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Cold,HardCashasaHandwashingIncentiveFreakonomicsFreakonomics

Blog
Cold, Hard Cash as a Handwashing
Incentive
January8,2010@2:30pm
byStephenJ.Dubner

Wheneveryouwriteabook,itsinterestingtoseewhichpartsofitpeoplerespondtoenmasse.With
SuperFreakonomics,theglobalwarmingchapterhascertainlygottenitsfairshareofattention,and
Levittnotedalotoffeedbackabouttheperilsofdrunkwalking.
Buttheresathirdstrongcontender:handhygiene,orthelackthereof,especiallyinhospitals.Heres
onefascinatingreplyfromJeffreyR.Starke,aphysicianinHouston:

IaminchargeofinfectioncontrolatTexasChildrensHospitalinHouston,the
largestchildrenshospitalintheU.S.,andamonthefacultyofBaylorCollegeof
Medicine.Wealsohaddifficultygettinghandhygienerateswherewewantthem
tobe.Wetriedalltheusualmethodsthatyoumentioninthebook,andafew
others,buthadadifficulttimegettingtheratesabove70percent.(Wemeasure
ratesbyuseofasecretshopper,anexpertininfectioncontrolfromoutsidethe
institutionwhoobservestheactualhandhygienebehavioroftheworkers.)
Wedecidedtouseamoredirectincentive.Ouremployeesparticipateinabonus
programcalledP3.Previously,alltherequiredperformancemeasureswere
financial.However,wemadehandhygieneratespartoftheprogramemployees
hadtoachieveandsustain>96percentcompliancewithhandhygienetogettheir
fullbonus.(Thisisapooledbonusplaneithereveryonegetsitornoonegets
it.)Wedidmuchbetter,butstillnotquitegoodenoughuntilwehitonasecond
idea:wemadethehandhygieneperformancepartofthehospitalexecutives
performancebonus,eventhoughtheydontcareforpatients.Magically,wehave
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attainedandsustainedarateofhandhygiene>98percent,andwonanational
awardforqualityimprovementfromtheChildrensHospitalsCorporationof
America.Equallyinterestingisthattherateofhandhygieneamongphysicians,
whoarenothospitalemployeesanddonotparticipateinanyperformancebonus
program,alsohasasustainedrate>98percent.Iguessthisisapositive
externality,perhapspressurefromemployeesonphysicianstomakeeveryone
lookgood.

StarkeaddedanoteaboutthegeneraluseofstatisticsinSuperFreak:

Itisarealprobleminmodernsocietythatmostfolksdontunderstandstatisticsat
all,andtheyareusedtoscarefolksallthetime.(MarkTwainwasrightthatthere
arelies,damnedlies,andstatistics.)MyfavoriterecentexampleistheH1N1
influenzavirus.Ilecturequiteabitaboutthistobothmedicalandlaygroups.My
standardbeginningisthefollowing:IfItoldyouthat99.9percentofpeoplewho
gettheH1N1influenzawillsuffernosignificantcomplications,wouldthatmake
youfeelbetter?(Almosteveryonesays,Yes.)IfItoldyouthat1millionpeople
inHoustonwillgettheH1N1influenza,and1,000ofthemwillsuffersignificant
complications,wouldthatmakeyoufeelbetter?(Almosteveryonesays,No.)
Ofcourse,bothexamplesarethesamenumberexpressedindifferentways.
Thesearedifficultconceptsformostfolkstograsp,andsomanyexpertstake
advantageofthis.

TAGS:handwashing,incentives

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Brian
January8,2010@7:50pm
They'renotthesamenumber.99.9percentdoesn'tgivemeasamplesize.

Julianne
January8,2010@8:09pm
TheH1N1examplesaren'texactlythesame.Thepercentageisthesame,butthescenario
isnot.Theyareonlycomparableifwhenconsideringthefirstexample,youthinkthe
contagionratewillbehighenoughtohit1millioncasesinHouston.Thatcontagionrateis
guaranteedinthesecondexamplewhichwouldinitselfbeenoughtogivemepause.

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Joe
January8,2010@8:23pm
Thepointisthatbothare*accurate*statisticsifusedindescribingthesamephenomenon.
Includingthecontagionrateisastrategicdecisionifyouaretryingtodownplaytherisksof
H1N1,youwouldsay"99.9%donotsuffercomplications".Ifyou'retryingtodotheopposite,
you'dmentionboththe1,000,000number,andthe1,000number.

Bennett
January8,2010@8:35pm
Brian,thepercentageisthesameineachscenario.

Dr.Manak
January8,2010@8:36pm
Didthehospitalexecscheat?ThatistheplayIwouldexpectcomingfromthestandardCEO
playbook.

JeffreyStarke
January8,2010@8:47pm
Dr.Manek,thereisnocheating.Themeasurementofhandhygieneisblindedtoallhospital
workersandadministrators,andisperformedindependentlybypersonsfromoutsidethe
institutionwhoareunknowntotheemployees.Thedataarefedbacktoeveryone.Our
administrationisverysupportiveofthis,especiallyafterseeingtheresults.

WilliamG
January8,2010@8:49pm
Ihaveanideatoencouragehandwashing,sincefinancialincentivesareonthetable:
Whensomeonesuccessfullywashestheirhands,adollarbillisdispensedfromthesink,and
thepersonwhowashedtheirhandscanimmediatelytakeit.

di
January8,2010@9:11pm
Rightuptherewithtellingyousomethingincreasesbreastcancerratesby30%.Thatmeans
from10%lifetimeriskto13%,ifyoulivetobe90yearsold,butsaying30%makesitsound
morethreatening.
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Joey
January8,2010@9:33pm
Hopefullyyou'refamiliarwithhttp://www.nytimes.com/2007/12/30/opinion/30gawande.html?
_r=2&oref=sloginit'shardtoachievehygienesuccesswhenregulatorygroupsactively
fightagainstit.

Cmor
January8,2010@9:39pm
@#7...withwhat'sfoundonadollarbill,thatwouldactuallydefeatthepurpose.

Brad
January8,2010@10:06pm
WilliamG:Howfilthyisthedollarbill?:)

LelandWitter
January8,2010@10:08pm
WilliamG(#7)Thatdollarbillhadbetterbedisinfected,sincepapermoneyis(widely
presumedtobe)filthywith"germs".

MarkS.
January8,2010@10:15pm
"Ihaveanideatoencouragehandwashing,sincefinancialincentivesareonthetable:
Whensomeonesuccessfullywashestheirhands,adollarbillisdispensedfromthesink,and
thepersonwhowashedtheirhandscanimmediatelytakeit."
Coinswouldbebetter,theyareeasiertosterilizew/odestroyingthem.Someoneevenfound
thatthehighnickelcontenteurocoinsareverynearlysterileineverydayuse.

John
January8,2010@10:17pm
"Ajudiciousmanlooksonstatisticsnottogetknowledge,buttosavehimselffromhaving
ignorancefoistedonhim."ThomasCarlyle

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ww3
January8,2010@10:48pm
Nowifonlyyoucouldapplytheconcepttorestaurants,therewouldbealotlessfoodborne
illnesses....

Sally
January8,2010@11:12pm
Number7isquitefunny.YouaregivingthemthedirtiestthingIcanthinkofasarewardfor
washingup.
Ifacepalmed.

Daniel
January9,2010@2:41am
Didthehandwashingimprovethehospital'seffectiveness?

Gary
January9,2010@4:12am
TheproblemwiththeH1N1exampleisthatthenumbersexpressthesituationasapositive
(99.9%areOk)andanegative(1000suffersignificantcomplications).It'snotjusta
misunderstandingofthenumbersthat'scausingthethedifferingresponsesofconcernit's
thesign.Itwouldbeinterestingtodoanexperimenttoseehowmuchignoranceofstatistics
andphraseologyeachcontributetotheresponse.

sinyc
January9,2010@6:37am
manwhowasheshandsafterpassing(sterile!)urinemaybetouchingataptouchedby
faecescontaminatedfingerofprevioustoiletuser.

mannyv
January9,2010@7:17am
Inalmosteverycase,makingexecutivespartoftheincentiveprogramisthepathto
success.Maybewecanincentivizeourelectedleadersatalllevelsthesameway?

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