What if we thought of the work in the health care quality and safety space along three axes traversing across the faces of a vast cube? Safety and Quality along one dimension – from preventing a harmful outcome on one end to promoting a good outcome. Safety is the absence of a bad outcome. Quality is the presence of a good outcome. It’s easy to imagine how things can get confusing when you try to differentiate between absence of a bad outcome and presence of a good outcome. If a patient does not develop a central line associated bloodstream infection during a hospital stay, is that absence of a bad outcome (central line infection) or presence of a good outcome (infection-free central line)? So, I find it easier to think of them along a continuum.
The second dimension would be the gamut from meeting regulatory and legal mandates on one end which is absolutely necessary to stay out of trouble, to reaching for all desirable outcomes, the sun and the moon and the stars for our patients regardless of whether they are mandated or not. The third dimension would be along the spectrum of working in a reactive mode (fire-fighting’ items like outbreak investigation and control or addressing an error like wrong site surgery) to working in a proactive mode like setting up prevention and performance improvement programs.
If we think along these three dimensions, then we could categorize all the patient care we provide as ‘patient care that involves microbes’ and ‘patient care that does not involve microbes’ from a quality and safety perspective. To me, safety in health care has two components – safety from infections, safety from other types of harm like falls, pressure ulcers, medication errors, etc. As an infectious diseases physician, I am acutely aware of how big a role microbes play in our ecosystem. The other aspects of work in the health care quality space – data analytics, performance improvement, epidemiology and statistics – these are platform tools to help with any initiative.
What’s driving my own thoughts on this topic? In my ten-year tenure as a healthcare epidemiologist in academic medical centers, I have experienced significant evolution of thought processes and structures all around me in the domain of health care quality. Infection Control as a field was renamed ‘Infection Prevention’. Infection control departments that were previously housed in hospitals and health systems within Infectious Diseases departments or Nursing departments are now almost all under Quality departments. The primary professional societies providing guidance in the field of infection control and healthcare epidemiology, the Society for Healthcare Epidemiology of America and the Association for Professionals in Infection Control and Epidemiology have both published guidance on competency models for healthcare epidemiologists and infection preventionists respectively in the modern era. (Links below) I have frequently thought about how the roles of healthcare epidemiologists and infection preventionists fit in with each other as well as with the roles of other professionals in the healthcare quality and safety space. I have observed many a conflict on this topic play out in various different ways. I have played with different mental models of how it all sits together. And the cube model is the best I have come up with so far. Of course, I’ll continue to think if there’s a better way to fit it all in. I invite my colleagues to do the same.