HAIs
Prevention Begins With Physician Leadership
In many hospitals, the policies, bundles, and compliance infrastructure are already in place. The opportunity is creating the physician engagement and multidisciplinary accountability that make those processes work.
Daily line necessity. Meaningful partnership with Infection Prevention. Thoughtful culture stewardship. Real-time physician-to-physician communication.
The protocol may already exist. The question is whether the clinical culture makes it real.
A persistently elevated HAI rate is rarely the result of a single problem. We identify the clinical and operational factors driving performance and work alongside physicians, nursing, Infection Prevention, and hospital leadership to address them in real time.
That may mean questioning whether a central line is still necessary, whether cultures are clinically indicated, or whether a Foley can come out today rather than tomorrow.
Those conversations cannot be created through audits alone. They require physician leaders who are clinically present, respected by their peers, and willing to intervene when it matters.
The Proof
At a CommonSpirit-affiliated ICU, CLABSI rates had underperformed the NHSN benchmark, with the SIR reaching 2.33 at its peak.
The maintenance bundle was already in place. The missing piece was consistent physician engagement.
CVCCM established daily line-necessity review and a real-time escalation pathway between Infection Prevention and physician leadership. Active concerns became same-day clinical conversations rather than retrospective discussions at the next meeting.
By FY26, the CLABSI SIR reached 0.00.
Not through a new checklist. Through a physician culture that made the existing process real.
CAUTI: Changing Culture, Not Just Practice
When CVCCM assumed ICU leadership, the hospital’s two-year cumulative CAUTI SIR was 1.00. Within three months, it fell to 0.00. During the most recent six-month reporting period, it again reached 0.00.
Again, the answer wasn’t another protocol.
Physician and nursing leadership established daily catheter necessity as a non-negotiable part of multidisciplinary rounds, reinforced evidence-based Foley management, and aggressively challenged unnecessary catheter days.
The result wasn’t simply fewer infections. It was a change in clinical culture that has sustained improvement for two years.