Editor’s note: The American Society of Nephrology has partnered with the U.S. Centers for Disease Control and Prevention (CDC) to develop the Nephrologists Transforming Dialysis Safety (NTDS) Project to promote infection prevention in outpatient dialysis facilities. The mission of the NTDS Infection Prevention Project is to engage nephrologists to “target zero infections” by aggressively pursuing the elimination of preventable infections in dialysis facilities.

We interviewed Leslie P. Wong, MD, MBA, chair of Quality, Assessment, Improvement and Education for the project, and Alan S. Kliger, MD, the chair of the project, about how nephrologists can lead infection prevention efforts in dialysis clinics.

Dr. Kliger Priti Patel, MD, MPH will be chairing an early program at Kidney Week entitled “The Dialysis Infection Crisis in the United States: A Call to Action” on Wednesday, Nov. 1. Up to 7.75 CME credits are available for the course. Register here.

NN&I: Why do you think the nephrology community has failed to reduce infections among dialysis patients?

Dr. Wong and Dr. Kliger: The Centers for Disease Control and Prevention has published best practices and offered clinical tools to reduce infections in the dialysis facility. Despite this, the rate of infections has been essentially unchanged. How can we understand this?  In part, it is likely that CDC guidance has not received widespread use. But there is likely more to this challenge than knowledge of guidelines. Our observation is many medical directors give inconsistent messages about the importance of infection prevention, and provide ineffective leadership. This can only change when our community recognizes that reducing infections is a national priority, and when medical directors make reducing infections a priority for their facility.

The challenge then will be, how do medical directors translate this into action? While medical directors are competent nephrologists, many lack the training to be effective team leaders. They may have differing mental models about their role in leading infection control efforts in the dialysis facility. Some medical directors may have tried to fight infection rates, but have failed because of lack of support or resources. Others may not have fully accepted their responsibility to promote infection control. Nephrologists Transforming Dialysis Safety (NTDS) addresses these root causes by emphasizing the need for effective team leadership in dialysis facilities and calling for a large-scale effort led by nephrologists to end preventable infections.

NN&I: What are the underlying causes of the high rate of infections among dialysis patients?

W&K: The continued high use of dialysis catheters is a known contributor to infections. However, catheters alone do not explain widespread problems in basic dialysis infection control. The CDC views poor dialysis hand hygiene as the single greatest risk factor for transmitting infections. Breaches in hand hygiene and other infection control measures have been the most cited violations in dialysis facilities for decades. This trend continues despite universal acknowledgement of the danger to patients. A weak culture of safety is the underlying issue in many units. Nephrologists and dialysis staff may lack buy-in or acceptance of infection control policies because of competing priorities, incomplete understanding of infection risks, and low individual accountability. While some policy violations are the result of unintentional mistakes, many breaches are conscious acts performed to maintain efficiency. These shortcuts taken by dialysis staff are natural adaptations to work stress and become entrenched habits if allowed to persist. These workarounds are then accepted as part of the facility’s culture and become difficult to change.

NN&I: Why do you think hand hygiene, which seems relatively simple, has been such a persistent problem?

W&K: Hand hygiene, especially as part of dialysis facility culture, is habitual. Like a bad golf swing, it’s actually more important to unlearn bad habits first. Commitment to unlearning old ways is necessary for culture change and often the most difficult initial problem to overcome.

NN&I: What kinds of culture changes need to occur in clinics to lower the rate of infections?

W&K: If dialysis facilities do not recognize and address the factors responsible for maladaptive behavior, infection rates will not improve. We need to distinguish compliance and commitment in the context of culture. The term compliance carries a highly negative connotation in dialysis units. This attitude reflects fatigue surrounding the topic of infection control compliance. Compliance efforts are viewed as burdensome, unrewarding, and driven by the threat of punishment. Commitment on the other hand, represents intrinsic motivation to accomplish a task or goal, usually guided by an aspirational element.

If we want to improve safety culture in dialysis, we must change focus on compliance to create a commitment to end infections. This paradigm shift requires an understanding of the culture at each dialysis facility and identifying which aspects need to be changed. Culture belongs to a group, never an individual – so culture change efforts have to involve the entire dialysis facility. This is a process that the medical director must lead. The medical director must provide a vision of what is desired and inspire others to pursue that vision. It starts with articulating and communicating the need to end preventable infections and then creating a sense of urgency for action. Paramount is establishing a higher purpose – ensuring patient safety, and making it clear that everyone in the facility is accountable. If the medical director does not lead, efforts at culture change will likely fail.

NN&I: Why should nephrologists lead the way in lowering infection rates?

W&K: Being a good leader involves self-reflection and analysis ­— emotional intelligence. If nephrologists aren’t committed to leading infection prevention, we need to understand why. Nephrologists have common personality traits that make us sensitive to the idea of being wrong or responsible for a bad outcome. This makes us prone to react defensively when an infection control issue is raised. As a result, we tend to attribute problems externally as a natural defense mechanism — we say it’s a problem of the hospital, or a problem of the dialysis facility ownership, or multiple other players. While these organizations do play a critical role in ending infections, each dialysis medical director must recognize his/her own accountability, and the accountability of their staff.

Infection events are often multi-factorial. This demands a systematic, process-driven approach to analyzing and preventing infections. Because behavior is often influenced at the unconscious level, nephrologists may be unaware of how their emotions affect their actions. Lack of this awareness can prevent medical directors from seeing the big picture, making the right decisions, and thereby promoting a safety culture.

The next reason is the structure of leadership at dialysis facilities. Medical directors as designated leaders have official and broad authority, but may not exercise their full power to improve patient safety. This may derive from a common misunderstanding about the role of the nurse manager and others as situational leaders in the dialysis facility. Situational leadership is necessary for any successful organization and relies on actions motivated by self-initiative in pursuit of a common goal. The nurse manager is an important and visible situational leader who has a “second-in-command” position to execute the mission of patient care as outlined by the medical director. Referring nephrologists and other dialysis personnel also act as situational leaders. Their effectiveness as a team to prevent infections relies on collective commitment at all levels fostered by medical directors.

NN&I: What role should/can dialysis companies play in lowering the infection rates?

W&K: In the system’s view of safety, latent failures occur when the priorities and decisions of management conflict with goals of safety. In order for a safety culture to evolve, there are some key steps dialysis organizations can pursue. First, they must be visibly committed to patient safety and infection prevention as a priority. They must help dialysis facilities identify and address the environmental stressors that contribute to workarounds and shortcuts to infection control.

Second, they must support an environment of psychological safety that encourages, rather than discourages the disclosure of errors and operational barriers to safety. Furthermore, local management needs to be encouraged and empowered to accomplish these aims. When upper management doesn’t align incentive structures and accountability to meet these goals locally, people focused on productivity may relegate safety to a lower priority. NTDS presents an opportunity for critical dialogue with dialysis organizations to improve alignment and address larger systems factors that influence safety culture.

NN&I: What can nephrologists do to start having a meaningful impact on their clinics’ infection practices? What are the first steps?

W&K: The roadmap for leading dialysis facilities to Target Zero Infections starts with being a good role model and visibly demonstrating desired behaviors to others. Next, nephrologists must communicate clear goals and expectations for infection control to both dialysis staff and colleagues. After this, nephrologists can help foster the environment of learning and process-driven inquiry that supports an environment of psychological safety.

NN&I: Can patients be empowered to speak up when they see behavior or practices that might lead to poor infection control? (I hear a lot from patients that they are scared of retaliation or being labeled noncompliant).

W&K: Patients have to be taught and shown what is right and wrong. They must be empowered to feel safe reporting to staff when they see unsafe practices. Dialysis leadership and staff must create an environment where patients know they are safe when they report such breaches. The attitudes and behavior of dialysis staff towards patients will largely mirror the facility’s safety culture and own sense of psychological safety. There must be transparency about efforts to change culture that everyone has to understand. If the message is mixed or inconsistent, efforts will quickly be undermined. Once a patient or staff member witnesses or experiences retaliation or ostracism, they will be unlikely to speak up and participate in change efforts again.

NN&I: Does NTDS still have the goal of lowering the rate to zero in the next three years?

W&K: The target of zero infections is an aspirational goal. We know that most infections are preventable, and that we will get to zero infections only when we are committed to end them. The first step is to declare our intention to achieve zero preventable infections. We then will measure our effectiveness as we go, and refine our methods to keep that goal in the crosshairs. If we can get there in three years, great. If it takes longer, we will learn along the way how we will get to goal. This aspirational goal will help guide the long-term vision of a better safety culture in dialysis.

NN&I: What role can human factors engineering play in reducing infections?  Have human factors engineers ever looked closely at dialysis clinics and infection rates?

W&K: Human factors engineering can help mitigate the risk of infection control errors in dialysis. But any designed safeguard can be bypassed by intelligent staff. We need to explore why these workarounds happen. The airline industry has often used a model of how human factors engineering produces a high level of safety in a complex, potentially hazardous environment. Comparing the differences between airlines and dialysis facilities is helpful to identify avenues for improvement. Cockpit culture requires not only standardized checklists — it empowers any member of the flight crew to question another if there is a safety concern.

In a dialysis unit, the culture may discourage people to speak up or confront a colleague who is not following infection control policies. While there is pressure on airlines to keep flights on time, in dialysis there are different conditions.

While people may tolerate airline mechanical delays because no one would risk an accident, dialysis patients whose health could suffer may not accept treatment delays and become upset and angry at dialysis personnel and the facility. This environment is exacerbated if there is management pressure to maintain strict turnaround times and keep patients on schedule, leading to shortcuts like not disinfecting the dialysis station properly. Importantly, if the flight crew ignores their checklist, they will suffer too if the plane crashes. Dialysis staff may not similarly perceive the risk of poor infection control practices.

NN&I: Do you think understaffing or lack of time for proper infection prevention plays a role in the high infection rate?

W&K: Historically, dialysis facilities have been designed to maximize productivity. In order to increase safety, some operational efficiency must usually be sacrificed.

Thoughtful application of human factors engineering could help redesign workflows and staffing to promote infection control, but only with collaboration involving nephrologists, patients, staff and dialysis organizations. Good patient care and smart business are not mutually exclusive, but both require strong ethics and forward-thinking leadership.