Dignity Health System IP Team


Creating a foundation to support infection prevention excellence

Roy Boukidjian, MSN PHN CIC NE-BC
Wendy Kaler, MPH, CIC
Marcy Maxwell RN, BSN, CIC
Julie Wardinsky, RN, BSN, CIC
Dignity Health
San Francisco, CA

The Dignity Health Infection Prevention team has systematically built an infection prevention and control (IPC) structure that supports infection prevention programs and improved patient outcomes in 39 facilities across three states. Despite differences in geography, culture, and professional experience levels across their facilities, the team has successfully standardized critical infection prevention processes and systems, enabling Dignity Health to achieve key CMS goals and internal infection-reduction targets.

The team started by providing policy templates to their local facilities, and progressed to evidence-based policies that each facility is mandated to adopt. “We made a big push when we realized our facilities were asking for policy and procedure guidance,” Marcy Maxwell said. The team also created an Infection Prevention Council to develop outcomes-driven action plans that supported policy implementation. “We tried to develop specific plans that everyone could implement at the same time and that could be measured continuously,” said Julie Wardinsky. 

Participation in the CMS Partnership for Patients Hospital Engagement Networks (HEN) has given the Dignity Health team additional support, motivation and resources. To audit and coordinate the HEN initiatives, the team successfully introduced “MeasureVentionists” – specially trained nurses who provide peer-to-peer bedside coaching. Working together, MeasureVentionists and Dignity Health infection preventionists reduced the system’s CAUTI and CLABSI rates by 40 percent.

The HEN contract also gave the Dignity Health infection prevention team time for facility visits to focus on implementation of current initiatives. “You can’t help change things if you don’t understand the local culture and challenges,” said Wendy Kaler. “On-site visits also made our local IPC staff feel supported.” 

While the system-wide foundation that the Dignity Health Infection Prevention team created has many components, Roy Boukidjian can succinctly summarize the key to their success:  “Mutual respect is really how you make this happen.”