Namibia ICAN 2011

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3rd IPCAN Conference

Crossing a red light

It’s mandatory in Germany

It’s a suggestion in France

It’s Christmas decoration in Italy

Barry Cookson

“Cheap & safe is possible !”

•  would you trust these people to fly with them (put your life in their hands)

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… the pilot will be among the dead Andreas Widmer

Why aren’t the HCWs doing what we ask

them to do?

How can anyone miss something so big?

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MulI-‐Resistant Medical Specialist

a

•  Resistant to good advice

•  Allergic to professional guidelines

•  Non-compliant with infection control

•  Blind to nosocomial infections

•  Other priorities

* not only physicians but includes nursing

… we don’t see that we put a paIent at risk!

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If hospital bugs would look like this – compliance with hand hygiene would be 100%

Problem Solution Combined « I don’t » Combined

solutions

I don’t know how to do it Education I don’t have the resource(s) System change I don’t do it Motivation

•  Education •  System change •  Motivation pull

School for the highly intelligent

•  Education •  System change •  Motivation

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Opportunities for hand hygiene per patient-hour of care

8 12 16 20

35

45

55

65

ICU

surgery

medicine

ob / gyn

pediatrics

Com

plian

ce w

ith h

and

hygi

ene (

, %

)

Patient-to-nurse ratio ( ) 2

7

6

5

4

3

8

1

Time 60-‐80 sec Time 15-‐30 sec

ICU 12 HCWs -‐ 40% compliance -‐ 4h of handhygiene

At 100% compliance 16 h of handhygiene

At 100% compliance 4 h of handhygiene

Stress kills IC



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Semmelweis “schlepping” his colleagues to disinfect their hands

Disinfect your hands

you murderer!

>150 years of blame were not really successful

•  Presenting something new and improved does not automatically change bahavior !

•  ‘The lesson from marketing is that people are more willing to change their behaviour when they feel good, flattered, challenged powerful, sexy or proud, than when they are flooded with facts’ (Hodgkin 1999)

Onya, the Redskins cheerer (who asked that her last name be withheld, citing team policy), has her picture on the team's Web site in her official bikini-like uniform and also reclining in an actual bikini. Onya, 27, who declined to identify the company she works for, is but one of several drug representatives who have cheered for the Redskins

•  Presenting something new and improved does not automatically change bahavior !

I want evidence !

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•  Economist, political thinker, philosopher - reputed to have been the last man to know everything there was to know in the world

Smith & Pell BMJ 2003

Do we need RCTs for all measures? Those who insist that all intervenIons need to be validated by a RCT need to come down to

earth with a bump

Volunteer Control group

You do agree with me that we do not want to cause an epidemic ?!

P < 0.01

Pre-‐SARS Post-‐SARS

SARS

Clin Infect Dis 2004;39:511-‐516

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•  Implementation of hand hygiene as an institutional “must”

•  Frequent observation and reporting of non-compliant HCWs

•  Initial warning by department head •  Punishment (salary decrease, stop work)

They received 100% compliance within a year, but do we like the idea

•  Providing a safe environment for patient care is a corporate responsibility, thus understaffing is corporate negligence! (hospitals have been successfully sued for inadequate nursing staff and facilities)

George Annas NEJM 354;19:2063-‐2066

Goldman NEJM 2006;355:121-122

•  Encourage a blame-free culture of safety orientation toward improving systems rather than blaming people

•  Right balance between blaming mistakes on systems (overwork, education, access to hand-rubs) and holding individual providers accountable (failure to follow clear rules in the face of well functioning systems = “violation”)

•  Violations in industry (airline, computer chips) versus health-care

Goldman NEJM 2006;355:121-‐122 Make HCW accountable + feel responsible!

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Patient involvement: … they cannot and should not be responsible for their own safety in an environment over which they have no control v

George Annas NEJM 354;19:2063-2066

InfecIon control -‐ how can we make it sIck ?

•  Because of the complexity of the process of change, it is not surprising that single intervention often fail …

•  … a multimodal approach is necessary

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Single control ConInious control

Surveiilance RegistraIon

CWZ Nijmegen

Online feedback of rates

MRSA

hhp://i-‐prevent.blogspot.com/

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You need to learn more about behavioral science!

•  Behavioral science –  Change of behavior

•  Communication skills

–  Convince –  Motivate –  Problem solving

•  “Expensive = good” (and opposite) •  “If an expert said so, it must be true”

–  Airline industry “captainitis”

•  “Because” –  Increase compliance even if no reasoning follows

(example cutting lines)

–  Possibly based on “because” … “just because” of parents when answering their children's questions

•  Perceptual contrast

–  Buying suite and sweater à expensive item first

–  Selling the car first, than the options

Shortcuts-‐ contrast -‐ consistency

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•  Most people have a strong desire to look consistent within their words, beliefs, attitudes

•  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, written-down and publicly made commitments can be used to influence others and ourselves

•  Question to home owners – place large billboard “Drive Carefully” in your lawn

•  Two groups: A) 17% complied B) 76% complied

•  Why the difference between A + B ? B was asked a few weeks before to display a small 3x3in sign in window “Be a safe driver”

•  “We view behavior as correct to the degree we see other performing it” –  When lots of people do it – it must be right

•  Others laugh = it must be funny à we react to the sound – not the content à works even if the sound is artificial (laugh-tracks)

•  “ We most prefer to say YES to the request of people we know and like”

•  Factors leading to liking: –  physical attractiveness (halo effect) –  similarity –  familiarity –  praise –  association

•  Occurs when a one positive characteristic of a person dominates the way a person is viewed

–  Good-looking = talent, kind, honest, intelligent

–  Works in many situations: even judicial process à handsome men lighter sentences

Works the other way around, too!

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•  “We like people that are similar to us” –  more likely to help those that dress like us

Familiarity

•  “Increases through repeated contact under positive circumstances”

Compliments

•  “We are phenomenal suckers for flattery” – Positive comments produce just as much liking

for the flatterer independent if they were untrue or true

•  “Teamspirit” – Car salesperson battling with his boss to give us

a good price – Good Cop/Bad Cop

•  SALE

–  Buying becomes more likely because it is associated with good experience in the past

•  Celebrities and advertisement

–  Establish a connection; it doesn’t have to be a logical one, just a positive one

•  An innocent association with either bad or good things will influence how people feel about us or a product

–  The good looking models next to the car

•  Rating of identical car changed with and without model

•  Men didn’t believe that their judgment was influenced

Namibia ICAN 2011

Health & Medicine

Transcript of Namibia ICAN 2011