤
No
target
behavior
analysis
¤
No
theory
on
predicted
mechanism
of
acHon
¤
Not
considering
impulsivity,
habit,
self-­‐control,
associaHve
learning,
…
Standard
approach
¤
First
canvas
the
full
range
of
opHons
available
¤
Second
raHonal
selecHon
from
them
²
to
match
the
behavioral
target,
the
target
populaHon
and
the
context
in
which
in
which
intervenHon
will
be
delivered
Improved
approach
Michie
et
al.
ImplementaHon
Science
2011;6:42

3. 17-­‐07-­‐15
3
Individual’s
psychological
&
physical
capacity
to
engage
in
the
acHvity
concerned.
Having
knowledge
&
skills
Michie
et
al.
ImplementaHon
Science
2011;6:42
Brain
processes
that
direct
behavior:
conscious
decision
making,
emoHnal
responding,
habits
Factors
that
lie
outside
the
individual
that
make
behavior
possible
or
prompt
it
``````
```````````
This
model
of
behavior
allows
designing
interven4ons
Michie
et
al.
ImplementaHon
Science
2011,
6:42
Michie
et
al.
ImplementaHon
Science
2011,
6:42
Michie
et
al.
ImplementaHon
Science
2011,
6:42

4. 17-­‐07-­‐15
4
A
wise
man
that
you
shouldn't
mix
it
in
the
fruit
salad.
A
smart
man
knows
that
a
tomato
is
a
fruit.
…
but
the
fact
that
I
don’t
like
tomato
in
my
fruit
salad
doesn’t
mean
that
I
am
wise!
“Diffusion
is
the
process
in
which
an
innovaHon
is
communicated
through
certain
channels
over
Hme
among
the
members
of
a
social
system”
Slides
on
diffusionin
part
from
Sara
Gossgrove
¤ Rela4ve
advantage
² Is
it
beJer
than
what
we
already
have
according
to
the
users
(not
you)?
¤ Compa4bility
² Is
it
consistent
with
exisHng
values
and
pracHces?
¤ Simplicity/ease
of
use
² Is
it
easy
to
understand/adopt?
¤ Trialability
² Can
the
innovaHon/change
be
experimented
with
on
a
limited
basis?
¤ Observability
² Can
users
see
the
results
of
the
innovaHon/change?
¤ Categories
of
adopters
² Innovators
(2.5%)
² Early
adopters
(13.5%)
² Early
majority
(34%)
² Late
majority
(34%)
² Laggards
(16%)
The
diffusion
curve
generally
takes
off
a]er
10-­‐20%
adopHon
Not
for
HH
¤
PercepHon
Failures
CommunicaHon
Failures
¤
Engagement
Failures
¤
LogisHcal
Failures

5. 17-­‐07-­‐15
5
¤ Those
non-­‐compliant
don’t
believe
the
evidence
or
think
their
situaHon
is
different
¤ What
can
you
do?
² Repeated
conversaHons
² Face-­‐to-­‐face
preferred
² Show
data
that
non-­‐compliance
harms
paHents
Address
message
to
all
levels
of
physicians
(trainees
to
clinical
leadership)
² Show
that
your
recommendaHons
are
similar
to
those
from
other
similar
insHtuHons
(peer-­‐
pressure)
¤
RecommendaHons
are
too
complex
or
we
sound
doubrul
¤
What
can
you
do?
²
Make
a
single
recommendaHon
or
provide
no
more
than
two
opHons
² Avoid
decision
paralysis
²
Be
confident
²
Be
enthusiasHc
decision
paralysis
¤ Don’t
care
about
hand
hygiene
² Involve
teams
in
making
local
guidelines
² Feedback
observaHons
and
provide
posiHve
reinforcement
² Appeal
to
emoHons
² Cases
of
real
paHents
who
were
harmed
² Evidence
that
the
individual
paHent
can
be
harmed
¤
Missing
means
to
disinfect
hands
or
reinforce
compliance
²
sufficient
dispensers
and
availability
at
point-­‐of-­‐
care
²
Talking
walls/reminders
¤
Missing
feed-­‐back
¤
Not
involving
KOL’s
¤ While
we
wish
to
make
the
most
thoughrul,
fully
considered
decision
possible
…
we
frequently
resort
to
comply
on
basis
of
a
single
piece
of
informaHon
(trigger)
¤ “Click-­‐whirr”
(automaHc
response,
fixed
acHon
paJern)

6. 17-­‐07-­‐15
6
¤ Commitments
¤ OpportuniHes
for
reciprocaHon
¤ Compliant
behavior
of
similar
others
¤ Feelings
of
liking
&
friendship
¤ Authority
direcHves
¤ Scarcity
informaHon
¤ Shortcuts
–
judgmental
heurisHcs
¤ Contrast
principal
¤ Consistency
Shortcuts-­‐
contrast
-­‐
consistency
¤ “Expensive
=
good”
(and
opposite)
¤ “If
an
expert
said
so,
it
must
be
true”
² Airline
industry
“captainiHs”
Shortcuts-­‐
contrast
-­‐
consistency
¤ Perceptual
contrast
² Buying
suite
and
sweater
à
expensive
item
first
² Selling
the
car
first,
than
the
opHons
Shortcuts-­‐
contrast
-­‐
consistency
Shortcuts-­‐
contrast
-­‐
consistency
¤ Most
people
have
a
strong
desire
to
look
consistent
within
their
words,
beliefs,
autudes
¤ Whenever
one
takes
a
stand
that
is
visible
to
others,
there
arises
a
drive
to
maintain
that
stand
in
order
to
look
like
a
consistent
person.
¤ Therefore,
wriJen-­‐down
and
publicly
made
commitments
can
be
used
to
influence
others
and
ourselves
Shortcuts-­‐
contrast
-­‐
consistency

7. 17-­‐07-­‐15
7
¤ At
the
beach
² Leaving
a
blanket
with
valuables
–
pretended
the]
–
4/20
people
in
the
area
reacted
² Saying
“watch
my
things”
first
à
19/20
reacted
If
I
can
get
someone
to
commit
(take
a
stand
or
go
on
record)
I
can
set
the
stage
for
automaHc
consistency
!
¤ QuesHon
to
home
owners
–
place
large
billboard
“Drive
Carefully”
in
your
lawn
¤ Two
groups:
A)
17%
complied
B)
76%
complied
¤ Why
the
difference
between
A
and
B
?
B
was
asked
a
few
weeks
before
to
display
a
small
3x3in
sign
in
window
“Be
a
safe
driver”
Shortcuts-­‐
contrast
-­‐
consistency
¤ Key-­‐person
as
role-­‐models
¤ Published
list
of
supporters
²
WHO
pledge
¤ Pre-­‐prime
your
customer
² Would
you
(theoreHcally)
be
supporHng
our
goals?
Followed
by
a
visit
to
commit
them
to
IC
Shortcuts-­‐
contrast
-­‐
consistency
www.sciencexpress.org
/
20
November
2008
/
Page
1
/
10.1126/science.1161405
§
Orderly
alley:
33%
liJering
§
GraffiH
alley:
§
69%
liJering
¤ when
people
observe
inappropriate
behavior,
this
weakens
their
concern
for
appropriateness
§
Orderly
alley
§
No
graffiH
sign
§
Flyer
on
handlebar
§
avoid
liJering
We
need
“order”
in
our
hospitals
and
people
showing
appropriate
behavior
!

8. 17-­‐07-­‐15
8
¤ “we
are
obligated
to
future
repayment”
¤ Regan
et
al.
“Coke
experiment”
² Joe
gave
others
(unasked
for)
a
drink.
Later
asked
them
to
buy
raffle
Hckets
from
him
à
those
who
got
a
Coke
bought
more
Hckets
à
those
who
“liked”
Joe
bought
more
Hckets
² but
….
relaHonship
between
“liking”
and
compliance
wiped
out
in
those
that
received
a
Coke
!
“a
feeling
of
indebtedness
by
doing
us
an
uninvited
favor”
ReciprocaHon
¤ Mailing
a
$5
gi]
along
with
a
survey
was
twice
as
effecHve
as
a
$50
payment
for
sending
it
back
(James
&
Bolstein
1992)
¤ à
a
small
iniHal
favor
can
produce
a
sense
of
obligaHon
to
agree
to
a
larger
return
favor,
since
most
of
us
find
it
highly
disagreeable
to
be
in
a
state
of
obligaHon
ReciprocaHon
¤ Reciprocal
concessions
² Boy
scout
selling
$5
Hckets
for
Saturday
night
event,
when
rejected
offering
$0,50
candies
(buyer
feels
that
second
request
is
a
concession
to
him)
¤ Rejec4on-­‐then-­‐retreat
strategy
² Over
ask
first,
than
come
with
intended
amount
² Ask
volunteers
for
1
week
of
community
service
than
ask
for
1
hour
ReciprocaHon
A
nice
Christmas
gi]
for
your
HCWs
–
shortly
before
launching
your
HH
campaign
ReciprocaHon
¤ Principle
of
Social
Proof
² Important
means
that
people
use
to
decide
what
to
believe
or
how
to
act
is
to
look
what
other
believe
or
do
¤ Social
proof
is
most
influenHal
under
two
condiHons
² Uncertainty
² Similarity
Similar
others/social
proof

9. 17-­‐07-­‐15
9
¤ “We
view
behavior
as
correct
to
the
degree
we
see
other
performing
it”
² When
lots
of
people
do
it
–
it
must
be
right
¤ Social
proof
is
most
influenHal
under
two
condiHons
² Uncertainty
² Similarity
¤
Similar
others/social
proof
¤ Laughing
tracks
² Others
laugh
=
it
must
be
funny
² we
react
to
the
sound
(even
if
fake)
–
not
the
content
² works
even
if
the
sound
is
arHficial
¤ Church
usher
salHng
collecHon
baskets
¤ InvenHon
of
shopping
carts
(S.
Goldman
1934)
² Shoppers
stopped
shopping
when
basket
full
² First
shopping
carts
not
used
² Hire
fake
shoppers
using
carts
throughout
the
shop
?
Similar
others/social
proof
Similar
others/social
proof
Asch
conformity
experiments
Uncertainty
Heart
aJack
or
drunk?
Other
bystanders
reduce
personal
responsibility
Similar
others/social
proof

10. 17-­‐07-­‐15
10
¤ Never
again
start
a
lecture
with
only
40%
disinfect
their
hands
…
² “all
HCW
agree
that
HH
is
the
most
important
…”
Similar
others/social
proof
¤ “
We
most
prefer
to
say
YES
to
the
request
of
people
we
know
and
like”
¤ Factors
leading
to
liking:
² physical
aJracHveness
(halo
effect)
² similarity
² familiarity
² praise
² associaHon
Liking
¤ Occurs
when
a
one
posiHve
characterisHc
of
a
person
dominates
the
way
a
person
is
viewed
² Good-­‐looking
=
talent,
kind,
honest,
intelligent
² Works
in
many
situaHons:
even
judicial
process
à
handsome
men
lighter
sentences
Liking
¤ “We
like
people
that
are
similar
to
us”
² more
likely
to
help
those
that
dress
like
us
Liking
Familiarity
• “Increases
through
repeated
contact
under
posiHve
circumstances”
• “We
are
phenomenal
suckers
for
flaJery”
– PosiHve
comments
produce
just
as
much
liking
for
the
flaJerer
independent
if
they
were
untrue
or
true
• “Teamspirit”
– Car
salesperson
baJling
with
his
boss
to
give
us
a
good
price
– Good
Cop/Bad
Cop
Liking
¤ The
nature
of
the
bad
news
infects
the
teller
even
when
the
person
did
not
cause
the
bad
news
² Blame
the
weatherman
Liking

11. 17-­‐07-­‐15
11
¤ An
innocent
associaHon
with
either
bad
or
good
things
will
influence
how
people
feel
about
us
or
a
product
² The
good
looking
models
next
to
the
car
² RaHng
of
idenHcal
car
changed
with
and
without
model
² Men
didn’t
believe
that
their
judgment
was
influenced
Liking
¤ Pavlov
² Normal
response
to
food:
salivaHon,
good
and
favorable
feeling
² AJach
that
feeling
to
any
goal
² “luncheon
technique”
(ask
during
or
a]er
meal)
² Subjects
become
fonder
of
people
and
things
they
experienced
while
eaHng
Liking
¤ Praise
instead
of
criHcize
!
¤ Let
others
report
about
the
outbreak
&
extra
measures
¤ InfecHon
Control
luncheon
Liking
(aJracHveness,
praise,
familiarity,
similarity,
associaHon)
¤ Air
freshener
² Will
be
using
it
in
cars
of
nursing
home
MD’s
as
part
of
an
HH
improvement
project
Liking
(aJracHveness,
praise,
familiarity,
similarity,
associaHon)
Would
love
to
have
them
at
doors
to
paHent’s
room
¤ Power
of
authority
(Milgram
study,
1974)
¤ Symbols
of
authority
² Titles
² Clothing
² Automobiles
Authority

12. 17-­‐07-­‐15
12
Authority
Expert/Authority
¤ Various
types
of
HCWs
understanding
their
level
of
the
job
¤ No
one
may
overrule
a
doctor’s
judgment
à
automaHc
obedience
to
doctors’
order
² MD
order
for
paHents
with
earache:
“place in R ear”
² Neither
nurse
no
paHent
quesHon
the
rectal
treatment
of
the
earache
¤ People
don’t
consider
the
situaHon
as
a
whole
but
aJend
or
respond
to
only
one
aspect
of
it
Authority
¤ TV
commercial
featuring
Robert
Young
(not
a
medical
authority)
warning
people
against
the
danger
of
caffeine
and
recommending
caffeine
free
coffee
¤ RY
is
associated
in
the
mind
of
the
US
public
as
trusted
Marcus
Welby,
MD
from
a
long-­‐running
TV
series
Authority
¤ Appearance
of
authority
is
enough
to
get
is
into
the
click,whirr
mode
¤ Symbols
of
authority
² Titles
² Clothes
² Trappings
Authority
¤ PresHgious
Htles
lead
to
height
distorHon
² Visitor
to
college
presented
as
“Student”
to
“Professor”
at
5
different
levels,
college
students
than
asked
to
esHmate
length:
Δ
0.5
per
category
or
2.5
in
overall
² Size
and
status
is
related
Authority
Germany
Netherlands
How
high?
No!
Why?
Yes
…
but
I
stay
put
Authority
(Voss,
not
in
book)

13. 17-­‐07-­‐15
13
¤ Motorists
wait
significantly
longer
before
honking
their
horns
when
stopped
in
front
of
a
green
light
behind
a
luxury
car
versus
an
older
economy
model
¤ True
for
all
symbols
of
authority:
people
grossly
underesHmate
the
effect
of
authority
influence
on
themselves
Authority
¤ People
assign
more
value
to
opportuniHes
when
they
are
less
available
² “limited
number”
and
“deadline”
² Difficult
to
get
=
valuable
² Loosing
freedom
of
choiceà
increases
wish
¤ Psychological
reactance
¤ Scarcity
and
informaHon
scarcity,
censorship,
reactance
¤ Announce
a
limitaHon
of
hand-­‐rub
and
than
find
a
“new
source
of
supply”
Authority
(obedience,
Htle,clothing,
cars)
¤ “Things
that
are
difficult
to
get
are
beJer”
¤ When
free
choice
is
limited
or
threatened
the
need
to
retain
our
freedom
makes
us
want
them
significantly
more
² “Terrible
two
and
equally
desirable
toys
of
which
one
behind
a
Plexiglas
barrier
² Parental
interference
with
young
love
scarcity,
censorship,
reactance
¤ Response
to
“banned”
informaHon
² Want
the
informaHon
even
more
² Believe
the
informaHon
more
even
though
it
wasn’t
received
scarcity,
censorship,
reactance
¤ University
undergrads’
wish
to
read
a
novel
a]er
2
different
ways
of
presentaHon
…
Restricted
to
those
of
21
years
and
older
Zellinger
1974

14. 17-­‐07-­‐15
14
¤ Taste
&
rate
cookies
from
jar
² jar
with
10
cookies
² jar
with
2
cookies
(scarcity
-­‐>
rated
more
favorably)
scarcity,
censorship,
reactance
scarcity,
censorship,
reactance
¤ University
HCWs’
wish
to
read
CDC
IC
guidelines
a]er
2
different
ways
of
presentaHon
…
Restricted
to
those
highly
educated
Limited Edition
Exclusive for HCWs
Where
you
wondering
why
the
handouts
are
so
scarce?
¤ IntroducHon
of
new
hand-­‐rub
or
catheters
in
your
hospital
² Present
&
announce,
restrict
it
to
ICU
and
those
units
that
first
order
scarcity,
censorship,
reactance