The Power of Habit

In my quest to become a more productive adult I decided to pick up Charles Duhigg's The Power of Habit.  I seem to have trouble forming/keeping good habits - good intentions are only a small part of the battle - so I thought this might be a book with some good ideas.

Well, sort-of.  Duhigg uses case studies and examples of corporate culture to demonstrate how habits have a cycle.  A cycle of cue --> routine --> reward --> [repeat] that is self-reinforcing.  A man with post-encephalitic brain damage so severe he has both retrograde and anterograde amnesia retained old habits of eating, taking a walk, and watching television; even though he couldn't create new memories the neuroscientists were able to train him to form new habits.  Target uses shopping data to analyze shopping habits and predict which coupons a customer would be likely to use (i.e. if a purchase shows onesies, a stroller, and a maternity top then the shopper is likely a pregnant woman and Target can send coupons for diapers) thereby getting the customer back into the store to buy more product.  The new CEO for Alcoa boosted productivity and profits by focusing on a single "keystone" habit - how worker injuries were handled (the cue loop for that one runs worker injury (cue) --> must be reported within 24 hrs (routine) --> get a promotion for using the system correctly (reward)).

Some of the examples don't fit so well.  The development and success of Febreeze is posited as the desire to have a clean-smelling house.  The chapter on Starbucks's career development programs is interesting but many of the notes say the program has been discontinued making the whole section less useful.  At the end of the book Duhigg tries to pull viral networking and the issue of biology vs. free will into the discussion but those last two chapters feel very tacked on.

The money chapters are Chapter 2 (The Craving Brain: How to Form New Habits) and Chapter 3 (The Golden Rule of Habit Change: Why Transformation Occurs) as well as the appendix which offers a readers' guide.  These sections go into depth using case-studies of people who have changed their habits.  One quite biting her nails.  Tony Dungy's training program is reviewed.  Brain imaging is discussed (surprise: the neural pathway for the "old" habit never goes away, the new is only overlaid which offers up one explaination why bad habits have tendency to come back).  The guide is nice in that it takes the habit loop evidence and lays it out very simply.  I haven't yet put it into practice (I have a really bad habit of always eating out and driving to work rather than cooking for myself and taking the bus) but the loop theory is good to keep in mind.

Of course, while I was reading The Power of Habit I was thinking about how to apply the habit loop to handwashing at work (even tweeted Eli about it).  For those of us in healthcare epidemiology, we sigh and grumble everytime we see the perennially abysmal hand-hygiene compliance numbers.  A lot of money is being thrown at the issue to study everything from high-tech sensor motes, immediate electronic feedback, and research assistants to watch HCWs wash their hands, to pizza parties, new antimicrobial handrubs, and focus groups.  The methods don't seem to stick, though.

In my own personal experience, it seems to come down to habit (if a physician or nurse claims poor education they ought to leave the profession).  And HCWs are experts at the habit of excuses for why they don't need to wash their hands.  I have stood and played the "what-if" game with nurses and doctors:

• What if I only have to silence an alarm? (the alarm is in the patient's environment, use the handrub on the way in) 
• What if I have a cup of ice for the patient?  (Since it's unlikely that you'll only put the cup down and leave, hit the handrub bottle on the way in and rub it in once you've put the cup down) 
• What if I have to step out and grab some meds?  (You'll be touching the cart/PYXIS/patient) 
• But I used the pumper bottle thirty seconds ago, why do I have to use it again on the way into see a patient?  (And you've touched the computer keyboard and the counter since then)
• What if, what if, what if....

So how would the habit loop of cue --> routine --> reward work in this situation?  The cue and routine portion is very straightforward: when you enter or exit a room, don gloves, etc. per the WHO Five Moments guidelines that is the cue, the act of hand-washing is the routine.  So where's the reward? Perhaps the Alcoa situation is similar and hospitals needs to start recording individual HCWs' hand-hygiene rates; those HCWs with good rates get first pick of vacation days or that becomes part of the promotion package (I can hear the union complaining now).  Or perhaps, given that tying HH rates into career might seem "mean", a hospital could provide HCWs with HH>90% a voucher for a free meal or coffee one a month.  We could back it up and apply the reward to the students - the more a habit is "baked in" in nursing or medical school the more likely it is to be carried through into the post-graduate workplace.

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