How to Lose Patients Without Even Trying

Failure to teach—and practice—proper hand hygiene can be detrimental to the health of your patients and your practice.


How to Lose Patients Without Even Trying

Failure to teach—and practice—proper hand hygiene can be detrimental to the health of your patients and your practice.

images Charles McMonnies is an adjunct professor at the School of Optometry and Vision Science, University of New South Wales, Sydney, Australia. He conducted a contact lens practice for over 40 years and has published more than 120 papers and articles. You can contact him at

By Charles W. McMonnies, MSc

Recently, I received an e-mail from an elderly woman who has impaired vision—I’ll call her Helen—inquiring about the skills and training of optometrists in Australia. She explained her circumstances and why she had contacted me.

In one eye, she had a failed corneal graft that was maintained by a bandage soft contact lens, requiring monthly replacement. She’d had multiple surgeries on her other eye, so that she couldn’t see well enough to replace the bandage contact lens herself. She’d been traveling some distance to a clinic in Sydney every month to have the lens replaced but was now searching for a new eyecare practitioner to assist her with this task.

Even though she’d had to teach her current practitioner how to replace her bandage lens, it wasn’t his apparent lack of training in this area that prompted her e-mail to me. The reason she’s leaving his practice is because of his poor hand hygiene. Helen’s intelligent and insightful note to me, part of which is reproduced in “Why Helen Is Searching for a New Eyecare Practitioner,” on the opposite page, detailed what she had observed and her concerns about her ocular health.

Although graduate courses for eyecare practitioners emphasize the need to maintain high standards for hand hygiene, studies have shown—and Helen’s e-mail confirms—that lapses can occur in practice. In this article, I explore hand hygiene from the practitioners’ point of view as well as from the patients’ point of view, and I offer suggestions to improve compliance.

Health Workers’ Hand Hygiene

Although all healthcare professionals would agree that hand washing is important, there is some disparity between this belief and what occurs in practice. One study found that many healthcare workers wash their hands for an average of only five seconds between patients (Boyce et al, 2002). In another study, nurses in post-anesthesia care units said that they didn’t have time or didn’t feel the need for repeated hand washing, or they said it’s too inconvenient (Petty, 2009). This same study found that healthcare workers had an average of 3.9 × 104 to 4.6 × 106 aerobic bacteria colony-forming units on their hands.

Epidemic keratoconjunctivitis is easily transmitted from and to patients, and hand washing is a key aspect of management (Stefkovicova et al, 2006). Poor hand hygiene is a common risk factor for hospital-acquired keratoconjunctivitis (Nercelles et al, 2010).

These problems occur not just because healthcare workers fail to wash their hands long enough or at all, but also because they use poor technique. Of a group of eyecare practitioners who rated their hand-washing technique as excellent before evaluation, only 20 percent gave themselves that rating after objective evaluation, even though they knew that they were being observed (Veys, 2010).

Contact Lens Patients’ Hand Hygiene

A review of studies performed over the past 25 years found that hand hygiene among contact lens wearers has been consistently poor (McMonnies, 2011). Another study exploring ways to improve compliance among contact lens patients found that successfully modifying behavior depends not only on showing patients how to wash their hands, but also on explaining why proper technique is important (McMonnies, 2011). Not appreciating why sets the stage for neglect, which is compounded by not knowing how. Infections and other contact lens wear problems resulting from poor hand hygiene show that failure to teach effective hand hygiene is another way to lose a patient.

Why Helen Is Searching for a New Eyecare Practitioner
From: Helen

To: Prof. McMonnies

Subject: Is changing of disposable soft lenses for sight-impaired clients in the repertoire of procedures that optometrists perform?

Hello Prof. McMonnies,

My optometrist is performing the above procedure for me each month, but his hand-washing technique before removing the old lens has deteriorated to the point where he is using no liquid soap, just a quick rinse of the hands in cold tap water, rapid paper toweling, usually followed by absent-mindedly touching his necktie and tapping the thigh of his trousers with his dominant hand before sticking the index finger of that hand, with considerable pressure, straight into my eye.

…I tactfully raised the perfunctory hand washing with my optometrist when he changed my lens yesterday. He was embarrassed, embarrassing me because I don’t know whether what I am asking him to do is part of his clinical training, and whether he is aware of the importance of washing his hands properly, and has been trained in how to do so. I guided him initially in how to go about changing my lens. His drop-off in hand washing is a fairly recent thing. Maybe he is trying to tell me something.

…I am a busy, well, interested, self-funded retiree with no relatives. At this stage of life, the interests of my acquaintances have narrowed to their grandchildren and their own ill health. I impose myself upon them as little as possible.

I, therefore, hope I can rely on competent skills in my local health professionals to avoid the now tiring train trip to Sydney for a lens change. I did have a visiting eye surgeon changing my lens for a short time…He was no better at hand washing and used to do his keyboarding after washing his hands, then put his newly dirtied finger in my eye.

I maintain a sense of humor and am grateful that, so far, I haven’t had an eye infection. In summary, are optometrists trained, willing, and able to change soft, disposable corneal lenses for sight-impaired clients, and are they trained to routinely, thoroughly wash their hands between clients for their clients’ safety and good eye health?

With best regards,


For contact lens patients who have rarely washed their hands before handling their lenses, a lottery analogy may help to modify their behavior. Details are available in my June 2010 Reader and Industry Forum article titled, “A New Analogy to Help Increase Contact Lens Compliance.”

Reinforce Learning

Instruction for the use and care of contact lenses covers a lot of information. How much will patients remember hours or days later? Average learning retention rates for different teaching methods vary from about 5 percent for a lecture to 10 percent for reading once, 20 percent for a demonstration, 30 percent for a discussion group, 75 percent for practice by doing and 90 percent for teaching others (Coffey and Gibbs, 2002). Even after a full explanation and demonstration, patients forget as much as 50 percent of the advice provided within minutes of a consultation (Donshik et al, 2007).

Because learning retention rates are highest when a person teaches others, ideally, contact lens wearers would go home and teach family members how and why to wash their hands effectively. Likewise, eyecare practitioners would maintain higher standards of hand hygiene themselves if they were more involved in teaching patients how it should be done (McMonnies, 2012).

Your Demonstration Counts

As Helen’s e-mail indicates, patients judge the standard of hygiene demonstrated by their practitioner. When you wash your hands in front of patients, you reassure them that high standards for personal hygiene are routine in your practice. In addition, while patients observe your hand-washing technique, you can incorporate some commentary to reinforce their previous instructions. Here are some key points that you can share with your patients while you are washing your hands:

• Start by rinsing your hands with running water. This removes some superficial dirt and makes it easier to work up an effective soap lather.

• Cover your hands with lather to loosen germs from the skin. Work the lather into your skin to improve the germ-removal process.

• Rub your hands together and rinse thoroughly to remove all soap lather and loosened germs in the soap lather. Thorough rinsing leaves the skin squeaky clean. All the soapy slipperiness (and germs) must be rinsed off.

• Dry your hands thoroughly because major eye infections can occur from micro-organisms in tap water. Use paper towels, because reusable cloth towels put germs back onto the skin, and hot air driers contaminate hands with aerobic bacteria, negating the hand-washing effort. By the way, taps are always contaminated because they are turned on by dirty hands. The used paper towel is perfect for turning off taps as well as for opening the door when leaving a bathroom.

Practitioners should use disposable paper or cloth towels in the office. Fortunately, there are professional-looking boxed paper towels available, as well as a variety of wall-mounted dispensers that can save desktop space.

Reinforce Good Practices

In addition to discussing and demonstrating good hand hygiene in your office, you should provide printed instructions describing proper technique. You may contact me at to obtain a Word document for printing on your practice letterhead. Apart from using the information in its entirety as a handout, you can deliver individual tips periodically in your practice newsletters or broadcast e-mails to patients or on your website. Reinforcing good hand hygiene is an ongoing process that will ensure healthy contact lens wear for patients and reassure them that you practice what you preach. CLS

To obtain references for this article, please visit and click on document #210.