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.