The Seeker: Infection Control Doctor Takes the Road Less Traveled
‘How we change behavior is at the core of infection control’
Suffice it to say — after viewing many a PowerPoint presentation — that a speaker divulging her thoughts, influences, barriers, and motivations that led her to succeed in infection control is a bit unusual.
Meet Leighann Parkes, MD, FRCPC, medical officer for infection prevention and control at McGill University in Montreal, who took a decidedly circuitous route to understanding and preventing infections. Driven by an innate curiosity, she eventually decided that the only way she could get the answers she was seeking was to become a medical doctor. This was after studying anthropology and religions. She retraced her journey at the IDWeek 2023 conference in Boston.
“I did take the path less traveled, and that did make all the difference,” Parkes said, paraphrasing a famous line from the poet Robert Frost. “I began at McMaster University [in Hamilton, Ontario] in the health sciences program. I was looking at the spectrum of health, from the very microscopic to the macro, looking at health policy and economics.”
In this wide-reaching overview, Parkes was troubled by a question that has stumped many a philosopher.
“I couldn’t answer the question ‘Why?’” she said. “Why were our interventions failing? What was underpinning this resistance with respect to behavioral change, and why did our words, when we communicated with patients, matter so much? How did they inform our sense of self?”
Parkes went to graduate school and studied discourse analysis by French sociologist Michel Foucault and anthropologist Mary Douglas on concepts of purity, danger, and contagion.
“I was almost answering those questions, and then I hit a wall,” Parkes said. “I [realized] the only way I’m going to really know this is if I go to medical school, so I did. I went to med school at McMaster, and that led me down the path of an internal medicine residency at McGill University, followed by infectious disease and medical microbiology, and then infection prevention and control at the University Health Network. I had some really great mentors that helped me understand how we create ourselves with communication — and how we change behavior is at the core of infection control.”
This should resonate with infection preventionists who have tried rewards, demerits, electronic surveillance, and secret observers — all to no enduring result on how best to improve hand hygiene compliance by healthcare workers. Yet, this cardinal principle of infection control, a deceptively simple act that can prevent cross-transmission of pathogens between patients, is honored about as often in the breach as the observance.
Reality Check
Parkes was steeped in training, an intellectual with a touch of idealism, who was heading for a reality check.
“As the freshly minted infection control officer, I was thrust in the midst of an accreditation cycle, — using the Canadian standards — and one of my first tasks was to audit our ear, nose, throat [ENT] satellite reprocessing center,” she said. “And we noticed very quickly that there were several very significant non-conformities.”
These included a lack of unidirectional flow from clean to dirty, improper storage of sterile objects, and use of a small, crowded space that made contamination more likely.
“This was time-sensitive,” Parkes emphasized. “Not only was there an accreditation [survey] rapidly approaching, we had patient safety at stake. So, we came prepared. We gathered up our shareholders, the leadership. We had our observations, and we had our action plan.”
Given the circumstances, the ENT unit was advised to immediately stop reprocessing reusable devices “while we do a complete overhaul of the infrastructure, the facility, and the processes in the center,” she said.
The response was immediate and unequivocal: “Complete resistance,” she said.
Parkes’ training in human psychology and behavior made one thing immediately clear: This was a completely understandable reaction. “When we’re faced with the prospect of change as humans, it is a psychological response — particularly if that change is unanticipated and sudden — to have negative feelings,” Parkes said.
Although these initial responses may primarily be emotional, the rational brain will create reasons to preserve the status quo.
“In central reprocess, their reason was ‘Hey, what do you know?’” Parkes said. “’You’re new. You don’t really understand how to apply the accreditation standards. Your observations are wildly overexaggerated.’ We had technical services say this is way too costly — we can’t do this in the time frame that we need to do it in. ENT was like, you’re going to halt our clinics, patient care is going to suffer, you are the bane of our existence. And the meeting dissolved.”
Reporting the results to her colleagues and supervisors in infection control, healthcare epidemiology, and nursing, Parkes “discovered very quickly that I was not in a silo. I was actually a part of this amazing machine.”
She was advised to make patient safety the centerpiece justification and rationale for any and all changes to the ENT clinic. “They gave me the best pieces of advice,” Parkes said “They said don’t take it personally and don’t fight the resistors. Instead, focus on understanding and addressing its root cause.”
Parkes met with her team again and discussed the barriers. One prescient question was what ideas do the unit staff have to improve the situation? Was it possible to bring them in to the change process? That discussion ended in the decision to create “agency” for the ENT staff, something that empowered the unit and brought them into the discussions, she said.
“The stalemate was transformed into issues of logistics, timing, manpower,” she said. “Those issues became actionable, and those actionable items became our process, and we ended up changing together under a shared vision. We converted the resistors. And when I stepped back from this and I looked at this incredible team that I was working with, I was thinking, what else exists out there?”
Plenty, it turns out, if infection preventionists and colleagues cultivated and created a culture of change.
“I like to tell everyone, very early on, to invest the bandwidth and time into learning how to create a culture of change,” Parkes said. “Actively working to create organizational culture is integral to infection prevention, and this isn’t something that’s taught in medical school. But it’s really important, because the cumulative impact of a successful individual change is what brings about organizational change. If individuals don’t make changes to their day-to-day work, then any transformational effort is not going to succeed.”
Pushback
An infection preventionist speaking during a recent webinar held by the Association for Professionals in Infection Control and Epidemiology was describing such challenges to change and was asked by an audience member “What do you do when you get pushback?”
Interestingly, the answer revealed that there are complementary themes in Parkes’ approach and that of Holly Taylor, MPH, CIC, of Ascension Texas in Austin. “One of the ways to get buy-in is to get feedback,” Taylor said. [This means] really proactively reaching out to folks and asking their opinion, and then integrating that opinion into the approach where you can.”
Thus, experienced infection preventionists may note that had Parkes done this initially, the temporary standoff might have been defused.
Taylor recommended being sensitive to the reasons someone may push back against change. “This is a great additional reason to get buy-in,” she said. “From my experience, pushback is something that is real. There might be a different organizational pressure that that person or that individual or that team member is experiencing that limits their ability to participate or engage in what is important to you. And, so, I think seeking to understand the driver behind the pushback is critical to being able to navigate it.”
Taylor came on board her hospital in 2019 and began strategic planning for infection control improvements with quality tools like Plan-Do-Study-Act (PDSA), and Strengths-Weaknesses-Opportunities-Threats (SWOT). Taylor used these tools to, among other things, assess the culture of her team and the importance of getting feedback.
“What is happening right now within the organization and your department, what your HAI [healthcare-associated infections] outcomes look like, what [your] HAI review and surveillance processes look like, what are the resources that we have within the team and how are those allocated … is that optimal?” she said. “Compare some of that against what the organization wants to achieve; what are the organizational goals and objectives?”
Taylor practiced “active listening” before she proposed changing anything, which should not be done without a thorough understanding of what you are changing and what you are changing it to. “What am I changing?” she said. “How am I changing it? Why am I changing it? What does success look like? How do I get buy-in and support?”
As a project unfolds and various iterations and revisions are suggested, there is one critical word you need to remember: “No.”
“Be strategic in that,” Taylor said. “Say no to those things that are outside of the scope of the strategic plan. Be able to say no strategically so that the department has the bandwidth to manifest changes, structures, and plans.”
If you can justify the bang for the buck of adding a few more infection preventionists, be prepared to propose and defend that as your new program structure begins taking shape.“I started with a SWOT analysis,” Taylor said. “I was looking at the actual personnel staffing the team, how the department was structured, how we do surveillance, and how do we strategically use data and technology?”
Remember, even making a single change requires taking a broad view and determining how many other things are going to be affected by making it, she advised.
Target: Reduce HAIs
“We needed to improve our HAI outcomes,” she said. “They were not where we wanted them to be.” Collecting baseline HAI data and meeting with key stakeholders in areas earmarked for improvement were important.
“There was a strong perception that we didn’t spend a lot of time with direct care staff, and we as a department spent more time identifying infections than preventing them,” she said. “So really addressing that perception was a key thing that I wanted to do within our plan.”
Taylor’s team reviewed their daily tasks and time requirements, altering the routine to begin rounding as part of “prevention-based activities,” she said.
“This was kind of at-the-elbow coaching and support of our direct care staff,” Taylor said.
Reducing some surveillance and data entry was used to free up some of this time, but it put infection prevention-based activities front and center. “This was definitely a limitation to our staffing complement,” she said.
The infection preventionist-to-bed ratio was a less than an ideal 1:190, yet even with a lean staff, Taylor proceeded with strategic improvements and attempts to reduce HAIs. “I needed to kind of balance asking for additional staff,” Taylor said. “What can I get by making the department better and more efficient? Fortunately, we had some awesome outcomes. We were able to make some significant improvements across multiple different HAI types, even during the midst of a COVID surge.”
Taylor’s efforts resulted in her staff request exceeding expectations. The department moved from a team of eight full-time infection preventionists to 14 full-time infection preventionists, which shifted [the ratio] to one infection preventionist per 100 beds, she said.
Meet Leighann Parkes, MD, FRCPC, medical officer for infection prevention and control at McGill University in Montreal, who took a decidedly circuitous route to understanding and preventing infections.
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