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.