Handwashing Hospital Report

Handwashing DesignNYU Langone Hospital

by Rachel Lehrer

Handwashing DesignWritten and Designed by Rachel Lehrer

MFA Transdisciplinay Design Thesis Project Parsons The New School for DesignCompleted May 2012

Timeline 4

Recommendations 6

Design Strategy 10

Embodied Research 14

Interventions 16

Conclusion 28

Appendix 29

Contents

2011

May August October Nov Dec January

2012

FebruarySeptember

IPC tour and intro mtg

12 hour nurse observation at HJD 12 hour nurse

observation in Oncology and BMT Units

Transform Mayo Clinic CFI Symposium, MN

1st Mtg. with Maggie Breslin of Mayo CFI

Proposal of Interventions with Michael and Cameron

Revision of Interventions

Addition of measurements to Interventions

Tactical Intervention mtg with Tania and Gabi

Mtg with Nurse Champions at IPC

2nd Mtg. with Maggie Breslin of Mayo CFI

Mtg with Gabi at IPC

IPC Committee Meeting

Timeline At NYU Langone

Outside of NYU Langone Timeline

March April

Embodied Research with IPC and Build-ing Services Day 1

Embodied Research with IPC and Build-ing Services Day 2

Met with Millie Hep-urn-Smith and toured Rusk Rehab Institute

Mtg with Unit 15 ICU Nurse Managers

Mtg with Gabi

Day 1 Spatial Association in ICU Day 2

Spatial Association in ICU

Tool belt mtg with Ross Leonardy

Day 1 Constructing belt with Ross Leonardy

Day 2Constructing belt with Ross Leonardy

Day 3Constructing belt with Ross Leonardy

Tool belt testing Neurosurgery ICUMtg with Millie

and Evrette in Rusk 1S

First Rusk HH Mtg

Footprint InterventionControl Day 1S Rusk

Footprint InterventionDay1 1S Rusk

Footprint InterventionDay 21S Rusk

3rd Mtg. with Maggie Breslin of May CFI

Second Rusk HH Mtg

Final Thesis Presentation

Midterm thesis presentation

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RecommendationsAfter spending a year working to increase hand hygiene compliance at NYU’s Langone Hospital I’ve developed a few recommendations aimed at increasing compliance. My recommendations are primarily drawn from my interventions. The interventions were innovative propositions that underwent short term testing within the hospital. However, the resulting findings could also be used to create larger tests subject to more rigorous quantitative verification. In some cases, I’ve just observed the good ideas and behaviors of those employed by the hospital and designed ways to support pre-existing behaviors that aid compliance. I’ll lay out simple recommendations and reference the research that grounds those recommendations. There are far more insights than those I will highlight in this abbreviated text so please peruse the rest of the document for a more complete view.

1) Have a designer in your Hospital. Several progressive medical institutions have an innovation and design center. These centers take on big questions posed by the institution but they also investigate their own insights. My role, first as a researcher and observer, collecting insights and allies and then as designer implementing my own interventions, and finally as a collaborator in a cross disciplinary hand hygiene team has made me reflect on my own changing value within the Medical Center. As a design researcher, I was able to collect best hand hygiene practices from across different units and informally share them with different nurse managers, nurse educators and

department leaders, etc... Taking the best practices from units that have different specialities, layouts, work flow and func-tions and operationalizing them across many different units requires a long term strategy for aggregation and imple-mentation. Best practices can be unit specific, but it takes an understanding of the decision architecture inherent in the built environment to extrapolate which best practices can and should be optimized across a range of spaces and practices. A designer can invigorate stale conversations on regu-lations, rules and requirements by developing interventions in collaboration with staff and on their own. Through joining pre-existing teams already tackling big medical questions, a de-signer can aid and give increased agency to health care staff by taking them through a design process. A highly tailored design process for medical interventions can create data to support change, aid in increasing awareness around some of the most important issues by involving users in designing their own behavior, drastically increase quality improvement mea-sures and provide a repository for crowd sourcing and testing the excellent ideas of those working at NYU Langone Medical center. Please see my work as a collaborator (p. 31), with Gabi Pinto and with a hand hygiene team at Rusk Rehabilitation Institute as evidence of the work a designer can contribute to the excellent ideas of others. These collaborations were in their infancy at the conclusion of this project, yet they each had an enormous amount of potential.

2) Nurses need a place to put their tools near a dispenser. When nurses walk into a room they have things to do, and many of those things require devices, medications, or tools that have to be carried into the rooms. This is especially a problem in older units where tools are not decentralized in patients rooms. Whether the solution is a nurses tool belt like I designed, or placing a shelf near the dispenser and gloves there was no larger roadblock to compliance, particularly sanitizing hands prior to putting on gloves, than having nurses hands full. I observed many nurses carrying equipment into a room and maneuvering the equipment into one hand so they could grab some gloves with the other. The work around of only using one hand is just not possible with hand sanitizer--cleaning hands is a two handed action. After grabbing gloves a nurses hands would be completely full and they would walk over to the patient where they could begin a conversation and place the materials on the bedside table, or bedspread and then put the gloves on without ever using the hand sanitizer. Once they approached the patient and used the patient’s table or surfaces it was extremely unlikely for them to then walk over to the dispenser. The clustering of the dispenser and the gloves is entirely moot if nurses hands are too full to utilize both at that point in space. Please see my work on developing a nurse tool belt (p. 20-23) to read more about my research and intervention into the problem of nurses having their hands full.

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5) Footprints should be used to bring attention to hand hygiene and keep the area underneath dispensers clear. Walking down any hall in NYU Medical Center, one will come across a plethora of mobile machines and equipment sitting in the hallway. These objects are literal roadblocks to compliance. Placing footprints underneath dispensers increases the compliance of visitors to the unit, but for those whose attention they do not attract they may serve to inscribe a space underneath dispensers where equipment may not be placed. In addition, there is rarely any signage that refers people, whether staff, family or visitors to use the dispenser. Employing a signage system that invites people to use the dispenser and simultaneously keeps equipment from crowding the space underneath it is a win win. Using signage and messaging on the floors in addition to the walls increases the probability that it will have a sustained effectiveness and avoid becoming background noise for those working consistently in the unit. Please see pages 24-27 for more research on the value of using Footprints.

3) Dispensers should always be associated with a single patient’s room and should reside in the hallway outside of the room. Oversaturation and undersaturation in hallways and lack of standardization in dispenser placement is detrimental to compliance. Highly visible and consistent placement in the hallway by a patient’s door frame reinforces the development and adoption of compliant habits. Having dispensers by a patient’s door but in the hallway, makes the act of sanitizing hands visible, public and reinforces the need for anyone, regardless of position, to be compliant upon entering a room. To read more about the spatial placement of dispensers please refer to page 19. Purell dispensers should also be placed inside the patient’s room but should always reside near the patient’s bed, ideally on the corner of the patients bed.

4) Disperse more lotion dispensers throughout the units. There is no question that consistent use of hand sanitizer degrades and compromises skin quality. Many nurses and physicians cited dry and chapped hands as a primary reason for not using hand sanitizer. Additionally, many nurses are so effected by the harsh chemicals and alcohol in hand sanitizer that they bring their own personal lotion, which can counteract the sanitizing effects of Purell. Placing more lotion dispensers around the units is a uncontroversial way to provide more support for compliant staff members. Please see pages 14-15 for more research on the harsh effects of consistently using hand sanitizer.

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Design StrategyA Movement Centered Approach

Muscle MemoryOur bodies know a lot. Consider the Iowa Gambling Task, a famous scientific experiment where the sweat on a participants palms when hovering over a losing deck suggested that the players body knew they were picking from a bad deck long before the players consciously did. Many of our daily interactions rely on our bodies ability to evaluate situations and make decisions moments before we consciously consider anything. This is in part because of muscle memory—learned movement patterns embedded in our bodies. Standardized spaces, movements and interactions consistently draw on our muscle memory. Ideally, all hand sanitizing dispensers would be in the exact same relationship to a door knob or bed frame but a lack of coordination between those who layout a fire sprinkler system, patient rooms and hand sanitizers (which are flammable) inhibits the spatial and movement standardization of hand sanitizing. In most hospitals, because of their random placement, every dispenser and room requires a different physical coordination for compliance, never creating consistent muscle memory. If movement isn’t included in the design and structure of spaces from the beginning, our body’s innate abilities will be under utilized and behavior steering will come at a much higher cost.

My past life as a dancer has made my design process movement-driven. In health care, this translates to a focus on understanding the physical roadblocks to peak performance. I’m a physical therapist for environments; our bodies are our inescapable collaborators. Through enactments, observing the subtle nuances of movement and through physically knowing the process of “hard wiring” movement rituals, I’ve been able to look at physical behaviors and spatial intention from the strategic vantage point of the body.

Working in partnership with an Infection Control and Prevention team and a health care designer, I have been addressing the feel and subjectivity of the kinetic experience of handwashing. To a certain extent I am practicing a very literal form of problem-solving, attempting to solve handwashing by actually watching how people wash their hands. But this turns out to be a surprisingly fruitful perspective. By looking at the medical problem from the perspective of movement, it immediately becomes clear that there are three primary principles worth exploring.

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Movement ScriptsDesign, especially interior architecture and industrial design, scripts our movement. Sadly, much of this impact is unintentional. In dance and improvising there is a fair amount of wiggling around and doing what feels good and easy but there is also an amazing potential for developing a type of movement logic. Call it structured improvisation or call it decision architecture but giving movement a framework to exist within is when innovation happens. It’s when idiosyncrasies arise and turn into polyrhythmic phrases; it’s when the accidental juxtapositions are exposed and result in new sensations; it’s when new techniques emerge and evolve. Exploring and moving differently requires well situated and behaviorally appealing prompts and structure. Looking at physically embedded movement sequences (i.e. handwashing in places like bathrooms, whether at home, work or restaurants is usually accompanied by looking in the mirror) can give us insight into scripts that resonate and create best practices.

Freedom and FluidityWhat allows nurses to be compliant despite the awkward placement of a hand sanitizing dispenser? Some nurses develop movement transitions and subtle body negotiations that result in seamless interactions between them and the sanitizing equipment. In a series of fluid movements, they typically pin their papers between their bicep and rib cage, release one arm to swing between the dispenser and its plastic lip and then rub their hands together in a complicated and vigorous duet of fingers.

While this is happening, they are also greeting their patients. Like an Olympic hurdler, the movements are all seamlessly calibrated; the professionals compensate for the failed ergonomics of their environment.

These three areas of interest are my physical lenses for re-designing handwashing. In focusing on the movement of individuals, I strap myself clearly to the optimistic side of the problem. I need the commitment of already dedicated individuals rather than institutional adoption. Hospital staff, with all of their limitations, are drawn to creative solutions. Their need to satisfy patients, superiors and protocols for 12 hour shifts require regular feats of physical and mental gymnastics. These feats are going unstudied. In a society driven by sight, our own physical behaviors are under examined and under designed. For me, physical behaviors frame the problem, research and solution. Rather than creating systems to observe or remind people to strive for nearly impossible goals in a poorly designed environment, designers need to grapple with all the good reasons why health care workers aren’t sanitizing their hands and look to the staff for solutions. Patients and health care workers deserve more from design.

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13

Embodied ResearchYou can’t change someone’s behavior before you understand it and so I began my research phase by observing the nurses, whose behavior I hoped to change, and the Infection Prevention and Control staff, who wanted me to change the behavior. At a well-attended meeting with leaders from multiple departments, I presented a provocation. I wanted those who control the dialogue and data around hand hygiene to feel what consistent hand hygiene compliance was like. For 4 hours on a cold day, some members of the Infection Prevention and Control staff practiced hand hygiene every 6 minutes and hated every second of it. Nurses, though, have to practice hand hygiene, on average, every 6 minutes for their entire 12 hour shifts. I was looking to increase empathy, to get the rule makers to understand what following the rules feels like. The value of this type of intervention is not in increasing compliance numbers or in spurring the drafting of a new mission statement but in re-inscribing the problem on the stressed bodies of those that oversee compliance. In a bottom line driven atmosphere, it is important to remind those at desks that hundreds of unique human factors are involved in increasing compliance. It is a complex problem that can’t be resolved by adding more signs that simply restate the goal in bigger type. Before the hospital gets clean hands, it must get its own dirty (and dry and itchy) too.

Surprisingly, this simple but starkly different approach and provocation earned me allies in the meeting. Immediately following my presentation an argument erupted between a microbiologist and an Infection Prevention and Control Practitioner that perfectly illustrated the divergent views on increasing hand hygiene – “it’s easy, if you are disciplined” vs “no, it’s always a struggle, even for the most committed.” When you have experienced the challenges of practicing hand hygiene consistently then the conventional narrative is upended and the forgetfulness and laziness of nurses ceases to be cited as the main roadblock to high compliance rates. The physical effect of using sanitizer- the dry and cracked hands that come with consistent compliance -was the most commonly cited lesson for many of the participants. Word of my empathizing project spread and I was connected with educators and practitioners who saw my struggle with the medical status quo as something that their clinical staff could benefit from.

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Some Participants

Physical experiences aren’t best captured in words but here are some quotes from participants:

feel for them now”

“It [practicing hand hygiene] interrupted both thoughts and physical actions”

nagging”

“It’s very easy to forget to do your hands because one patient needs something and the patient behind you needs something and you turn around and you just do it and it’s not because you don’t care about hygiene, it’s because you also care about what you’re doing. It’s a contradiction”

“When I first started, washing your hands seemed like a simple, easy thing to do but it [pain and dryness] kind of hinders washing your hands.”

I definitely understand the effects [of washing your hands] more”

Intervention:Spatial Association

My earliest intervention focused on the spatial and psychological appeal of dispensers. I monitored the usage of 5 wall mounted dispensers in a hallway and placed signs that identified them as the least used (5th place) versus most used (1st place) dispenser. Health care workers who used the dispensers were rewarded by seeing the number on their nearest dispenser improve. During one morning of testing, a dispenser was used nearly 250% more than on a day without this kind of feedback. Though this intervention was designed to create quantitative data that directly demonstrated improvements to the hospital’s bottom line, it also provided nurse managers and myself with important information on which dispensers, in which spatial location were most useful.

Signs used on Day 2

“This causes as much talk as the rounds.”-Nurse Practitioner to me during rounds on day 2

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Quantitative Data: Control: 10am-1pm

Rm.13/14 8

Rm.15 7

Rm.16 26

Rm.17 12

Rm.18 0

Total 53

Day 1: 10am-1pmPosted pastel colored signs with lots of text and no removal and switching of signs

Rm.13/14 2

Rm.15 6

Rm.16 12

Rm.17 9

Rm.18 6

Total 35

Day 2: 10am-1pmPosted bright signs with minimal text and constant feedback resulting in frequently switched signs

Rm.13/14 10

Rm.15 32

Rm.16 19

Rm.17 14

Rm.18 24

Total 99

Pure

ll U

sag

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Dispensers13/14

10

20

30

15 16 17 18

17

13/14 1516

1718

Spatial AssociationICU 15WNurse Manager Elaine RowinskiA single hallway5 hand sanitizer dispensers3 days of observations2 signage iterations

Dispenser 16 was only asso-ciated with the Nurses break room and not a patient’s room. It exhibited the least benefit from the intervention.

Dispenser 13/14 was shared by two patient rooms and was used the least of all the dispensers.

Dispenser 18 had the largest increase in usage

Spatial AssociationOutcome & Recommendations

Moving forward: If this type of spatial feedback is a solution, then a first step might require building services to keep track of how often they refill the dispensers and evaluate the spatial placement of those that are most used. In newer units, the tendency is to over-saturate an environment with dispensers. In oversaturated rooms, dispensers were going unused. Protocol should require dispensers to be immediately outside of a doorway to a patients room. This way dispensers and the practice of hand hygiene can be associated with the transitional space of a doorway. The act of sanitizing hands should be associated with entering the patient zone. Dispenser placement needs to encourage the development of habits that connect the act to a specific and consistent space.

Outcome: The day 2 iteration of the Spatial Association intervention succeeding in increasing usage in 80% of the dispensers. It increased usage by nearly 250% for dispenser 18. Usage decreased for dispenser 16, which was not associated with any patient room but was associated with the nurses break room and therefore wasn’t “owned” by any single nurse. It was the least competitive dispenser and therefore benefitted the least from the intervention. The 2nd iteration was successful in increasing usage and creating competition between nurses and their respective patients rooms. The difference between the day 1 and day 2 iteration was the readability of the signs and my role in switching the signs. In contrast to day 1, during day 2, I was moving the signs and responding to the nurses behavior in real time. During day 1, I posted signs that had poor readability and only adjusted the signs hourly.

Recommendations: Dispensers should always be associated with a single patient room or doorway. Dispenser 13/14 should be moved to the outside of patient room 14. Patient room 13 is oversaturated with dispensers (they are in the ante-room and outside the room). There should be no dispenser for room 13 in the hallway and instead it should just reside in the ante-room. Do not place dispensers in corners. They receive minimal usage and oversaturate the hallway.

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Intervention:Tool beltMy next intervention was a tool belt for nurses, designed with Ross Leonardy. The idea emerged from seeing nurses in older centralized units consistently walking into patients’ rooms with their hands full. We worked to create a belt with modular units and silver-impregnated antimicrobial pockets sized specifically for the most commonly needed tools; and we chose materials that withstand the same bleach wipes used on shared medical equipment. During the initial trial, Nurse Erin O’Shea discharged patients, delivered pills and of course kept her hands clean in the Neurosurgery ICU. I watched the unexpected failings and the minor successes emerge continuously through the hours of her shift. I saw how one of the belt’s cumbersome pockets, which drastically cut down on her need for trips to the supply closet between patients, nevertheless made her movement more restricted. She carried less in her hands, traveled less to retrieve supplies and now had an individual hand sanitizer strapped to her belt; but while all of these things made the hand sanitizing that the hospital requires her to do more possible, it did not ensure compliance – and added new constraints to her workflow.

Tool belt in use

Feedback:The Nurse was primarily concerned with the aesthetics of the belt. She decided that the black pocket with the shinny silver-impregnated fabric was her favorite. The grey pockets were useful but they protruded too much from her body and felt too cumbersome. They also bunched up when they were empty of materials. The white pocket also bunched up when not in use and “doesn’t look cool.”

Observation: The belt held an enormous amount of supplies which required only one trip to the utility closet over the course of two hours. The only continually used material that wasn’t held by the belt was her cardex (for taking notes). The belt was very useful when discharging patients, drastically cut down on her trips to the supply closet and yet the Nurse still occasionally failed to follow hand hygiene protocol, especially before putting on gloves. The Nurse almost exclusively used the hand sanitizer on the belt yet it didn’t necessarily increase her hand hygiene compliance. The belt didn’t keep her from carrying medication in her hand.

In general, the belt made her movement smaller and more spatially confined. She had to travel less in space, leave the patient zone less and therefore was required to sanitize her hands less frequently.

Materials held in tool belt (minus the cardex)

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Moving forward: This tool belt prototype needs to undergo more testing. In addition to testing in the Neurosurgery ICU, the belt should be tested in other older units with centralized utility closets, like the ER. As of now, I recommend developing a second belt prototype that minimizes the largest grey pockets, uses a uniformly shiny and bright fabric, and is tested on multiple unit nurses simultaneously. It became clear that peer pressure among nursing staff was a hindrance to receiving buy-in. Though the youngest unit nurses were willing to test the belt, their cohorts were continually negative about testing new hand hygiene compliance practices. Recruiting nurse managers to support this practice and experimentation will be crucial.

Tool beltRecommendations

Recommendations: Improved belts should be made available to nurses at NYU Langone. There was no question that wearing belts decreased the number of times a nurse was required to practice hand hygiene. If there was buy-in from nurse managers, staff nurses would be much more willing to test prototypes and experiment with wearing belts. Additionally, the Infection Prevention and Control department should collect data not just on compliance but on movement in older centralized units. How often are nurses travelling in and out of patient zones to collect supplies? How are tools in patient rooms clustered? If hand sanitizer dispensers are always near gloves, should they also be near a counter top where medication can be placed before hands are cleaned and gloves are put on? I am happy to continually consult on improving the decision architecture in each patient space.

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Intervention:FootprintsAnother intervention, in a high traffic rehab unit, reappropriated the visual tools of physical therapy to bring attention to hand sanitizing dispensers that were partially obscured. I placed scrub-colored footprints and various other visual cues around the dispensers. Communicating on a different plane (than signs on walls) in a familiar visual language, these cues provided subtle pulls into the dispenser’s sphere, attracted new visitors to use the dispenser and served as an introduction to the unique culture of the rehabilitative space.

Rusk 1S is a unique space. The entire unit staff, from Building Services to Nurses were consistently practicing hand hygiene upon entry and exit to each and every doorway.

In my view the layout of 1S can provide us with some valuable takeaways. While the hallways were cluttered, there was always a clear view of staff entering and exiting patients rooms. The moment of entering the patient zone was always visible and therefore, the only opportunity to practice hand hygiene prior to entering the patient zone could be seen by anyone in the hallway. 1S is a space that leverages peer pressure by making non-compliance highly visible. The staff and patients benefitted from a space in which compliance was always demonstrable.

In many cases, nurses and doctors will pass on an opportunity to practice hand hygiene in favor of another alternative closer to the patient. However, with multiple alternatives for practicing hand hygiene outside and inside the patients room, health care workers can easily get distracted from practicing hand hygiene once inside a patient’s room.

Rusk 1S greatly benefitted from 1) the high visibility of compliance thanks to the long hallway, 2) the standardized placement of the hand sanitizing dispensers. They were directly outside of the doorway to almost every patient room, storage closet or hallway. 3) And the leadership of a nurse manager who leveraged the high visibility to insist on compliance from an entire unit staff and their more mobile cohorts like MDs, pathologists, and PTs. In 1S, the entire unit staff was encouraged to monitor each other and others in their space.

Day 2 of testing in 1S hallway

Quantitative Data: Control: 10am-12pmI observed all 15 dispensers in 1S to determine unit compliance and the appropriate dispensers and users to target. Dispenser Use

Dispenser 1 0

Dispenser 9 3

Dispenser 10 1

Total 4

Day 1: 1pm-3pmPlaced blue footprints around dispensers 1, 9 and 10

with no other visual cues.Dispenser Use by Visitors*/Locals

Dispenser 1 0/0

Dispenser 9 1/4

Dispenser 10 2/1

Total 3/5 = 8

Day 2: 1pm-3pmClarified the relationship between the footprints and the dispenser by adding messaging, arrows and hand prints.Dispenser Use by Visitors*/Locals

Dispenser 1 10/0

Dispenser 9 1/6

Dispenser 10 4/12

Total 15/18 = 33

Pure

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sag

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Dispenser 1

5

10

15

Dispenser 9 Dispenser 10 25

*Notes on Data Collection: It was clear that health care workers based on the unit were highly compliant, so I targeted dispensers on either side of the long hallway to catch “visitors” to the space. I classified people as “visitors” if they were not based on the unit. Visitors included, MDs, PTs, those using the hallway as a thoroughfare and a patient’s family and friends. “Locals” are individuals who work almost exclusively on the unit.

Layout of dispensers:

Dispenser 1 was located directly adjacent to the main door to the unit. It was just a few steps from the large heavy door that signified leaving or entering the unit zone. Dispenser 1 wasn’t associated with any patient room.

Dispenser 9 was located at the opposite end of the hallway from Dispenser 1. Dispenser 9 was consistently plagued by wheelchairs, beds, catering carts, and other mobile devices being placed underneath or in front of it. It was the last dispenser before large double doors that lead to another unit and elevators.

Dispenser 10 was at the same end of the hallways as Dispenser 9 but on the opposite side. It rarely had mobile devices placed in front of it. Although as you can see in the picture, it occurred occasionally.

Disp. 9

Disp. 1

Disp. 10

Disp. 1

Both images from day 1 of testing

Outcome: The footprints quickly faded from prominence for the unit staff, whose compliance the hospital does monitor; but they received significant attention from visitors travelling through the unfamiliar halls, whose compliance the hospital does not monitor. My intervention successfully targeted a population out of the hospitals view. !

Recommendations: Install footprints and accompanying signs on a semi-permanent basis in 1S. Being a unit that is consistently busy with “visitors” the footprint intervention is a low impact way of communicating to visitors that they have entered a “unit zone” that considers hang hygiene and patient health important. Units may want to experiment with the length of the footprint trail and the wording and graphic design of the of intervention.

Other floor signage that keeps carts, wheelchairs and other mobile medical devices from blocking access to dispensers should also be tested. A radius of 4 feet should be clear surrounding the dispensers.

Rusk 1S is a highly compliant unit that should be mined for best practices.

Additions to footprints on day 2

Footprint Recommendations

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Conclusion

The solution is not a single process or product or able to be purchased with one lump sum but lies in reconfiguring people, spaces, objects and expectations all together, over the course of many years. The treatment is not a magic pill but a series of small gifts. Each one can incrementally improve the likelihood of compliance, but only if encouraged by a service institution that understands the long term effectiveness of slight, diverse, persistent nudges. Having won the right to be within the hospital’s attempts to improve hand hygiene rates, but as an outsider, free from the demand for defined and measurable outcomes, I have been able to travel through the hospital collecting all the non-quantifiable factors that nevertheless affect hand hygiene rates: a nurse’s personal habits, the unit’s spatial layout, its speciality and leadership, etc. all affect the disease of non-compliance and each needs to be taken into consideration when formulating a plan of action. As with most long-standing problems, if a singular solution existed then we would have solved it already.

This project required hundreds of hours of work. Meetings presentations, emails, research, observations, testing, prototyping, iterating, re-testing, documenting, designing, collaborating and writing have all been essential parts of this process. I relied on the dedicated and inspiring Infection Prevention and Control Team to initiate nearly every aspect of this process. Please see the Acknowledgements Section in the back of this document to see a more complete picture of the incredible team that made this project possible.

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Appendix

Core77 Articles 30

Collaborations 31

Intervention Proposals 34

Bibliography 36

Acknowledgements 38

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“Moving Through Hospitals: Designing Handwashing”http://www.core77.com/blog/medical/moving_through_hospitals_designing_handwashing_21760.aspPosted March 6th, 2012Pt. 172 Tweets71 Facebook Likes3 Comments

Designing Handwashing Part 2: Diverse Nudges in a Hospital”http://www.core77.com/blog/medical/designing_handwashing_part_2_diverse_nudges_in_a_hospital_22185.aspPosted April 12th, 2012Pt. 2102 Tweets53 Facebook Likes2 Comments

I published two articles for the design blog Core 77

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CollaborationsOver the course of the past year working with the NYU Medical Center I have been the resident designer.

Projects spearheaded by the medical staff have called for a designer’s skills and I have stepped in to

collaborate on others good ideas.

I was invited by Millie Hepurn Smith at Rusk to join cross disciplinary meetings on hand hygiene compliance. Millie exposed me to a receptive group of willing and generous collaborators. The first collaborative intervention emerged from a prototype developed by Infection Prevention and Control Practitioner Alex Rowan-Hazlerigg. Alex saw the a need for Filipino Nurses to have a non-verbal way of rewarding compliance or reprimanding non-compliance they observed on their unit. The idea was to have small cards that could be handed out by the nurses to compliers or non-compliers.

Through brainstorms, we came up with the idea of identifying unit goals and/or unit rates for hand hygiene compliance on the cards. Identifying rates and goals gives those working in the unit a greater sense of ownership and lets those visiting or floating on the unit know that patient safety through hand hygiene must be practiced in that space.

With our discussions in the forefront of my mind, I developed prototypes for compliance cards. Using illustration and infographics keeps the cards light without diminishing the importance of message.

Rusk

Compliance Cards

Goal: increase hand hygiene compliance and patient and employee satisfaction

To Do:Gather Suggestions/Recommendations for increasing hand hygiene compliance and increasing patient and employee satisfaction to share with Michael and eventually IPC Committee Meetings

Preliminary Suggestions for Investigation:

1) Spatial Location: Look into where dispensers, gloves, trash and counters are located, what they are clustered with, how standardized the placement is and there level of convenience.

2) Nurse Feedback: Optimize the insights of the user (nurses). First, ask questions of nurses. Second, gather lessons/feedback or insights and cluster into “types” of suggestions. Then, work towards a way of operationalizing that feedback.

3) Patient/Family Perspective: Locate data on patient satisfaction and the current survey used by NYU. Draft a survey to ask patients and their families to gather insights into their feelings on staff and visitor hygiene behavior.

Gabriela Pinto

“We are just getting more interactive, we’ve been more interested in what they [Health care workers] do, we’re looking at their routines and looking at the spatial location of dispensers. I don’t think they [IPC Dept.] ever thought about that before they came into contact with you.” -Gabriela Pinto, interview March 21, 2012

Gabi and I worked closely together over the course of the year. With the encouragement of the head epidemiologist, Michael Phillips MD, and through her inchoate interest in a design driven approach she was inspired to initiate her own interventions.

I worked with Gabi to develop a human-centered strategy for the data collection, research and implementation of her interventions.

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Nurse Insights

In a early IPC meeting with practitioners, the idea of clustering equipment arose. Lesson: keep like items together to maintain awareness of interactions with devices that can host infections.

Francesca Tedesco, an RN from HJD: used what she called a “goody bag” to keep her supplies with her and keep her hands from being full. Lesson: Nurses need something to keep their hands free when they enter rooms.

Francesca also would verbally tell patients that she was going to retrieve gloves, or going to use Purell in order to ally patients fears that she was not attending to their needs. Lesson: keep patients updated on why you are doing things to increase their understanding and satisfaction.

Carmen a nurse manager always rubbed her hands when walking into patients rooms so the patient was aware that she practiced hand hygiene. Lesson: Keeping patients in the loop and treating them as though they are aware of HH protocol acts as added incentive to be compliant.

HJD nurse said younger nurses are more likely to tell MDs to practice HH. Lesson: younger RNs should be the first to target for increasing HH compliance during rounds.

Nurses have often shown that they can likely predict how busy their day will feel. As we know from HH studies, people are less likely to practice HH compliance when they perceive themselves to be busy. Lesson: nurses can foresee their busyness and might be able to nip non-compliance in the bud.

Erin from ICU12 mentions the need for a sterile pocket in scrubs. Lesson: make materials that health care workers interact with anti-microbial when possible.

I have collected insights and best practices from across the hospital. I’ve shared the below insights with Gabi to aid in her effort to optimize and operationalize the intelligence of the health care workforce.

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Intervention ProposalsNo. 1

FOOTPRINTS

Abstract: Place footprints beneath and around Purell dispensers and sinks to reinforce movement and interaction with the devices. 1

1 Purell dispensers are easily ignored. There are no spatial indicators that direct users to interact with the devices. There are no directions suggesting ways of interacting with the devices. A few RNs, who were among the most compliant fi gured out incredibly effi cient move-ments that made interacting with Purell dispensers a fl uid part of their behaviors.

Understanding: Choreographic changes are beholden to the larger cultural and environ-mental standards of a hospital. Movement should reside in a skill-based realm that doesn’t require thought. How can sanitizing devices be integrated into preexisting move-ment behaviors? How can movement fl uidity be emphasied around these devices ? How can the lessons from some intellegent movement patterns of RNs be shown to others. I will continually readjust the footprints of users to match the most effi cient and most compli-ant users.

Environmental Impact:

Timeline: 3-4 days in a single locationLevel of Obtrusiveness 1-10: 1Materials: paper and tape

Measurement:

to a spatial area

increased use of Purell

handwashing compliance

No. 2MIRRORS

Abstract: Place a small mirror above Purell dispensers to allow for behaviors that generally accompany hand sanitizing.

1

1 Purell dispensers are easily ignored. There are no behavioral indicators that nudge users to interact with the devices. There are no visual cues that suggest ways of interacting with the devices or provide immediate payoff by pausing at the devices.

Understanding: What is the payoff of stop-ping at a Purell dispenser? What behaviors does rubbing our hands together remind us of? By placing a mirror above the Purell dis-penser people will recieve payoff in an oppor-tunity to look at their own refl ection without having to stray far from behaviors that com-monly accompany looking in a mirror.


Timeline: 2-3 days in a single locationLevel of Obtrusiveness 1-10: 3Materials: mirrors, nails

Measurement:

or health care workers

the Purell dispenser

about handwashing compliance

No. 3

TOOL BELT

Abstract: Distribute tool belts to RNs to minimize the amount of time they spend with their hands full.

1

1 Nurses were frequently observed ignoring opportunities to sanitize their hands because their hands were full of devices, medication, papers and pens. Occasionally, nurses would deposit the material in their hands on an open counter and then return to the Purell dispenser. However, returning to the Purell dispenser once having moved past it was the exception, not the rule.

Understanding: Nurses bring devices and medication into a patients room. They are also responsible for recording the care that the pa-tients receive. These responsibities often con-fl ict with handwashing because they require a nurses hands to be occupied upon entry into a patients room, making the act of rubbing one’s hands together impossible until they have pro-gessed well beyond the spatial location of the Purell dispenser. The likelihood of returning to the location of the Purell dispenser is low.


Timeline: 2-3 days in a single locationLevel of Obtrusiveness 1-10: 2Materials: Tool Belts

Measurement:

tors or health care workers

of the Purell dispenser

about handwashing compliance

These 7 interventions were created in the Fall of 2011. They were my initial proposals given to the hospital Epidemiologist, Michael Phillips at the IPC. After showing them to hospital staff, he chose 3 for implementation.

No. 4

OPEN COUNTERS

Abstract: Install small open counters below Purell dispensers so RNs with occupied hands are more likely to place and organize objects in an area that makes sanitizing their hands convinent. By making the space around the dis-pensers more useful, more people might be inclined to engage with the device purely because of its accessibility.

1

1 Nurses were frequently observed ignoring opportunities to sanitize their hands because their hands were full of devices, medication, papers and pens. Occasionally, nurses would deposit the material in their hands on an open counter and then return to the Purell dispenser. However, returning to the Purell dispenser once having moved past it was the exception, not the rule.

Understanding: This experiment is driven by RNs frequently having their hands full while entering a patients room. The experiement could also move Purell dispensers so they are placed above open counters, which would ensure that nurses movement in the space was minimal.


Timeline: 2-3 days in a single locationLevel of Obtrusiveness 1-10: 3Materials: small shelf, nails

No. 5

SPATIAL ASSOCIATIONS

Abstract: Visually identify the most often refi lled Purell dispensers to reinforce best practices as it relates to space. 1

1 Hospital employees receive minimal feedback on their handwashing compliance. This leads to less awareness of who and where handwashing compliance take place and less personal pride and ownership over handwashing compliance data.

Understanding: Creating an atmosphere where people feel a sense of competition and ownership over the spaces they spend the most time in encour-ages usage to escalate in the spaces people identify with. This experiment leverages hospital employees feelings of pride in their work. It also takes the onus off of employees and makes the Purell usage the sys-tem of comparison rather than one’s own behavior.


Timeline: However many weeks required to track at least two rounds of data collectionLevel of Obtrusiveness 1-10: 1Materials: Stickers

Measurement

conversation about handwashing compliance

commonly used dispensers1st in

COMPLIANCE

No. 6

TARGETED PURELL

Abstract: Identify Purell dispensers as being for a particular hospital 1

1 Hospital employees receive few visual nudges suggesting handwashing compliance and they recieve no targeted nudges. Throughout my observations, M.D.s have been signifi cantly less compliant.

Understanding: The culture of the hospital almost relieves MDs of practicing handwashing compliance. They are not at risk of being reminded to wash their hands and they are not identifi ed as being a primary user of Purell dispensers, nor are they subjected to data collection on their individual handwashing compliance. Idenitfying a Purell dispenser as being “for Physicians” or “for M.D.s” will target physicians as important participants in the handwashing compliance system. Additionally, executing No.5 and No.6 together will actually provide short term data on the compliance of MDs in a particular area.


Timeline: 1 week- 2 months. Level of Obtrusiveness 1-10: 2Materials: stickers

For

MD’s

No. 7

QUESTIONING

Abstract: During rounds, and upon entry into each patients room, an RN or other team member collectively asks the physicians, “Has everyone washed their hands?”1

1 Throughout my observations, M.D.s have been signifi cantly less compliant. Nurses have also expressed their unwillingness to question an M.D.s practices, despite knowing that it endangers patients.

Understanding: This completely predictable, repetitive task of a team member asking a question during rounds reinforces several things. First, it gets doctors used to using Purell upon entry into a room. Second, it empowers a nurse and/or other team member to question a physician if he/she is not adhering to handwashing protocol. Lastly, it makes patients aware of the importance of handwashing compliance.


Timeline: 1-3 daysLevel of Obtrusiveness 1-10: 2Materials: Nurses and MDs participation

“Has everyone

washed their

hands?”

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NYU’s internal epidemiology documentation and statistics on compliancehttp://www.scpr.org/news/2011/08/24/28417/three-year-effort-aims-cut-back-hospital-related-i/#new-comment-formhttp://xnet.kp.org/innovationconsultancy/http://xnet.kp.org/permanentejournal/winter04/hand.htmlhttp://www.centerfortransforminghealthcare.org/projects/display.aspx?projectid=5http://www.macoalition.org/Initiatives/docs/MassGeneralHospitalPresentation.pdfhttp://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.htmlhttp://humansindesign.tumblr.com/post/6301543899/how-do-we-get-drs-to-wash-their-hands-more-frequentlyhttp://www.nytimes.com/2006/09/24/magazine/24wwln_freak.html?pagewanted=2&ref=healthhttp://abcnews.go.com/m/story?id=13849268

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Medical practice shouldn’t exist in a vacuum and neither should design- this project certainly didn’t. I continually relied on the help, advice and intelligence of others. Below is a list of just some of the people that have contributed essential elements to this project. I needed and relied on my professors, outside designers like Maggie Breslin, who felt the need to give back to the community, the massive amounts of people I collaborated with at NYU Medical Center, Rusk Rehabilitation Institute and the Infection Prevention and Control Department, random folks at parties who contributed to my unsuccessful socializing but successful problem solving and the solidarity, advice and deep knowledge of my classmates.

A special thank you to Cameron Tonkinwise, who brought the problem of hand hygiene to my attention and spent an entire year guiding me through theory, practice, research and writing. I would have never considered hand hygiene to be a captivating subject but getting to spend a year talking with Cameron Tonkinwise about it has made me feel otherwise. I owe much of the success of this project to him.

Acknowledgements

Advisors:Maggie BreslinLara PeninCameron Tonkinwise

NYU Facilitators and Collaborators:Millie Hepburn SmithGabriela PintoAlex Rowan-HazleriggTania Williams

NYU Employees who have provided valuable time and energy towards assisting and improving my work:John CorcoranEvrette James-HolderMichael NozdrovickyErin O’SheaMichael PhillipsElaine RowinskiFaith SkeeteFrancesca Tedesco

My fellow Parsons students:Amy FindeissMai KoboriRoss LeonardyGrace TuttleKelly Tierney

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Thank you for reading.

[email protected]

Documents

Handwashing Hospital Report