The acronym KISS (Keep It Simple, Stupid) is attributed to the American aeronautical engineer Kelly Johnson.
On the face of it, simplicity makes sense, but it can be complicated. As Appleyard (2011) argues, ‘simple solutions don't work in a complex world’.
Few things are more complex (or should that be ‘complicated’?) than the way we think. We are prone to deviating from logical, reasonable thought and behaviour: we overestimate our knowledge, worrying more about the prospect of losing something than making a similar gain, and ‘[i]n the presence of other people we tend to adjust our behaviour to theirs, not the opposite’ (Dobelli, 2013:2).
Let us consider handwashing. It is clear that handwashing can prevent infections, yet the median compliance rate among health professionals is around 40% (Ibrahim et al, 2018). Even placing cameras to monitor handwashing protocols does not boost compliance rates to anywhere near 100%, as demonstrated by Ooi and Griffiths (2018). Before camera installation, the handwashing technique of obstetric surgeons conducting elective and emergency operations was recorded as 50% unsatisfactory, 20% satisfactory and 30% excellent. Post-intervention rates were 27.5% unsatisfactory, 30% satisfactory and 42.5% excellent (Ooi and Griffiths, 2018). Although the authors tried to mitigate the Hawthorne effect—when behaviour changes in response to observation and assessment (Sedgwick, 2015)—the participants still knew they were being monitored, yet 27.5% recorded unsatisfactory scores.
Given that the annual global rate of neonatal death attributed to invasive infectious disease is around 1.4 million, Hoang et al (2018) installed a video recorder adjacent to a washbasin in a neonatal intensive care unit to try and increase handwashing times of staff and visitors to a minimum of 20 seconds. Over 9 months, the mean handwashing duration rose from 18.4 seconds to 25.7 seconds for staff; and from 16.3 seconds to 22.9 seconds for visitors. Microbiological testing found that increasing handwashing time was significantly associated with a decrease in qualitative bacterial growth from organisms harvested from participants' hands.
Despite the apparent reluctance of many healthcare workers to perform the simple—and ethically necessary—procedure of washing their hands, there are at least some steps that can be taken to increase compliance rates.
However, it seems that some health professionals are prepared to (and here the pun is appropriate) throw in the towel. Mahida et al (2017) therefore asked whether it was time for an end to the cycle of unrealistic targets, evidence of poor performance, and interventions that only proved effective in the short term. The answer is no. If evidence-based medicine means anything, it means acting where action has been shown to improve patient care, and in that context, it is not unrealistic to aim for 100% compliance.
Having worked for 30 years in a virus laboratory, manipulating a rich panoply of bugs all bent on infecting us, my colleagues and I were keen not to take our work home—a sufficient incentive that ensured an eager 100% compliance with handwashing protocols. Similarly, midwives and other staff with direct patient contact have no excuse, except when dire emergencies dictate otherwise, for not taking the time to protect both themselves and their patients by washing their hands.
As Saito et al (2018) remind us, 5 May is the World Health Organization's ‘Prevent sepsis in health care’ campaign day (Saito et al, 2018)—an opportunity not only for health professionals to reflect on their own attitudes to handwashing, but also to ensure that they do not follow the labyrinthine routes of complicated thinking identified by Dobelli (2013) to justify not doing so.
It's simple, really.