Systems Thinking and Leadership: How Nephrologists Can Transform Dialysis Safety to Prevent Infections : Clinical Journal of the American Society of Nephrology

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Systems Thinking and Leadership

How Nephrologists Can Transform Dialysis Safety to Prevent Infections

Wong, Leslie P.

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Clinical Journal of the American Society of Nephrology 13(4):p 655-662, April 2018. | DOI: 10.2215/CJN.09740917
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Infections are the second leading cause of mortality in ESKD, resulting in 10% of deaths annually (1). Although many infections are preventable, nephrologists have been unable to solve this deadly and costly problem. In response, the Centers for Disease Control and Prevention (CDC) and the American Society of Nephrology (ASN) have created Nephrologists Transforming Dialysis Safety (NTDS), a landmark initiative to promote the nephrologist’s role in eradicating dialysis infections. This effort will challenge nephrologists as medical directors and attending physicians to “Target Zero Infections” and lead positive change. The work of NTDS is timely. Nephrology is being reshaped by larger transformative changes in health care, with a greater focus on value and increased provider accountability (2). Nephrologists need new knowledge and skills to navigate these changes and promote better patient outcomes (2–4).

The chief medical officers of major dialysis organizations in the United States have agreed on this need to address dialysis infections and patient safety (5,6). Hand hygiene highlights this issue. Year after year, improper hand hygiene is the most frequently cited safety violation in dialysis facilities, despite repeated attempts at staff education (7). This persists, despite widespread awareness of the problem and the ready availability of CDC infection prevention tools and recommendations (8). The US Department of Health and Human Services includes dialysis facilities in its National Action Plan to eliminate health care–associated infections (9). Difficulty implementing these recommendations (Table 1) raises the broader question of why local actions aimed at preventing infections often fail (10). The answer likely stems from using solutions too simplistic for the multiple issues involved (10).

Table 1. - National dialysis infection prevention recommendations (information from refs. 8 and 9)
CDC 2016 Core Interventions for Bloodstream Infection Prevention HHS 2013 5-yr National Metrics and Evaluation Targets
Decrease catheter prevalence All bloodstream infections by access type
Chlorhexidine for catheter site skin antisepsis Access-related bloodstream infections by type
Antimicrobial ointment at catheter site Seasonal influenza vaccine
Catheter and vascular care access observations NHSN reporting
Staff education and competency Catheter use in patients on hemodialysis
Hand hygiene observations Screening for hepatitis C antibody
Surveillance and feedback using the NHSN Hepatitis B vaccine in patients on hemodialysis
Patient education and engagement
CDC, Centers for Disease Control and Prevention; HHS, Department of Health and Human Services; NHSN, National Healthcare Safety Network.

A nephrologist juggles inpatient consults, office hours, travel to and between dialysis facilities, and other administrative tasks—with little down time. Ownership of dialysis facilities has largely passed from nephrologists to large corporations, with most nephrologists operating independently of the dialysis facilities in which they practice. At the same time, nephrologist medical directors have been given more expansive duties and responsibilities under Medicare’s Conditions for Coverage. This larger scope of accountability was intended to empower nephrologists with official authority to make important decisions, improve quality, and ensure patient safety in their facilities. However, this power has been embraced with varying levels of enthusiasm, understanding, and effectiveness (2,3,11). Many leadership functions are unfamiliar to nephrologists with little formal training or experience managing people and organizations (4). This paper explores the systemic factors contributing to the ongoing dialysis infection crisis in the United States and the role of nephrologists in instilling a culture of safety, in which infections can be anticipated and prevented.

Systems Thinking and Learning Organizations in Targeting Zero Infections

Health care organizations often fail to learn from their mistakes and may lack effective solutions for complex problems, like infections (12). The Institute of Medicine (IOM) has proposed, iteratively, a comprehensive strategy to embrace continuous learning and improvement to help manage health care complexity (13). This mirrors the tenets of patient safety, with its emphasis on organizational learning (12–15). Harnessing human and organizational capabilities that improve the reliability and efficiency of care processes can help manage multidimensional problems, like dialysis infections (13). Inability to improve outcomes in chronic diseases with multiple contributing conditions, like ESKD, may result from not taking a holistic approach that accounts for the clinical, logistic, decision-making, and economic challenges involved (13). Failure to achieve patient safety and deliver high-reliability care is in the tendency of decision makers to simplify their view of the situation (16). Targeting dialysis infections thus requires nephrologists to adopt a broader, more comprehensive perspective and resist the temptation to simply the problem (16).

Systems thinking describes a diverse combination of theories and practices from the fields of economics, management, engineering, and psychology used to solve complicated problems (5–8). Dialysis facilities can be viewed as systems that show many interconnected and interdependent elements of a dynamic system (Table 2) (10). These elements possess complex linear and nonlinear relationships with variable cause and effect (10,16). Many facilities addressing infections make the mistakes of reducing their focus to a small subset of information available, simplifying cause and effect relationships, and limiting decisions to a few static options (5,16). This approach fails to consider systems interactions, resulting in reliance on short-term technical solutions that fail and lead to unintended consequences (10,15).

Table 2. - The dynamic systems elements in a dialysis facility and how they influence infections
Element Problem Context Solution Intended Consequence Unintended Consequence System Effect
Patient Bloodstream infection Limited understanding of infections Antibiotics Resolution of infection Clostridium difficile, antibiotic resistance Hospitalizations, mortality, costs
Dialysis technician Multiple tasks, limited time Rewards on the basis of efficiency Shortcuts Increased efficiency Conscious deviation from policies Patient harm policy resistance
Floor nurse Multiple tasks, limited time Litany of rules and regulations Fix problems via punitive actions Maintains compliance Ineffective role model for technician Less focus on patients and critical thinking
Nurse manager Variable behavior of dialysis staff and nephrologists Variable management skills Create management action plans Address compliance issues Focuses on paperwork and not clinical care Reduced visibility and ineffective nursing leadership
Nephrologist Limited time for dialysis rounding Competing priorities Rely more on dialysis facility Increased practice efficiency Reduced accountability Limited support of facility initiatives
Surgeons and interventionists Limited number of provider options High catheter prevalence Outreach to operators Reduce wait time for appointments Patients assigned to newest partner High number of access-related complications
Medical director Variable engagement Variable leadership skills Relies on nurse manager to lead Increased practice efficiency Ineffective QAPI and team leadership Poor safety culture in dialysis facility
Dialysis organization Margin versus mission Competition, economics, regulation Vertical and horizontal integration Increased market growth and profitability Mistrust of corporate motives and priorities Poor nephrologist engagement and collaboration
Government agency Patient safety and reduction of harm Suboptimal health outcomes and high costs Expanding regulatory requirements Improve health outcomes and lower spending Short-term fixes arising from fear of punitive action Regulation fatigue, lack of trust in agencies
QAPI, Quality Assessment and Performance Improvement.

Mapping actions and feedback loops into archetypes is a systems thinking technique that helps identify behavior contributing to a problem (14,15). Figure 1 portrays the archetype “shifting the burden,” which shows two routes to approaching a problem (15). There is a fundamental solution that addresses the underlying root causes, but it is frequently not appreciated. Instead, a symptomatic solution is usually chosen—the quickest, most apparent, or previously used method (15). This linear route is attractive, because it provides timely results and exists within the comfort zone of decision makers (15). However, because this misses the real underlying issue(s), the problem predictably reappears (15). Moreover, unintended consequences (shown by the negative sign) drain organizational focus and energy, preventing development of the fundamental solution (15).

Figure 1.:
Unintended consequences of short-term solutions to infection control problems: an example of the systems archetype shifting the burden. CDC, Centers for Disease Control and Prevention. Modified from ref. 15, with permission.

Applying Systems Thinking to the Dialysis Facility

Figure 1 illustrates the archetype of a facility with a problem of poor adherence to the CDC guidelines for bloodstream infection prevention that is cited by a state surveyor. The fundamental solution is creating a more effective culture of safety to promote infection control. However, an immediate plan of correction is required. The symptomatic solution is to focus on staff retraining and disciplinary action, which satisfy the plan of correction and result in short-term improvements in compliance. However, the disciplinary actions by the state against the facility and the facility against employees have the unintended consequence of creating fear of punishment. This results in staff being afraid to report errors or policy breaches owing to fear of retribution. Furthermore, the initial success, reinforced under-reporting, leads to complacency and delays recognition of leadership and systems issues contributing to a poor safety culture. In this light, it is no surprise that dialysis infection control problems eventually resurface. Table 3 provides several examples of how systems thinking can be used to better solve infection control problems by identifying fundamental solutions.

Table 3. - Examples of using systems thinking to solve infection control problems
Problem Linear Thinking Linear Solution Unintended Consequence Systems Thinking Fundamental Solution System Effect
Dialysis staff members do not reliably follow policies Staff are poorly trained and educated Re-educate and retrain staff in infection policies False security that problem is solved after remediation Identify the work stressors causing workarounds Correct workflow problems leading to shortcuts Human factors designed work processes
High rate of bloodstream infections The problem is related to high catheter use Create vascular access nurse lead to increase AVFs Failure to recognize other contributors Perform a broad and thorough root cause analysis Implement a comprehensive QAPI program Longitudinal, holistic action and surveillance
Technician or nurse makes a major error The employee is a “bad” worker and risk to patients Discipline or terminate employee Other staff are afraid to admit or report mistakes Mistakes are an expected outcome of care Foster psychologic safety for staff Mutual trust facilitates earlier error detection
Employees are not accountable for actions The facility needs to hire “better” people Discipline or terminate employee Skepticism and resentment lead to staff turnover Accountability is a reflection of leadership Management models consistent behaviors Climate of shared responsibility for infections grows
Dialysis staff members resist attempts to change behavior Staff are unwilling or unable to change behavior Provide extrinsic rewards to promote changes Reduced intrinsic motivation and “getting the why” Challenging culture creates resistance Use leadership to overcome staff anxiety and fears Staff learn and adopt new beliefs as the new culture
Medical director is not an effective team leader Medical director is unwilling or unable to do job Nurse manager takes over visible leadership role Confusion about hierarchy of authority in unit Mental models about authority affect behavior Clarify designated and situational leadership roles Leadership improves at all levels of facility
Lack of trust between doctors and management The dialysis company only cares about profit Doctor distances self from dialysis company agenda Organizational initiatives fail to inspire doctors A business model should reflect its strategic goals Revise strategy and operational model Organizational alignment fosters trust and goals
Reimbursement does not promote infection control Link payments to performance to improve safety Introduce quality measures tied to infection rates Fear of financial penalties results in under-reporting Facility culture will drive behavior around incentives Change culture and incentives to promote safety Reduces fear and encourages transparency
AVF, arteriovenous fistula; QAPI, Quality Assessment and Performance Improvement.

Each dialysis facility is required by Conditions for Coverage to have a Quality Assessment and Performance Improvement (QAPI) program. QAPI is the ideal vehicle for application of systems thinking and robust data-driven methodology for identifying the root causes and specific interventions for infections (11,12). However, the QAPI process is not always intuitive, and many medical directors fail to appreciate or use this mechanism to its full potential (11). QAPI effectiveness can also be affected by (unwitting) attending nephrologist behaviors, such as refusing to follow protocols, not responding to facility or medical director inquiries, or conflicts with dialysis staff (17). Adopting systems thinking fits the QAPI process perfectly, and it would facilitate greater introspection and dialogue about the root causes of infections and encourage facility-wide cooperation. Better leadership and participation in QAPI and using systems thinking are tremendous improvement opportunities for medical directors and attending nephrologists alike.

Nephrologist Leadership Is a Requirement for Culture Change

However, use of effective process improvement, like QAPI, and creating supportive learning system competencies, including technology, are not enough (13,16). Ending preventable infections requires leadership’s commitment to achieving zero patient harm and a fully functional culture of safety throughout the organization (13,16). Culture of safety is a critical factor in dialysis infections that is frequently acknowledged but less frequently realized (18). Culture describes the unspoken norms and rules that govern the behavior of a group of individuals (19). Groups facing common threats, like people in a dialysis facility, learn behaviors to help them survive. If these adaptations are successful, they are accepted tacitly and operate powerfully at the unconscious level (19). These adaptations help embody the culture of each dialysis facility and its degree of commitment to patient safety.

Dialysis infections often result from workarounds to infection control policies (7). Many of these shortcuts are intentional acts to improve performance rather than unintended errors (12,20). Complicated patients, highly technical processes, and short turnaround times create threats to work efficiency and stress in busy dialysis units. Management priorities and peer interactions may worsen this climate. A time-pressured caregiver consciously bypasses dialysis infection control policies to “get the job done.” Seeing no immediate harm, he/she feels more comfortable repeating the shortcut. If the shortcut works well, other individuals see and adopt this behavior. A gradual shift of group norms called behavior migration occurs (12,20). Eventually, the workaround becomes imbedded in the culture of the dialysis facility, making change difficult.

The power of culture is apparent when infection control practices are challenged, which provokes resistance from dialysis staff, patients, and even the most experienced physicians. Questioning tacit cultural assumptions creates fears of loss of power, incompetence, punishment, or ostracism (19). This triggers defense mechanisms, resulting in hostility, denial, or blaming behaviors (19). Overcoming these emotions is the responsibility of leaders, who must communicate the urgency and need for change; then, they must obtain participation and remove barriers to effect long-lasting results (21). The medical director can have a powerful effect by setting the tone for infection prevention and showing the desired behavior and attitudes (19,21). By providing guidance and communicating a vision that eliminating preventable infections is both necessary and possible, the medical director can motivate and inspire others to follow. Eventually, reduction of anxiety occurs, and followers start to imbed the leader’s beliefs as part of a new culture (19,21). Conversely, medical directors or other nephrologists can derail culture change if they are observed “not walking the talk” or give mixed messages to dialysis staff. Leadership and culture of an organization are interdependent. If either tolerates low expectations for patient safety, its members can and will make poor decisions (22).

The formula to promote a dialysis culture of safety relies, therefore, on two key factors. First, systems thinking—developing and adopting a broader, systematic approach to improving processes of care. Second, there must be visible and engaged leadership by the medical director who inspires a shared commitment to patient safety. Unfortunately, many nephrologists, including medical directors, do not view leadership as their responsibility (2–4,11,23). Although the nurse manager provides important situational leadership, the medical director as designated leader of the dialysis facility must be the driving force to instill a culture of safety (13,21). By ensuring that the hierarchy of authority and responsibility is clear, the medical director creates synergy with the nurse manager’s efforts to align attending nephrologists, dialysis staff, and patients to prevent infections.

The Importance of Strategic Leadership and Alignment

The majority of United States patients on dialysis are cared for in facilities owned by dialysis organizations that manage multiple facilities, often in many states—making oversight and communication between upper levels and front-line workers more difficult. Dialysis organizations have been charged with poor management, inadequate staffing, and prioritizing areas other than patient safety (24). However, the leadership of these organizations grasps and understands the importance of what is at stake with infection prevention (2,4,11). It is clearly to the advantage of dialysis organizations from a business sense to prevent infections to promote healthy patients who do not require hospitalization and live longer lives. These organizations have already spent considerable time and resources to detect and prevent infections. However, these efforts have not translated into sustained improvement at the operational level. Legislated infection control measures, like the National Healthcare Safety Network, have created controversy about facility under-reporting and data integrity, obfuscating discussion about the real goal of a large-scale, systematic, and process-driven infection control program in the United States to support local and regional efforts (25,26).

Leadership efforts to instill changes are often greeted with resistance, because individuals do not share the same mental models about the problem and how it affects them (27). Mental models are the ingrained assumptions, ideas, and beliefs that influence how individuals understand their environment and behave—all elements of culture (27). A major source of dissonance encountered trying to change safety culture is misalignment of mental models, perspectives, priorities, and incentives throughout the macrosystem of United States dialysis care. Figure 2 illustrates a blueprint for aligning key levels of leadership that influence dialysis safety. With a systems thinking approach, the need for strategic alignment between senior leadership, middle managers, and front-line caregivers is apparent (13). Eliminating preventable infections will require senior leadership (the NTDS-ASN, dialysis organizations, and the CDC Making Dialysis Safer Coalition) to set the tone and aims at a strategic level (13). This will require medical directors and corporate middle managers at the organizational level to translate and execute this mission by enacting leadership and culture change (13). At the front-line level, the direct perspective of caregivers and patients will need to be understood, and appropriate interventions will need to be made via QAPI and human factors engineering to enable a safety culture.

Figure 2.:
A systems blueprint for transforming dialysis safety at key levels of leadership. CDC-MDS, Centers for Disease Control and Prevention Making Dialysis Safer Coalition; NTDS-ASN, Nephrologists Transforming Dialysis Safety-American Society of Nephrology; QAPI, Quality Assessment and Performance Improvement.

An important lesson from the business sector is that attempts to implement major changes in strategy are often undermined by feedback loops in prevalent operational models that favor maintenance of the status quo (28). Figure 2 shows the interdependence of medical directors and those in the dialysis organization middle management who control operational aspects of care. Appreciation and modification of existing mental models are necessary to redesign business models to support desired changes (28). Indeed, the IOM stresses that, although systems-based learning is central to improving outcomes, the operational model is what makes this learning actionable in organizations by aligning goals, resources, and incentives (13). Although legislation and reimbursement ideally would support these changes, there remain considerable challenges to match policy decisions to a more individualized approach to quality in dialysis facilities (25). Systems thinking could help enhance understanding between policymakers and the dialysis community about the intended and unintended effects of legislation (Table 3).

NTDS and the Future

Systems thinking also helps us appreciate why nephrologists may not have realized their potential for leading change in dialysis (2,4,11,13). Dialysis organizations often set policy from the top down, with the high purpose of providing safe and efficient care. An unintended consequence is that nephrologists feel disconnected from their role as leaders and decision makers in dialysis facilities. Medical directors and staff nephrologists may become complacent or disengaged as a result. Dialysis business practices may blur the line between nephrologist and customer, making it difficult to view dialysis organizations as colleagues. Although many stakeholders are involved in preventing dialysis infections, they cannot be expected to work on this issue effectively if nephrologists and dialysis organizations, the two constituents closest to the problem, are not fully engaged. The new approach will require nephrologists and dialysis organizations to re-examine their mental models and engage in open discussion about mutual goals, accountability, and steps needed to identify and address operational and leadership needs to advance patient safety and outcomes for the nearly 600,000 Americans on dialysis (29). NTDS is working with nephrologists and dialysis organizations to encourage this dialogue.

The mission to Target Zero Infections requires nephrologists to broaden their accountability and be effective leaders who help align interdependent health care systems (3,29,30). Some nephrologists may resist changes, because they the lack of training and experience in leadership (4). Others may have concern that there is inadequate time to devote to infection prevention. It is important to identify strategies to empower local physician leadership to accomplish these aims. The best and most insightful leader in a dialysis facility will not have a major effect in changing culture unless he/she can focus more on care processes in the dialysis facility. It will be important for medical directors to carefully consider their mental models of efficiency versus effectiveness. To improve patient safety, some time and assumed work efficiency must usually be sacrificed (12). However, a systems thinking view asserts that overall efficiency actually improves if time invested upstream with QAPI results in effective long-term preventative measures that avoid costly and harmful infections from occurring in the first place.

Although the challenge seems daunting, there are two important factors to consider. Nephrologists are naturally highly intrinsically motivated individuals already familiar with (physiologic) systems thinking. Systems learning and leadership training provided by NTDS is a readily available resource that can encourage application of nephrologists’ inherent systems orientation to infections. Working with dialysis organizations, NTDS with other senior leadership can help identify the financial and operational barriers that demotivate nephrologists. Addressing these demotivators along with providing a clear mission, education, and support can be powerful means to harness the inherent willingness and volition of professionals, like nephrologists (31). Studies of extrinsic rewards versus intrinsic motivation suggest that tangible rewards ultimately do not energize or sustain activities in the long term; rather, it is aspirational goals and learning—of which patient safety and leadership are of high order (12,31).

Patients on dialysis are often afraid of infections but receive little education about how infections occur and how they can be prevented. Patients, who spend many hours in the dialysis facility, are well positioned to observe and monitor how best practices to prevent infections are or are not being followed. Were patients trained to understand the importance of hand hygiene, surface cleanliness, access care, and catheter avoidance, they might better participate in infection control and feel empowered to speak up without fear of reprisal. Ultimately, we need to create the foundation for patient empowerment by asking nephrologists to lead culture change as medical directors, colleagues, teachers, and role models.

Infection prevention is a problem of dynamic complexity that will require systems thinking, culture change, and a commitment to learning by nephrologists to solve. Transforming dialysis safety must start with a vision and collective mindfulness that preventable dialysis infections cannot be tolerated. Nephrologists will need to partner with dialysis organizations in innovative and more effective ways. Nephrologists who commit to Targeting Zero Infections will find the skills and knowledge attained valuable to their careers as the demand for systems thinking in health care expands.




The author wishes to thank Dr. Alan Kliger; Tod Ibrahim; the Nephrologists Transforming Dialysis Safety Quality, Assessment, Improvement and Education work group; Dr. Anitha Vijayan; Dr. Priti Patel; and the American Society of Nephrology Nephrologists Transforming Dialysis Safety staff for their assistance with this manuscript.

Published online ahead of print. Publication date available at

See related articles, “Urgent: Stop Preventable Infections Now,” “Addressing the Problem of Multidrug-Resistant Organisms in Dialysis,” “What We Learned from Ebola: Preparing Dialysis Units for the Next Outbreak,” and “100% Use of Infection Control Procedures in Hemodialysis Facilities: Call to Action,” on pages , , and , respectively.


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dialysis; hemodialysis; ESRD; infections; patient safety; Humans; United States; Nephrologists; nephrology; Physician Executives; Leadership; Caregivers; Cause of Death; Kidney Failure; Chronic; Infection Control; Centers for Disease Control and Prevention (U.S.); Delivery of Health Care; Curriculum; Systems Analysis

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