BMJ Qual Saf 21:499-502 doi:10.1136/bmjqs-2011-000396
  • Original research

Getting doctors to clean their hands: lead the followers

  1. Paul Visintainer3
  1. 1Division of Infectious Diseases, and Division of Healthcare Quality, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  2. 2Internal Medicine Department, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  3. 3Division of Epidemiology and Biostatistics, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  1. Correspondence to Dr Sarah Haessler, Division of Infectious Diseases, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA; sarah.haessler{at}
  1. Contributors All authors had full access to the data in this study and played a role in writing this manuscript.

  • Accepted 19 January 2012
  • Published Online First 22 February 2012


Background Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence.

Methods Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physician's HH compliance.

Results 718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physician's HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters.

Conclusions If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physician's behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.


  • Competing interests None.

  • Ethics approval Ethics approval was provided by Baystate Medical Center IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data available on request from the corresponding author.

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