Table 2.

The dynamic systems elements in a dialysis facility and how they influence infections

ElementProblemContextSolutionIntended ConsequenceUnintended ConsequenceSystem Effect
PatientBloodstream infectionLimited understanding of infectionsAntibioticsResolution of infectionClostridium difficile, antibiotic resistanceHospitalizations, mortality, costs
Dialysis technicianMultiple tasks, limited timeRewards on the basis of efficiencyShortcutsIncreased efficiencyConscious deviation from policiesPatient harm policy resistance
Floor nurseMultiple tasks, limited timeLitany of rules and regulationsFix problems via punitive actionsMaintains complianceIneffective role model for technicianLess focus on patients and critical thinking
Nurse managerVariable behavior of dialysis staff and nephrologistsVariable management skillsCreate management action plansAddress compliance issuesFocuses on paperwork and not clinical careReduced visibility and ineffective nursing leadership
NephrologistLimited time for dialysis roundingCompeting prioritiesRely more on dialysis facilityIncreased practice efficiencyReduced accountabilityLimited support of facility initiatives
Surgeons and interventionistsLimited number of provider optionsHigh catheter prevalenceOutreach to operatorsReduce wait time for appointmentsPatients assigned to newest partnerHigh number of access-related complications
Medical directorVariable engagementVariable leadership skillsRelies on nurse manager to leadIncreased practice efficiencyIneffective QAPI and team leadershipPoor safety culture in dialysis facility
Dialysis organizationMargin versus missionCompetition, economics, regulationVertical and horizontal integrationIncreased market growth and profitabilityMistrust of corporate motives and prioritiesPoor nephrologist engagement and collaboration
Government agencyPatient safety and reduction of harmSuboptimal health outcomes and high costsExpanding regulatory requirementsImprove health outcomes and lower spendingShort-term fixes arising from fear of punitive actionRegulation fatigue, lack of trust in agencies
  • QAPI, Quality Assessment and Performance Improvement.