I’ve worked with a number of hospitals over the past few years, and in every one the issue of infection control is a big priority. As it turns out, nosocomial, or hospital-acquired infection, is a major killer because the hospital environment is in many ways an incubator of infectious transmission. Bugs can spread in four ways: from patient to patient, staff to patient, patient to staff and staff to staff. The Centers for Disease Control and Prevention (CDC) estimates that 1.7 million hospital-associated infections from all types of bugs combined cause or are linked to 99,000 deaths each year.

To control the spread of infection, hospitals have strict and detailed policies and procedures for disinfection, sterilization and vaccination. But the most important of all of these is the simple task of washing your hands. The CDC confirms that “the most important measure for preventing the spread of pathogens is effective hand washing.” Yet hand washing continues to be the single biggest obstacle to infection control. In the face of overwhelming urgency, evidence and motivation, hospitals continue to fight a battle of compliance with their clinical workers on the issue. People forget. They don’t have time. They want to avoid the hassle.

To get something to stick, it’s helpful to understand the way change roots itself in an organization. Change has to sink, level by level, into the cultural soil. There are three levels of transition a change must pass through before it can stick. If the leader doesn’t manage through all three levels, there’s always the chance that change will unravel, that people will stop washing their hands.

Level 1: System Change. The first level of change is at the systems level. It means putting in place all of the nonbehavioral supports for the new behavior. A system is a set of mutually reinforcing elements that will help hold the change in place. For hand washing, it means putting in place the policies and procedures, the training, the modeling, the resources, the communication, the measurement and the accountability.

Level 2: Behavioral Change. The second level is behavioral. Change goes to the behavioral level when people begin to behave differently under new conditions and with the aid of new or different resources. They are in the system. They are washing their hands when and where they should. By appearances, you may think change is here. You have outwardly confirming evidence, right? Don’t be fooled. People may not like the new behavior or fully understand it. They may not be convinced of it. They may even resent it. If you took the system away, people would likely revert to the mean. They would go back to their old behavior.

Level 3: Cultural Change. The final level is culture. Unless change finds purchase in the culture, it won’t last. Over and over, I observe that behavior changes before minds do, before hearts do. Change sticks when the culture finally supports it. By culture, I mean the prevailing norms of the organization. In every case, culture changes last. It’s the most stubborn element to change in any organization because it takes people time to internalize, accept and support the new behavior even though they may already be supporting it behaviorally. People need time to internalize change and make it their own. They need time to psychologically adjust to a new reality because, as Joseph Bower and Donald David have observed, “Thinking within the organization gets grooved.” It takes time to carve new grooves and overcome the past.

John Ehrenfeld, the executive director of the International Society for Industrial Ecology, concludes, “In the final analysis, underlying cultural values will always trump technology and design in determining behavior.”

If you consistently feed and starve the right things, change eventually becomes part of the DNA of the organization. It will become embedded and internalized in the culture and yield sustained results. With sustained results, the organization enters into a virtuous cycle in which the results support the new behavior and the behavior supports the new results. Over time, this dynamic recasts the culture until the organization doesn’t spring back to past patterns. There’s new muscle memory.

Let’s go wash our hands, shall we?