2. People Don’t Always Do What They Say They Do
According to what Dubner has found in his research, data often just shows the best version of people, not how people actually behave.
An interesting example is in hand washing. Dubner related the story of a study conducted in a pediatric hospital in Australia where 73 percent of all doctors self-reported that they do, of course, wash their hands after using the bathroom.
However, when the hospital administration asked nurses to spy on doctors (listening by the door to see if running water sounded after flushing), the nurses reported that only nine percent of doctors wash their hands.
3. Changing Behavior is Extremely Difficult
Hearing about the study mentioned in Australia, Dubner said that Cedar Sinai Medical Center in Los Angeles became concerned that their own doctors may not be washing their hands, and when they also asked nurses to spy on doctors, the nurses reported that only 60 percent washed their hands.
Wanting 100 percent hand-hygiene compliance, the hospital formed a committee charged with reaching this goal.
“They came to the conclusion that it wasn’t a lack of knowledge about hygiene as they were, after all, doctors,” explained Dubner, “so they tried incentives to get the doctors to change. The first incentive was just a memo sent out on behalf of the committee asking doctors to wash their hands. Of course, nothing changed.”
Realizing that, as a rule, positive incentives work better than negative ones, the committee then formed a “posse patrol” that would hide in patients’ rooms during a doctor’s rounds, and if the doctor washed his or her hands after using the bathroom, the posse would spring out, congratulate the doctor, and then present them with a $10 Starbucks gift card.
“I have to admit, as I was studying this experiment, I thought to myself ‘That’s a dumb idea because these doctors make a lot of money. What would they care about a small gift card?’ But you know, that was my mistake, because if there’s one thing you should never underestimate, it’s the power of ‘free.’ I’m sure many of you at Infocomm would literally wait in a long line to get a pair of sweat pants for your dog if it was free.”
Dubner continued the story, saying that though the doctors did respond well to the gift cards, telling the committee they liked the idea, the needle still didn’t move and the rate of hand-hygiene compliance didn’t change.
“What the committee didn’t anticipate was that by gamifying incentives—offering a small reward for small steps to progress—the doctors themselves gamified the idea. So what probably happened is that after they received the card, they knew the posse would no longer be on the floor or rotation, so they began not washing their hands after that. Or perhaps they figured out the posse’s schedule and only washed their hands when they knew the posse was on their round,” he speculated.
The incentive that finally did work? A horrifying visual aid.
Dubner related that it was finally an oft-quiet committee member who suggested that the committee members themselves, composed of hospital leadership, put their hands in a petri-dish to see if the committee washed their own hands. The anonymous results revealed that the committee was just as bad as the doctors.
“The committee, embarrassed at their own hand-hygiene compliance rate, then took a photo of one of the unwashed, bacteria-covered petri dish hands and used that image as a screensaver on every hospital computer as a reminder that everyone should wash their hands. And this is the incentive that worked! The hospital reached 100 percent compliance,” said Dubner.
“It just goes to show you,” he noted, “that incentivizing, predicting what will work and the process of trial & error is a tough road that takes time and patience.
(Next page: The basics of human behavior often elude us)