Metrics, Decision Makers and Hospital Epidemiologists

This is a guest post by Silvia Munoz-Price, MD, PhD, Enterprise Epidemiologist and Professor of Medicine, Division of Infectious Diseases, Froedtert and the Medical College of Wisconsin.

During the past few weeks I have been mulling over two issues related to Quality and Infection Control that have to do with metrics, their use, and the impact that they have in our hospitals. Two separate topics but related to a certain degree.

1. My hospital has a strong Quality Department and a stronger culture of safety. For the most part we have very few serious infections and even fewer MRSA, VRE, and almost no multidrug resistant Gram negative rods. Our compliance with hand hygiene is 73% (as per >5000 observations collected over a couple of months by managers from units that are not their own and concordant readings obtained by the Infection Control Department. I am trying to tell you that 73% is probably close to accurate). From my perspective, if indeed true, this is an acceptable rate. I think we should concentrate on preserving this rate and maybe focus on areas/providers that need more attention. However, my hospital wants this number to be close to 100%. So, here are my questions: should we invest more time, effort, and money to push for higher compliance with hand hygiene? What would be the return on investment of increasing our hand hygiene compliance and how could we measure its impact? What type of infections would we prevent by increasing hand hygiene compliance? Yes, our CLABSIs and CAUTI rates could be better, but would they noticeably improve by pushing hand hygiene above 80%? (I’m intentionally not discussing C. difficile infections as these have a different etiology in my hospital). And most importantly what other interventions would we be overlooking by focusing so much on hand hygiene? Who decides where to allocate time, effort and money?

2. Over the past couple of decades I have observed a shift in Infection Control throughout the various places I have worked at from minimal interest/resources given to Infection Control, to a phase where more visibility was given to Infection Control matters --probably due to metrics--to the allocation of more interest/resources, to publicly reported metrics, to institutional notoriety and reimbursements linked to metrics, to a tunneled vision about metrics. On this topic, many years ago I observed a human behavior that since I have observed multiple times: when we started placing fluorescent powder on surfaces and giving feedback to providers on the degree of removal, cleaning rates improved (https://www.ncbi.nlm.nih.gov/pubmed/21460514). Feedback was then given weekly and in a public manner, with a substantial amount of pressure placed on EVS to improve. The numbers got much better. We eventually figured out that EVS providers bought their own ultraviolet lamps to find the fluorescent markers and spot clean them. What happened? The metric made sense at the beginning, initially it probably achieved its intended outcome (more frequent cleaning) but then a threshold was crossed, after which what mattered was the metric (as a number) and no longer the intended outcome (more frequent cleaning).  I think the same is happening to our hospitals. Metrics were beneficial initially (more resources for Infection Control, more visibility, more engagement of staff, lower infections) but I would argue that we are on the other phase of the metrics (unintended consequences).  All the pressure we are placing for lower and lower metrics (get to zero CAUTIs!) might be backfiring. We are deploying large teams and resources to decrease certain conditions which is shifting our capability to address issues that might be equally or even more important in our respective hospitals   (e.g. post craniotomy  SSIs).  So, who decides how to allocate our limited resources? I would argue that Quality is now the main decision maker and that these decisions are strongly guided by publicly reported metrics. Is this good or bad for our patients? I am not sure. Is this good for the field of Hospital Epidemiology? I don't think it is. Hospital Epidemiologists need to re-think their involvement in Quality and become their hospitals’ Chief Quality Officers. That is the only way I see that we will impart some sense to the decisions of resource allocation. However, the opportunity for our specialty to lead in this field might have already passed.     

Who the H is a Healthcare Epidemiologist?

We are happy to feature this guest post from Dr. Pranavi Sreeramoju, Associate Professor and Chief of Infection Prevention at UT-Southwestern!

A few years ago, I overheard my husband tell his friend, “yeah, my wife is a teacher at the local medical school”. “Why didn’t you tell him I am a healthcare epidemiologist?” “It’s a mouthful”, he replied. The rest of the conversation went like this:

“Why not say I am a physician?”

“My friend will think you make a lot of money. You don’t.”

“Why not physician epidemiologist?”

“Again, it’s a mouthful”

“Why not use my real job title, chief of infection prevention?”

“You don’t have a lot of authority on your job”

“Why not associate professor?”

“Aren’t you constantly stressing out that your boss thinks you are a publications and grants underachiever?”

“Why not just epidemiologist?”

“Didn’t some of your team members say they are epidemiologists? I thought some of them were nurses and some of them were not. You went to medical school for fourteen years.”

I was clearly losing at this point. “Well, majority of the effort on my job is to oversee the infection prevention program. Not for teaching.”

“Don’t you teach your colleagues when and how to clean their hands all the time?”

Hmmm. I usually didn’t lose arguments with him, but I lost this one. During my fellowship (in infectious diseases) days, my mentor Stephen Weber used to introduce himself to medical students as a mid-level hospital bureaucrat. At that time, I chose to pursue hospital epidemiology as a career mainly because I like to work with patient outcomes at a population level and I didn’t want to travel for work as they did in global health. Traveling for work is not the same as traveling for fun and exploration.

In the thirteen years since that decision, I have had a never-ending professional identity crisis of sorts. I changed what I called myself from ‘hospital epidemiologist’ to ‘healthcare epidemiologist’ when a colleague insisted that my scope is limited because hospital epidemiologists didn’t address the healthcare system as a whole. Well, my professional society has healthcare epidemiology in its name although my professional society journal’s name has hospital epidemiology in it. Not too long ago, APIC changed its name, but not the acronym (thankfully; like the change in name from PCP to PJP), from Association for Practitioners in Infection Control to Association for Professionals in Infection Control and Epidemiology. Even the infections we work on changed name from hospital-associated infections to healthcare-associated infections and I have had to explain the difference multiple times to several colleagues.

When I was recruited to my current job over nine years ago, the chief medical officer at that time, Jay Shannon, wanted me to have the job title, chief of infection control (which later became chief of infection prevention), on par with other physician chiefs of clinical services, because the ‘transformation work’, a.k.a., reduction of HAI rates needs to be done with them. Subsequently, the department I am responsible for changed name from infection control to infection prevention, to keep up with national trends in nomenclature fashion. I had some angst over it because we didn’t know how to prevent every infection, and because I had more influence over the committee I chair rather than the department, the committee is called infection prevention and control committee (“We control what we can’t prevent”; my committee members bought that argument!). Regardless of the four job titles I have ever had in my career, medical director of infection control, hospital epidemiologist, chief of infection control, and chief of infection prevention, I have introduced myself as a healthcare epidemiologist to my fellow ID colleagues, although not so much outside ID.

Not that it’s a mouthful as my late husband complained, but more because it’s hard to explain in functional terms to those outside ID. Is a healthcare epidemiologist a glorified infection preventionist with an MD degree? Is a healthcare epidemiologist truly a mid-level bureaucrat in a health system? Is the healthcare epidemiologist someone who helps his or her team stamp out regulatory fires or prepare them to prevent those fires perpetually, like I have had to do? Does the person reduce HAI using public health tools that were taught in the school of public health, and/ or the ‘quality and performance improvement’ tools including bundles that the folks in quality departments worship? Aren’t those tools very similar anyway? Is this person on par with a quality officer or a safety officer in a health system? Does this person present fancy looking ‘key driver’ maps to hospital boards which look a lot more fashionable than the substance in them? Does this person do nerdy and geeky things like mathematical modeling and does this person do clinical research that rigorously studies transmission of pathogens in healthcare settings? Does a healthcare epidemiologist do antimicrobial stewardship? Or diagnostic stewardship? Does a healthcare epidemiologist evaluate clinical outcomes of patients with infectious diseases? Does this person help achieve the triple aim articulated by the Institute of Medicine in their report on quality chasm in hospitals? Does this person work on ‘culture of safety’ in healthcare systems because if you didn’t have a strong culture of safety, then someone will be seen not washing hands right when the regulatory surveyors are walking down the hospital corridors, and the healthcare epidemiologist has accountability for the ‘findings’? Is the healthcare epidemiologist an ‘infection control officer’ for the health system? Some colleagues have also called me chief of infectious diseases because they didn’t know the difference between infectious diseases and infection prevention, a difference, which I have had to explain. Can someone without fellowship training in infectious diseases have healthcare epidemiologist as a job title? Is a healthcare epidemiologist a ‘suit’?

To protect my sanity, I came up with four categories for my job activities. Protecting the floor (e.g., avoiding a regulatory survey failure, controlling an outbreak), Doing the required (implementing programs that are required by stakeholder agencies including regulatory agencies), Aiming high (working on studying or improving outcomes that are not necessarily required by external stakeholders), and Reaching for the stars (e.g., doing innovative research, implementing novel teaching techniques). I began to articulate to everyone that I work on the HAI component of Safety, the ‘S’ in STEEEP, an acronym to describe attributes of Quality of health care provided to patients. However, the different dimensions of HAI extend into timeliness, equitability, efficiency, effectiveness and patient-centeredness, not to mention cost outcomes and satisfaction for patients and healthcare professionals. That’s when I came up with the frame of ‘quality of care related to microbes’. See a previous blogpost I wrote on this topic. However, that doesn’t extend to HIV and other microbes. I have badly wanted to come up with a unifying phrase or a term. I tried to make an acronym out of Infection, Control, Prevention, Epidemiology, Quality, Safety, Teaching, Research, Public Health, and Healthcare Delivery Improvement, and didn’t get anywhere close to a cute acronym that I was after.

These days, I introduce myself as a physician epidemiologist, physician leader for infection prevention, or someone who works on quality of care related to infections, when I talk to those outside infectious diseases. Maybe I should call myself an Infection Quality Officer, or IQ officer for short. May be a LEAP officer, an idea that occurred to me as I helped my mentee apply for the leadership in epidemiology, antimicrobial stewardship and public health fellowship.

I see that other academic departments and divisions that establish programs to address quality of care in the patient population they serve, call the person in this role, a ‘xxxx (department or division name) quality officer/director/chief’ who is either a system-wide quality officer (who works with other divisions and departments in the entire healthcare system) or a divisional quality officer (who works geographically within the division or department. Why doesn’t everyone in infectious diseases who works on quality of care (regardless of whether it is healthcare epidemiology, infection prevention, antimicrobial stewardship, quality of care for specific diseases like HIV or specific populations like transplant patients) band together and create one position- chief/director/office of quality in infectious diseases, like other academic departments or division? Is that giving in to too much peer pressure?

Time, Power and Infection Prevention

With the increased attention to infection prevention and antimicrobial resistance globally, we now have more seats at the table. In fact, many of us are or will soon be at the table in positions of leadership (power) in our hospitals or organizations. We can include our colleagues at CDC, who are being asked to do more and manage larger research portfolios. The time we imagined 10-20 years ago, where our clinical and research roles would be appreciated is now, but with the now comes an overwhelming urgency - we are overworked.

With that in mind, I read a very interesting post by Maria Popova on UC Berkeley psychologist Dacher Keltner's book, The Power Paradox: How We Gain and Lose Influence. Two quotes in particular struck me as they applied to our current situation as hospital epidemiologists and infection preventionists:

"The power paradox is this: we rise in power and make a difference in the world due to what is best about human nature, but we fall from power due to what is worst. We gain a capacity to make a difference in the world by enhancing the lives of others, but the very experience of having power and privilege leads us to behave, in our worst moments, like impulsive, out-of-control sociopaths"

"But in reading these alarmingly consistent studies, I had to wonder about one crucial confound(er) that remains unaddressed: People in positions of power also tend to be busier — that is, they tend to have greater demands on their time. We know from the now-iconic 1970s Good Samaritan study that the single greatest predictor of uncaring, unkind, and uncompassionate behavior, even among people who have devoted their lives to the welfare of others, is a perceived lack of time — a feeling of being rushed. The sense of urgency seems to consume all of our other concerns — it is the razor’s blade that severs our connection to anything outside ourselves, anything beyond the task at hand, and turns our laser-sharp focus of concern onto the the immediacy of the self alone."

I encourage you to read her full post and ponder how the Power Paradox might (or might not) apply to our new and larger roles in infection prevention. For example, I've noticed during discussions at national meetings and in peer-reviewed publications that we're blaming healthcare workers if they don't wash their hands or criticizing physicians if they overprescribe antibiotics. Keltner suggests that the Paradox can be handled by putting our focus on other people including empathizing, giving, expressing gratitude, and telling stories. It might seem that our focus on others (patients) might protect hospital epi folks, but what about the people we need to work with if we're to be successful - other healthcare workers?

The new healthcare epidemiologist

The April issue of Infection Control and Hospital Epidemiology has a white paper on skills and competencies for the healthcare epidemiologist. True to form, the paper reflects the rather timid approach that SHEA never seems able to shake. As a disclaimer, I should state that I sit on the Board of Trustees of SHEA, and I’m not saying anything in this post that I haven’t shared previously.

While the paper mentions that the healthcare epidemiologist should have an understanding of quality improvement and safety, and is a valuable partner to the Chief Quality Officer (CQO), what it should state is that the healthcare epidemiologist is uniquely qualified to be the CQO. Infection prevention was the first QI program ever to emerge and remains better developed than QI and patient safety. Many healthcare epidemiologists have advanced degrees in public health or epidemiology, and the skill set is directly transferable to QI and safety. Increasingly hospitals are developing CQO positions, but very few of these positions are held by healthcare epidemiologists. In some cases, CQOs may not have a true appreciation for the value of the healthcare epidemiologist, and some of us fear that healthcare epidemiologists as we know them may ultimately be replaced by less trained individuals. Interestingly, Dick Wenzel published a book on quality improvement in 1992, but unfortunately, SHEA chose to remain confined to infectious adverse outcomes rather than expanding into the quality realm.

So my recommendations are these:

1. SHEA should move aggressively and quickly into the quality and safety space.
2. To broaden the skillset of the healthcare epidemiologist, SHEA needs to sponsor education on leadership, implementation science, human factors engineering, Six Sigma, Lean, and other quality improvement and patient safety topics.
3. As much as I hate to talk about certification given the absolute mess the American Board of Internal Medicine has made of our certification processes, I continue to believe that healthcare epidemiology will never be seen as a valid entity until there is certification. Once certification occurs, then it becomes possible to build the requirement for a healthcare epidemiologist into payer’s conditions of participation, hospital accreditation, and hospital quality rankings. We need to make the healthcare epidemiologist indispensable. 
4. SHEA’s journal, Infection Control and Hospital Epidemiology, should specifically solicit papers focused on noninfectious adverse outcomes, quality improvement and patient safety. 

In a nutshell, SHEA should define the role of the healthcare epidemiologist more broadly, which in the long run will help its members more easily achieve leadership positions in hospitals and have a seat at the table when important decisions are made.

Graphic: Stratabridge 

SHEA 2015 - New Format - Abstracts - May 14-17

I’m excited to announce that I will be co-chairing the 2015 SHEA meeting with Susan Huang. The new format will combine the highly regarded SHEA Basic Training Course in Healthcare Epidemiology with plenary, abstracts and symposia focused on infection prevention topics including long-term care, implementation science, science communication, MDROs, device infections and antibiotic stewardship. A strong emphasis will be placed on networking and mentoring sessions. The meeting will take place in Orlando, Florida (May 14-17th). The abstract site will be open from August 1, 2014 to January 16, 2015 and awards will be given to the top abstracts and posters at all career levels. So, get busy making science and look forward to seeing you in Orlando!

15th ESCMID-SHEA Training Course in Hospital Epidemiology - Brussels

Last year I joined the faculty of the annual ESCMID-SHEA training course in hospital epidemiology. It was one of the most rewarding and educational experiences I've had during my 15 years in hospital epidemiology. The course is held annually in a location that allows close interaction and fellowship between the students and faculty. For this year, we've updated the content with a new course concept. The course has three contemporaneous modules:

Module A: Healthcare-associated Infection Prevention and Management Core Module (Limit 50 participants)

Module B: Applied Infection Control Module (Limit 35 participants)

Module C: Healthcare-associated Infection Advanced Epidemiology Module (Limit 25 participants)

Date: 22-25 September 2013

Please see the brochure and website for further details on registration and the individual modules.

Course Faculty:
Marc J. M. Bonten, MD, PhD Utrecht, The Netherlands
Ben Cooper, BSc, Msc, PhD Oxford, UK
Markus Dettenkofer, MD Freiburg, Germany
Bart Gordts, MD, MBA Antwerp, Belgium
Loreen Herwaldt, MD Iowa, USA
Arno Hoes, MD, PhD Utrecht, The Netherlands
Jan Kluytmans, MD, PhD Amsterdam and Breda, The Netherlands
Leonard Mermel, DO, ScM, AM (Hon), FSHEA, FIDSA, FACP Rhode Island, USA
Eli N. Perencevich, MD, MS Iowa, USA
Evelina Tacconelli, MD, PhD Tübingen, Germany
Christina Vandenbroucke-Grauls, MD, PhD Amsterdan, The Netherlands
Andreas Voss, MD, PhD Nijmegen, The Netherlands
Andreas F. Widmer, MD, MS Basel, Switzerland