How to remind employees to wash their hands hundreds of times a day

August 16, 2016

A compliance clock is ticking every time a nurse, doctor, or other healthcare worker enters or exits a patient’s hospital room.

According to the World Health Organization (WHO), healthcare workers should wash or sanitize their hands during the 60 seconds prior to entering a patient’s room and again during the 30-second window immediately following their exit from a patient’s room. These guidelines apply to every instance when a caregiver spends more than 20 seconds in a patient’s room. But even though hand washing has been widely proven to decrease significant risks to patient health, WHO estimates that hand-washing compliance in hospitals often falls below 50 percent.

Establishing the consistent implementation of standardized processes to meet compliance standards is a challenge in many other industries as well.

The key to improved outcomes in the areas of safety, cost containment, efficiency, and quality often involves changing or influencing workers’ behavior. New research from Olin that focuses on hygiene compliance in hospitals provides helpful insights for all managers tasked with establishing processes to meet compliance standards.


Proventix, which offers monitoring technology designed to encourage process compliance in hospitals, shared a treasure trove of data with Olin’s Hengchen Dai and her co-authors. The company provided three and a half years of data from 71 hospital units in 42 US hospitals, representing more than 5,000 caregivers and approximately 20 million hand-washing compliance opportunities. The data allowed the researchers to study how monitoring for compliance using technology can affect both short- and long-term rates of compliance with hand-washing guidelines across a variety of healthcare organizations.

Specifically, the monitoring devices use radio frequency identification (RFID) chips developed by Proventix to track how often individual caregivers enter or exit patient rooms and whether the caregivers use hand-hygiene dispensers at each hand-washing compliance opportunity. Many of the dispensers have liquid-crystal display screens that give real-time feedback to caregivers on their hand-washing compliance performance.

For each hospital unit, Proventix enacted an initial pilot period during which only a small group of badge-wearing caregivers were monitored for compliance. During this pilot period, Proventix tracked how often hand-hygiene dispensers were used overall as well as by the individual caregivers who had been selected as pilot testers. Following this period, electronic monitoring of individual caregivers’ compliance was activated across the entire unit.

“Individual electronic monitoring is not a panacea, by itself.”

— Hengchen Dai

The researchers were not surprised to find that electronic monitoring generally had a positive effect on compliance behavior. Most hospital units in the study experienced an increase in compliance after electronic monitoring of individual caregivers was activated. In particular, hospital units with higher premonitoring compliance experienced a larger boost in compliance due to monitoring than did those with lower premonitoring compliance. Following an initial boost, compliance continued to increase gradually for a two-year period before declining.

Following an initial boost, compliance continued to increase gradually for a two-year period before declining.


  • Electronic monitoring alone does not form new habits. Sustained managerial attention, in addition to multifaceted interventions, is key to consistently improving compliance over time.
  • Norms, culture, organizational design, and leadership appear crucial to the effectiveness of electronic monitoring in creating sustained compliance.
  • Managers in healthcare settings should consider using electronic monitoring as one part of a toolkit to encourage process compliance and better design healthcare operations systems.

To illustrate, a graph of hand-washing compliance over time would look like an inverted U-shape, with initial compliance increasing significantly before leveling off and then eventually declining. According to Professor Dai, “We initially thought that by constantly monitoring people, they might form habits. We thought it would become ingrained behavior—a cue—and that every time they walked in or out of a patient’s room, they would remember to wash their hands. But we actually not evidence for habit formation.”

Perhaps most surprisingly, the study showed that the termination of electronic monitoring led to a significant decline in compliance, to a level even lower than premonitoring levels. This finding should be a warning to managers who think electronic monitoring alone can solve compliance problems, according to the researchers. “Deploying electronic monitoring without a long-term plan for supporting its retention may be short-sighted because it could end up actually harming process compliance.” One of the most important implications from this research is that electronic monitoring is just one tool that managers can use to improve compliance with standardized processes. According to Professor Dai, “individual electronic monitoring is not a panacea, by itself. Organizations looking to build process compliance must think about how electronic monitoring fits within a broader system encompassing not only technology, but also norms, culture, and leadership, among other things.”

Using a multipronged strategy that includes tactics such as electronic monitoring could help healthcare operations managers promote consistent hand-washing compliance, leading to higher patient-safety outcomes and lower healthcare costs overall. Looking to the future, Professor Dai believes that more research into the interventions that positively affect compliance behavior and influence the development of long-term compliance habits is central to the solid promotion of sustained compliance.

“Motivating Process Compliance Through Individual Electronic Monitoring: An Empirical Examination of Hand Hygiene in Healthcare ”


Hengchen Dai, Assistant Professor of Organizational Behavior, Olin Business School, Washington University in St. Louis

Co-authors: Bradley R. Staats and David Hofmann from the University of North Carolina at Chapel Hill and Katherine L. Milkman from the University of Pennsylvania’s Wharton School


Management Science, online in Articles in Advance 05 May 2016