Which boosts hand hygiene long-term: peer pressure or cash incentives?

When it comes to improving and sustaining hand hygiene compliance rates, peer pressure may be more effective than the promise of a cash bonus, according to a study in a California hospital described in a March Harvard Business Review article.

For the study, hospital employees could all earn a $1,200 bonus if the hospital as a whole met the compliance target — measured by "secret shoppers" — after 90 days. Workers received bi-weekly progress reports on the hospital's progress.

Hand hygiene compliance was measured at an organization level, so it included all clinicians. However, because physicians at the hospital were not employees of the hospital, they were not eligible for the cash bonus but their compliance still counted toward the overall target rate.

Nurses and other employees worked to include physicians in the improvement initiative in other ways, including peer pressure. "Physicians that demonstrated good hand hygiene practices would have their names written on hand-shaped paper cards and posted on a wall," according to Harvard Business Review. "The chief nursing officer would send physicians 'love notes': celebratory emails underlying good performance, or respectful — but firm — reminders of the importance of their cooperation to achieve the collective goal."

Researchers found that employees who were eligible for the bonus improved hand hygiene practices during the 90-day challenge, but their performance worsened afterwards. On the other hand, physicians showed slower improvement during the 90 days, but they maintained their improved rates beyond the intervention.

"While monetary incentives generated a more pronounced improvement, it was short lived. On the other hand, peer pressure techniques generated a change in organizational behavior that persisted beyond the removal of the incentive," according to Harvard Business Review.

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