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Plant the Seeds of Change with Just-in-Time Coaching

By Lori Moore, MPH, BSN, RN, CPPS


Hand hygiene has been recognized as one of the most important measures to reduce germs in healthcare facilities, and educating healthcare workers to the basic fundamentals has become a cornerstone of hand hygiene programs.1-2 While providing education and conveying the importance and need for hand hygiene is the first step, these activities alone are insufficient to achieve and sustain significant improvements.3


Healthcare professionals responsible for performance improvement often struggle to better understand why healthcare workers aren’t cleaning their hands according to policies and guidelines. Valuable time and resources are invested in identifying barriers or reasons for noncompliance, developing countermeasures to resolve or minimize the barriers and then implementing those countermeasures to improve hand hygiene.2,4-5 This is an iterative process that cycles over and over. Despite efforts, all too frequently, hand hygiene does not improve or improvements are not sustained. This is because human behavior is the result of many influences including not only the environment but also social norms and culture, and although these influences are usually interdependent, some have more force than others.6


Every healthcare worker has their own routines, habits and patterns of working as they move throughout their day which includes when and how they perform hand hygiene. These habits are often deeply ingrained and performed automatically without conscious thought. It is these long-standing habits and practices of healthcare workers that contribute to a culture that lacks the social expectation to perform hand hygiene per policies and guidelines.7 When rates are consistently low, it is an indication that the current habits for hand hygiene are insufficient, and old habits need to be broken and new habits formed in order to create a culture more conducive to achieving hand hygiene improvement goals. James Clear8 posits that the task of breaking old habits is like uprooting a powerful oak tree with deeply entrenched roots. Conversely, he states that the task of building new habits is like cultivating delicate flowers one day at a time; the seed of every new habit is based on a deliberate, conscious decision, but as that decision is repeated over and over again, a new habit sprouts and becomes intrinsic and automatic.


It is not enough to tell healthcare workers the expectations for hand hygiene behavior and then periodically provide them with data regarding compliance rates.7 There must also be social pressure by leaders and peers to perform the expected behavior. Applied consistently, this social pressure can establish new social and behavioral norms. Consequently, in order to change behavior, there needs to be a prompt or a reminder at the right moment3 that leads to a new decision to perform hand hygiene and if applied frequently and consistently, these reminders will eventually lead to new habits that become part of the natural workflow for healthcare workers.


Just-in-Time coaching has been a mechanism employed by infection preventionists and other leaders for providing reminders when hand hygiene opportunities are missed. However, this on-the-spot coaching and reminding occurs only sporadically and too infrequently and inconsistently to sustain behavior change and establish new norms. Recognizing that unit leadership and frontline healthcare workers have the advantage of residing on the nursing units and are closest to the patient, who better to speak up and provide consistent, immediate reminders? A unit-led Just-in-Time coaching program incorporates shared accountability by encouraging all healthcare workers, regardless of role or position, to reinforce good hand hygiene habits and consistently and respectfully intervene and provide positive real-time feedback to one another when opportunities are missed.9   


The starting point in motivating behavior change is to understand the complex factors and interactions associated with hand hygiene.3 Implementing behavior change is not based on single generic interventions but involves a combination of interventions targeted at specific obstacles to change.2 Education and knowledge can support a change in behavior; but alone they do not necessarily cause it. Likewise, identifying barriers and implementing solutions can support behavior change; however, mitigating barriers will have little effect until new habits are built. Unit-led Just-in-Time coaching, as part of a multimodal strategy to improve hand hygiene and patient safety, can provide fertile ground in which to plant seeds of behavior change, sprout new habits, and influence social norms. The ultimate goal is to create a culture in which it becomes the expectation to be reminded to clean hands when an opportunity is missed rather than the exception.10-11



  1. Boyce JM, Pittet D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(RR-16):1-45.
  2. World Health Organization. WHO Guidelines for hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009.
  3. Association for Professionals in Infection Control and Epidemiology. APIC Implementation Guide: Guide to Hand Hygiene Programs for Infection Prevention. APIC;2015.
  4. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386.
  5. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf. 2015;41(1):4-12.
  6. Whitby M, McLaws ML, Ross MW. Why healthcare workers don’t wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol. 2006;27:484-492.
  7. Linam WM. Speaking up: the next step to improving health care worker hand hygiene. Hosp Pediatr. 2017;7:245-246.
  8. Clear, J. Atomic habits: an easy and proven way to build good habits and break bad ones. Penguin Random House; 2018.
  9. Sickbert-Bennett EE, DiBiase LM, Teal LJ, Summerlin-Long SK, Weber DJ. The holy grail of hand hygiene compliance: just-in-time peer coaching that leads to behavior change. 2020;41:229-232.
  10. Weinstein RA. Hand Hygiene—of reason and ritual. Ann of Intern Med;141:65-66.
  11. Wachter RM. Understanding patient safety. McGraw-Hill Companies; 2008.


Lori Moore joined GOJO in 2013 as a Clinical Application Specialist. In this position, she provided leadership and support to healthcare organizations as they implemented electronic compliance monitoring. She has been a trusted partner to hospital key stakeholders in the development, design and implementation of hand hygiene improvement efforts. In January 2017, she transitioned to the role of Clinical Educator. Through this position, Lori provides clinical support and education to assist healthcare professionals on their journey to improve hand hygiene.

Lori’s clinical background is in critical care, and she worked in the medical intensive care unit at the Cleveland Clinic Foundation for 10 years. Her passion for patient safety and quality of care sparked her interest in infection prevention, and she worked as an infection preventionist prior to joining GOJO.