As I mentioned in my last post, these should be the best of times for “Infection Preventionists” (formerly known as Infection Control Officers). After years of trying to get someone – anyone – to pay attention to their work, their day in the sun has finally arrived. But they are far from a joyful bunch. Why?
In my talk to 4,000 members of the Association for Professionals in Infection Control (APIC) last week, I riffed on this question. After being prepped like a pre-debate presidential candidate by my friends Amy Nichols and Barb DeBaun (thanks!), I told the group that they are going through the inevitable but unpleasant phase of being attention- and accountability-rich but resource-poor. In other words, now that healthcare-associated infection rates are key measures of safety (with real skin in the game in the form of public reporting and “no pay for errors”), infection control departments are under immense pressure to stamp out these infections like cockroaches.
This is much harder than it looks. In areas in which evidence-based processes have been identified that can markedly decrease infection rates, they face the classic cat-herding challenge of ensuring 100% compliance with practices like hand hygiene and use of maximum sterile barriers.
In other areas, the sad fact is that we don’t really know how to prevent the infections (at least if we’re going to use a standard of evidence-based process-outcome links). I’d place virtually all of the proposed “no pay for errors” infections (other than central line-associated bloodstream infections) in this category: MRSA, C. difficile, Legionella, even nosocomial urinary tract infection. The latter is a particularly telling case – my friend Sanjay Saint of Michigan has clearly shown that many patients have Foley catheters that stay in far too long or never should have been inserted in the first place. His research has also identified the embarrassing truth that many physicians are unaware that their patient has a Foley; in some of the cases, no one remembers ordering a catheter in the first place (a phenomenon he has amusingly dubbed “Immaculate Catheterization.”) Nevertheless, although a study in this month’s Journal of General Internal Medicine confirmed Saint’s earlier observation that automatic stop orders reduced the duration of urinary catheterization, they had no impact on overall infection rates.
Even without ironclad evidence about what exactly to do, Infection Preventionists are hard at work trying to decrease infection rates through microbiologically-sensible process changes, and bless them for these efforts. The problem is that – without adequate information technology and clerical support – they are spending a huge amount of their time data-gathering, and not nearly enough in change management. It is the usual story: in every industry, management always expects workers to accomplish boatloads of today’s new work while using yesterday’s resources. (This is analogous to adding no new resources to deal with markedly increased numbers of incident reports or root cause analyses.)
I offered a hopeful message to the APIC crowd, since I think it is inevitable that they will get the resources they need – not because the C-Suite will be sprinkled with the fairy dust of charity, but because it will be too expensive to have trained professionals doing data gathering when there are more cognitively and sociologically complex tasks that need to be tackled.
I also discussed what I thought the Infection Preventionists could learn from the field of patient safety. The answer is plenty:
First, It’s The System, Stupid. The patient safety field has demonstrated that education (“let’s do an in-service for the nurses and a conference for the docs”) is the weakest method to create meaningful and durable systems change. The emphasis should be on more robust strategies: double checks, simplification, standardization, focusing on human factors, and using information technology as a forcing function. Pronovost’s work in Michigan showed that thoughtful use of checklists markedly increased adherence to best practices in central line catheter insertion, leading to an impressive fall in infection rates.
Secondly, effective strategies are both top down and bottom up. Heavily centralized strategies tend to squelch provider enthusiasm and stifle local innovation, and they often can’t be adapted to local circumstances. On the other hand, programs that overemphasize unit-based control fail to benefit from economies of scale and engender constant wheel reinvention (the Step-Down Unit has no way to learn of the ED’s successful strategies). The best organizations nurture unit-based structures, but embed them within a central framework and resources.
Third, strong programs emphasize both stories and data. Overemphasis on stories can feel moralistic, manipulative and non-actionable to front-line providers. “We get it already,” say some; “stop pounding us over the head.” On the other hand, organizations that are religiously data driven tend to be lacking in inspiration and a bit robotic.
Fourth, the patient safety movement has taught healthcare that “culture eats strategy for lunch.” All of the cultural change that we’re aiming for in patient safety (creating a no blame climate, learning from errors, dampening down hierarchies, promoting effective communication) are equally relevant to infection prevention.
Finally, no Infection Preventionist can be successful if he or she does not find an ally in the organization’s top physician leader (these days, often a Chief Medical Officer [CMO] or a Vice-President for Medical Affairs [VPMA]). I encouraged the audience to try to figure out who this person is in their organization, and to make him or her their best pal. Ultimately, when the medical and nursing staff push back on some policies and edicts (as they inevitably will), one needs a powerful person covering his or her back. This should be the person with ultimately responsibility for hospital performance, and whose job it is to argue for resources for performance improvement. Chances are pretty good that the infection control enterprise has similar needs to the patient safety, quality, and compliance operations, so there might well be some economies of scale.
Part of the reason I focus on this final point is that I have come to appreciate the indispensable role of the CMO/VPMA in hospital efforts to improve quality and safety. In my next post, I will explore the remarkable evolution of this position – which is becoming more important with each passing day – in more detail on the occasion of the upcoming retirement of UCSF’s extraordinary CMO, Dr. Ernie Ring.