Table 3.

Examples of using systems thinking to solve infection control problems

ProblemLinear ThinkingLinear SolutionUnintended ConsequenceSystems ThinkingFundamental SolutionSystem Effect
Dialysis staff members do not reliably follow policiesStaff are poorly trained and educatedRe-educate and retrain staff in infection policiesFalse security that problem is solved after remediationIdentify the work stressors causing workaroundsCorrect workflow problems leading to shortcutsHuman factors designed work processes
High rate of bloodstream infectionsThe problem is related to high catheter useCreate vascular access nurse lead to increase AVFsFailure to recognize other contributorsPerform a broad and thorough root cause analysisImplement a comprehensive QAPI programLongitudinal, holistic action and surveillance
Technician or nurse makes a major errorThe employee is a “bad” worker and risk to patientsDiscipline or terminate employeeOther staff are afraid to admit or report mistakesMistakes are an expected outcome of careFoster psychologic safety for staffMutual trust facilitates earlier error detection
Employees are not accountable for actionsThe facility needs to hire “better” peopleDiscipline or terminate employeeSkepticism and resentment lead to staff turnoverAccountability is a reflection of leadershipManagement models consistent behaviorsClimate of shared responsibility for infections grows
Dialysis staff members resist attempts to change behaviorStaff are unwilling or unable to change behaviorProvide extrinsic rewards to promote changesReduced intrinsic motivation and “getting the why”Challenging culture creates resistanceUse leadership to overcome staff anxiety and fearsStaff learn and adopt new beliefs as the new culture
Medical director is not an effective team leaderMedical director is unwilling or unable to do jobNurse manager takes over visible leadership roleConfusion about hierarchy of authority in unitMental models about authority affect behaviorClarify designated and situational leadership rolesLeadership improves at all levels of facility
Lack of trust between doctors and managementThe dialysis company only cares about profitDoctor distances self from dialysis company agendaOrganizational initiatives fail to inspire doctorsA business model should reflect its strategic goalsRevise strategy and operational modelOrganizational alignment fosters trust and goals
Reimbursement does not promote infection controlLink payments to performance to improve safetyIntroduce quality measures tied to infection ratesFear of financial penalties results in under-reportingFacility culture will drive behavior around incentivesChange culture and incentives to promote safetyReduces fear and encourages transparency
  • AVF, arteriovenous fistula; QAPI, Quality Assessment and Performance Improvement.