Hand Washing, Standard Work, and PDSA Testing

in Implementation, Improvement Science, PDSA, Variation

By David M Williams, PhD

Photo by Curology on Unsplash

Many changes we want to implement in daily practice appear obvious and simple. It’s easy to see why leaders want to jump to implementation. Just do it! We don’t need to waste time testing. Let’s just roll it out; people will adopt it. 

COVID-19 is requiring us to change rather quickly. We are motivated because we want to protect the health of our family, community, and those we serve. That doesn’t mean that change works like flipping a light switch, and the challenges people are facing are a good case study in why PDSA testing is helpful for quick learning and adaptation.

Let’s take a look at a simple process—hand washing. Before the pandemic, it wasn’t on most people’s daily radar. If you were to do a convenience sample from your front porch of five people walking by and asked them if they knew how to wash their hands, how many would you expect would have said “No?” Probably not a single one.

Take this a step further and invite each person to your kitchen sink. Ask them to demonstrate how they wash their hands. What would you expect to see? Do you think they would do it like they normally did it before you asked? Of course not. It’s safe to expect they would likely demonstrate a higher quality approach than their actual norm. It’s also a good bet the five people would vary in their approach. One wets their hands before applying the soap while another lathers before rinsing under the water. Some use warmed water while others stick with cold water. People may simply run their hands together, but the person who works in healthcare could have a more specific method. The duration of washing time would probably vary too. 

This is a great example of a process we think everyone knows, but where there exists variation in practice. How might we help people do it right? What change ideas do you have? How about we create a standard approach and make it available? 

Here is the World Health Organization (WHO) poster on proper handwashing. They recommend following this process and washing your hands for 20 seconds or more. How long is 20 seconds? WHO encourages singing “Happy Birthday” twice as a guide. Not your favorite song? Here’s an app to convert one you like into a handwashing song. Washyourlyrics.com

Figure: World Health Organization – Hand Washing Recommendation 

This is great. So we created an effective method for people to properly wash their hands and we’ve supported them with a tool to do it for the correct duration. Now we can implement, right? We can publish this on social media, promote in the media, and— BANG!— everyone will become great hand hygiene practitioners, right?

This change idea is great. It creates a clear, step-by-step process to standardize doing it right, and the simple song aids in doing it for the needed duration. What would you expect to see if you implemented this process? Do we need to test on a smaller scale? 

Below is a super helpful guide for thinking about PDSA testing and what size makes sense. Three factors can influence the choice of scale for a test: current level of commitment, confidence in the change, and the failure of cost. Consider the WHO handwashing process against these criteria. How big of a test would you do?

Figure. Langley et al The Improvement Guide (2nd Ed). Table 7.1, Pg 146.

The degree of belief in the effectiveness is likely on the high end. We’d like to think the public has a strong level of commitment. What’s the risk if people attempt to adopt this process but don’t do it exactly right? I bet many of you would land comfortably in either doing a large scale test or jumping to implementation. I would have, too.

Now consider the real world. If you are like me, you have upped your handwashing compliance and are more consistently aligned with the WHO recommended process. It’s also likely it is an improvement to your norm— much more frequent and less variable than before. Not too hard to do, right? What have you learned from this change that you didn’t predict or is not included in the WHO guidelines? Here are some learnings we may share:

  • Washing your hands regularly and properly results in dry hands. Do you have hand lotion available to mitigate?
  • Do you regularly wear jewelry like a wedding band? Do you take them off or wash around them? How would you take them off, or where would you put them down? How do you keep them clean also? 
  • This process is reasonable at home or at the office but can be tough in public restrooms. There may not be “single-use towels” to dry your hands or allow you to not touch surfaces after washing your hands.
  • You may have to consider the order of the process to limit touching surfaces. For example, pushing a lever is required to dispense the “single-use towel” or there is a door handle or latch you must touch and move to exit. You need to dispense enough towels to dry your hands and to open the door without touching surfaces.
  • There are places where you don’t have access to soap and water where you may make contact with surfaces unexpectedly. Hand sanitizer or disinfectant wipes are a great option (assuming you can get them).

These are a few learnings that emerge as we become hyper-alert to the need for hand hygiene and try to be more conscious of proper practice to reduce the potential for spread. Some of these might have been predictable. Some emerged through doing the process and learning. It’s a reminder that even the simplest process benefits from clear standard work and operational definitions. PDSA testing can support us in learning how to do the process and adapt as we gain a new understanding of what is required to do it well.

In normal times and in uncertain ones like today, the theories and methods of improvement science provide a method for learning and discovery, aid us to get the results we desire reliably and predictably, and help us focus our attention on what matters. 

If this was helpful, share and include me @DaveWilliamsATX. Sign up here to receive a monthly email from me that includes all my blog posts and other Improvement Science resources I think you’d appreciate.