Getting to Zero: Is It Safe? • Author(s): Michael B. Edmond, MD, MPH, MPASource: Infection Control and Hospital Epidemiology, Vol. 30, No. 1 (January 2009), pp. 74-76Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/592411 .

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infection control and hospital epidemiology january 2009, vol. 30, no. 1

c o m m e n t a r y

Getting to Zero: Is It Safe?

Michael B. Edmond, MD, MPH, MPA

From the Division of Infectious Diseases, Virginia Commonwealth University School of Medicine, Richmond, Virginia.Received July 21, 2008; accepted July 31, 2008; electronically published December 9, 2008.

Infect Control Hosp Epidemiol 2009; 30:74–76� 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2009/3001-0013$15.00. DOI: 10.1086/592411

This article is one of three in this issue (see also the articlesby Fraser and by Richards) adapted from a joint plenaryaddress entitled “Can We Really Get to Zero?” given at the18th Annual Meeting of the Society for Healthcare Epide-miology of America (Orlando, Florida; April 5–8, 2008). Theplenary session was structured as a formal debate, and eachspeaker was assigned a point of view to represent. The po-sitions presented may or may not represent the actual opin-ions of the authors.—The Editor

“Getting to zero” has been applied to many different con-cepts, but the first application to healthcare-associated infec-tions (HAIs) appears to be the Institute for Healthcare Im-provement’s program to reduce ventilator-associatedpneumonia. The Association for Professionals in InfectionControl and Epidemiology (APIC) then played a major rolein disseminating the concept. The “getting to zero” movementis the product of 3 forces: the expansion of external pressureson infection control programs, the intrusion of suboptimalevidence, and the convergence of quality improvement andinfection control.

Today, there are numerous external influences on infectioncontrol programs, many of which are interacting to create acomplex web of forces.1 Some are apparent (eg, legislativemandates), while others are more elusive (eg, the role ofindustry). Some provide helpful guidance. Yet others, suchas consumer advocacy groups, have priorities that may notbe completely aligned with those of infection control experts.The effect of professional societies has been mixed—the So-ciety for Healthcare Epidemiology of America (SHEA) hasbeen somewhat passive, allowing other stakeholders to dom-inate and define the agenda, and APIC, although more proac-tive, seems to use the current spotlight on HAIs primarily topromote its organization. Accreditation organizations andpayers, such as Medicare, have taken guidelines, developedby professional societies, and converted them into mandates,transforming recommendations into all-or-none prescrip-tions that may be associated with unintended consequences.

These external influences have arisen in response to theincreasingly common perception that healthcare is a com-

modity and patients are consumers. Thus, the key stake-holders are demanding higher levels of accountability, in-creased transparency, and rapid solutions to highly complexproblems.

The second key force driving “getting to zero” is subop-timal evidence, which I define as evidence that is weak, flawed,or even absent. The consequences of suboptimal evidence ininfection control include the use of administrative data todefine and publicly report HAIs, smallpox vaccination ofhealthcare workers, annual fit testing of N95 masks, attemptsto quantify hand hygiene compliance, and perseverating onmethicillin-resistant Staphylococcus aureus while other im-portant pathogens become increasingly prevalent.

Hospital epidemiologists are well aware of the complexitysurrounding HAIs, from the numerous risk factors leadingto infection in patients with multiple comorbidities to thecomplicated literature on prevention. A MEDLINE searchwith the term “nosocomial infection” yields 35,000 publishedpapers, and there are, currently, at least 4 textbooks devotedto the topic. “Getting to zero” simply fails to capture thecomplexity of HAIs, seems to jettison more than 3 decadesof research in healthcare epidemiology, and does not conveythe important message that, although the majority of HAIsare preventable, some are not.

The third key driver of “getting to zero” is the convergenceof quality improvement with infection control programs. Un-til recently, infection control and quality improvement op-erated in different spheres, with quality improvement focusedon noninfectious adverse events. Today, that separation nolonger exists, and, in some cases, infection control interven-tions are managed partially or entirely by quality improve-ment personnel. These groups have different strengths, per-spectives, and approaches (Table) that, sometimes, lead toconflict.

“Getting to zero” can best be described as a sound bite,which is defined as a social communication phenomenoncharacterized by a short phrase or sentence that captures theessence of a concept.2 Derived from a culture that resistscomplex messages, sound bites lack context and are prone tointerpretation and manipulation. This leads to simplicity

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getting to zero: is it safe? 75

table. Conceptual Differences Between Hospital Epidemiology and Quality Improvement.

Characteristic Hospital epidemiology Quality improvement

Focus Exploration and analysis ModificationPrimary task Defining problems and elucidating risk factors Designing and implementing interventionsAnalytic orientation Population based Often case basedPrimary influences Science and medicine BusinessStrength Rigorous methodology and validity Process designApproach Structured, relatively uniform Encourages innovationDelivery style Instructive CollaborativeSolutions Targeted: solutions evolve from understanding

the problemEmpiric: attempt various solutions and

keep what works, discard the restTactics Data oriented, relatively dull Flashy campaigns, catchy slogansPerspective Long term Short term, evolvingTempo Relatively slow Relatively fast

bias,3 characterized by a focus on superficial appearancesrather than reality; an emotional rather than an intellectualapproach; and the suppression of critical discourse.

“Getting to zero” is a concept that was introduced by thequality improvement community and embraced avidly bystakeholders, but it is a sound bite that represents suboptimalevidence. It is commonly interpreted to mean that the goalof reducing the number of HAIs to zero is attainable, and,therefore, all HAIs are preventable; this ultimately leads tothe belief that the occurrence of an HAI must be someone’sfault.

Recently, “getting to zero” has been transformed into zerotolerance for HAIs and for practices leading to HAIs. Zerotolerance is a criminal justice concept that originated withUS drug policy in the 1980s. It offers no tolerance for offenses;any infraction, regardless of error or extenuating circum-stances, is met with punishment. Thus, it fosters rigid, un-reasonably harsh responses and the creation of a punitiveculture. Yet, healthcare workers are often overworked, fa-tigued, and placed in stressful environments with inadequateresources, and they work in a system where we are just be-ginning to engineer out the errors. Moreover, in the case ofHAIs, the moment when transmission occurs is unknownand the cause invisible. Our challenge must be to focus onhumane means of rewarding, motivating, and empoweringhealthcare workers to optimize practices; not to use a zerotolerance approach to further punish them.

The “zero” obsession has a number of worrisome, unin-tended consequences. It sets up unrealistic expectations onthe part of the public and healthcare administrators, leadingto unreasonable demands on infection control programs. Itfosters a punitive culture, since someone must be at fault forcausing infections. It separates infection control from safetyand quality, when infection control concerns trump otherimportant safety issues. It has shifted the development ofinterventions away from an approach based on local riskassessment to the promotion of a one-size-fits-all approach.Healthcare workers and hospital epidemiologists have becomedemoralized when the expectations for getting to zero persist

but the elusive zero has not been attained. From a societalperspective, we continue to divert ever-increasing resourcesto marginal improvements in inpatient healthcare quality,while more people in the United States lose access to care.

Never has there been more attention focused on hospitalinfection control. At this critical time, SHEA must strugglewith several key questions: Who are we? What is our mission?How do we add value? Are we serving our members, andhow do we best do that? How do we broaden our outlookto include the public and other stakeholders? How do weeffectively integrate infection control into the broader contextof patient safety and quality? How do we transmit our col-lective knowledge and experience and ensure that our ex-pertise is sought and recognized? How do we maintain ourrelevancy and ensure the survival of our field?

To assist in answering these questions, I offer some practicalsteps:

1. Reexamine the mission, and become more proactive!2. Actively seek out opportunities to educate the public

about HAIs.3. Develop a program for healthcare worker education that

emphasizes a positive message about HAI risk reduction.4. Aggressively articulate expertise to stakeholders (eg, the

Joint Commission, the Centers for Medicare and MedicaidServices, and legislators).

5. Target hospital chief executive officers for education onHAIs, the value of hospital epidemiologists and infection con-trol programs, the need for investment in program infra-structure, and ways to partner with infection control col-leagues to set realistic goals for the reduction of the incidenceof HAIs.

6. Help members acquire new skills (eg, team building andproject implementation).

7. Create a blueprint of gaps in the science from whichresearch priorities can be identified.

8. Demand critical examination of evidence for practices,and advocate for linking expectations for compliance to thestrength of the evidence.

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76 infection control and hospital epidemiology january 2009, vol. 30, no. 1

9. Create an infection control curriculum with competen-cies for medical students and house officers.

10. Advocate for funding of research on HAIs and fortraining of new hospital epidemiologists.

11. Consider certification as a mechanism to establishlegitimacy.

12. Maintain credibility by avoiding conflicts of interestwith industry, and avoid promoting public awareness of in-fections for self-promotion or financial gain.

In summary, words (and the precision with which they areused) and how concepts are framed matter. “Getting to zero”is a sound bite that misleads the public and is not helpful tohospital epidemiologists. The “zero” approach to HAIs isrigid, dishonest, and antiintellectual, and it drives a cultureof blame. And for all of these reasons, the answer to thequestion “Is it safe?” is a resounding “No.”

Effective infection control is not about campaigns andsound bites. Rather, it requires a thoughtful, logical, local

approach to the investment of resources in personnel, tech-nology, and interventions that produces sustainable reduc-tions in all HAIs. No one is better poised to guide this processthan the hospital epidemiologist.

acknowledgments

Potential conflicts of interest. The author reports no conflicts of interestrelevant to this article.

Address reprint requests to Michael B. Edmond, MD, MPH, MPA, POBox 980019, Virginia Commonwealth University Medical Center, Richmond,VA 23298-0019 (medmond@vcu.edu).

references

1. Edmond M, Eickhoff TC. Who is steering the ship? External influenceson infection control programs. Clin Infect Dis 2008; 46:1746-1750.

2. Wikipedia. Sound bite. Available at: http://en.wikipedia.org/wiki/Sound-bite. Accessed July 21, 2008.

3. Scheuer J. The Sound Bite Society: How Television Helps the Right andHurts the Left. New York: Routledge; 2001.

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