Wash Your Hands!

Personal hygiene is incredibly important!  Just consider some of the following statistics, as reported by the Centers for Disease Control and Prevention (CDC).  Handwashing can reduce the spread of infections, such as the common cold (by up to one-third) and deaths from diarrhea (by up to one-half).  If everyone washed their hands with soap and water, 1 million deaths per year would be prevented!  And how about this for a fun fact, the average swimmer contributes at least 0.14 grams of fecal material to the water, usually within the first 15 minutes of getting in the pool.  Taking a shower before swimming removes this fecal material from the body and can significantly reduce the spread of infections.  

Despite all of the evidence showing that basic handwashing significantly reduces the spread of infections in the hospital, most studies report that hospital workers follow this basic infection control measure on average only about 75% of the time.  Of course, rates vary significantly from hospital to hospital, with most studies reporting compliance rates from a low of 30% to a high of 91%.  As such, there is a lot of interest in trying to improve compliance with handwashing in the health care setting!

Some hospitals have tried using monetary incentives as a way to improve handwashing compliance.  I've posted about some of the advantages and disadvantages of monetary incentives in the past.  On the positive side, providing monetary incentives can reinforce desired behaviors (e.g. handowashing) or increase an individual's motivation to work hard to achieve an organizational goal.  Monetary incentives rely upon Homo economicus, the theory that we are rational beings that would choose to maximize our own self-interest and thus address the principal-agent problem.  However, on the negative side, providing monetary incentives effectively changes the relationship between the organization and the employee from a cooperative one to a transactional, contractual one.  Once that transactional relationship has been established, if the monetary incentive is withdrawn, the employee no longer feels the need to exhibit the desired behavior.  I have also talked about the so-called "crowding out effect" and intrinsic versus extrinsic motivation (see my post, "Holes" for more).  Alternatively, neoclassical economic theory suggests that agents (in this case, the employees) can derive utility from contributing to organizational goals, even in the absence of monetary incentives.

With all of this in mind, Harvard Business School professor Dr. Susanna Gallani analyzed the results of a natural experiment conducted at one large hospital, in which monetary incentives were used in an attempt to improve handwashing compliance.  All hospital employees contributed to the goal of improving handwashing compliance from a baseline (during Q1, or the pre-intervention period) of 91% (which is actually pretty good) to the stretch goal of 95% by the end of Q2.  If the stretch goal was met, every employee would receive $1,200 at the end of Q2.  Notably, physicians also contributed to the overall goal but were not eligible for the monetary bonus (physicians were not allowed to be employed by the hospital due to the corporate practice of medicine laws in California, where the study was performed).  Instead, hospital employees motivated the physicians to wash their hands through peer pressure, reinforcement, and social rewards such as recognition.  These practices ended at the completio of the intervention in Q2.

Importantly, handwashing compliance did improve by the end of Q2, and the employees received their bonus.  However, over the course of the next two quarters (Q3 and Q4, respectively), handwashing compliance decreased to the pre-intervention levels or in some cases, even worse than before the incentive plan!  Physicians, on the other hand, demonstrated a slower improvement in handwashing compliance relative to the hospital employees.  However, the improvement in handwashing compliance persisted through the end of Q4!  As Gallani concluded, "While monetary incentives generated a more pronounced improvement, it was short-lived.  On the other hand, peer pressure techniques generated a change in behavior that persisted beyond the removal of the incentive."

Dr. Gallani published a summary of her findings in the Harvard Business Review (see the article, "Incentives Don't Help People Change, but Peer Pressure Does").  Dr. Gallani suggested that even if the monetary incentives didn't produce sustained improvements in handwashing compliance with the hospital employees, "the existence of the monetary incentive helped generate the peer pressure applied to the physicians, leading to longer-lasting success."  It's a very interesting take on the whole intrinsice versus extrinsic motivation argument, and it strongly suggests that perhaps leaders and managers should pay greater attention to how they motivate their employees.