Be Curious, Not Judgmental: Why Infection Preventionists Need to Lead with Questions

When a step-down unit records three central line-associated bloodstream infections (CLABSIs) in six weeks, the instinct is to act quickly. The nurse manager’s diagnosis arrives almost immediately: a line maintenance problem, solved with more staff education.

But what if that instinct is wrong? That opening scenario set the tone for a thought-provoking session, “Leading with Curiosity: Embracing Uncertainty in Infection Prevention Practice,” presented by John P. Delano, MPH, CIC, LSSGB, FAPIC, and Anne L. Reeths, RN, MS, CIC, FAPIC of Advocate Health. Their argument: infection preventionists are operating in an environment of increasing complexity, and the professional habit most needed to navigate it — curiosity — is one that healthcare organizations routinely suppress.

As H.L. Mencken once observed, “For every complex problem there is an answer that is clear, simple, and wrong.” The session made the case that IP leaders need a better toolkit for sitting with uncertainty before reaching for solutions.

What Curiosity Actually Is — and Is Not

The presenters were careful to define their terms. Drawing on the research of Kashdan et al. (2018, 2020) and other scholars, they distinguished curiosity from several things it is commonly mistaken for. Curiosity, in this context, is not a personality trait you either have or lack. It is not indecision, or analysis paralysis, or the reflexive challenging of authority. It is not abandoning evidence-based protocols in favor of improvisation.

The working definition offered for the session: disciplined inquiry under uncertainty. It is, in other words, a practice — and one that operates across multiple dimensions. Drawing on Kashdan’s Five-Dimensional Curiosity Scale Revised (5DCR), the session outlined how curiosity is actually multidimensional:

Joyous exploration — the intrinsic pleasure of discovering new ideas and information

Deprivation sensitivity — the discomfort experienced when a knowledge gap goes unfilled

Stress tolerance — the willingness to sit with uncertainty and ambiguity without rushing to resolve it

Social curiosity — the desire to understand others’ perspectives (both overtly and covertly)

Thrill seeking — the appetite for novel, complex, or high-stakes experiences

Different IP situations call for different kinds of curiosity. Investigating a CLABSI cluster requires specific curiosity — focused question-solving around why a particular event occurred. Exploring emerging pathogens or new surveillance technologies calls for diversive curiosity — broad, open-ended exploration. Understanding what frontline nurses experience during line care requires social curiosity.

Why This Matters Now

Modern infection prevention work has never been more complex: emerging pathogens, antibiotic resistance, evolving guidelines, multi-site operations, and deep interdisciplinary dependencies all demand nuanced, adaptive thinking. The stakes of not asking enough questions are high — missed near misses, premature closure in investigations, stagnation in prevention strategy, and poor adoption of evidence-based practices.

And yet, workplace data suggest curiosity is being systematically constrained. One U.S. worker survey found that two-thirds of workers reported barriers to asking more questions at work, and 60% reported barriers to practicing curiosity in the workplace. For infection preventionists specifically, the COVID-19 pandemic compounded this: nearly half of U.S. IPs reported burnout during the pandemic — and burnout, the session argued, directly impedes the cognitive and emotional resources needed for curious inquiry.

There is also a direct patient safety link. Research published by Greene et al. (2020) found that organizational safety culture characterized by psychological safety is associated with increased use of recommended HAI prevention practices that require speaking up and cross-role coordination. Curiosity and safety culture are not separate concerns — they are intertwined.

The Four Levels of Curiosity: Where Leaders Can Intervene

One of the session’s most useful frameworks was the four-level model of curiosity, which helps IP leaders understand where, specifically, they can make a difference:

Trait curiosity — a relatively stable, dispositional tendency toward seeking new information. Leaders can recognize individual differences here, but cannot fundamentally change it in others.

State curiosity — a momentary, situational information-seeking response triggered by uncertainty or a knowledge gap. Critically, this can be cultivated — leaders can spark inquiry during events and uncertainty by asking the right questions at the right moments.

Leadership curiosity — deliberate behaviors that leaders model and encourage, including asking open-ended questions, seeking disconfirming evidence, and genuinely inviting dissent.

Organizational/Team curiosity — a cultural norm in which inquiry, voice, and learning from failure are the expected standard, not the exception.

The session’s core message here was pointed: “We cannot rely on naturally curious individuals. We need systems that activate and protect curiosity.

Curiosity in IP Evidence: Three Operationalized Constructs

While direct evidence of curiosity’s impact in IP settings is still developing, the presenters identified three well-researched constructs that effectively operationalize what curiosity looks like in practice:

Psychological Safety creates the conditions where curiosity behaviors — speaking up, questioning assumptions, admitting uncertainty — can actually occur. The relationship is bidirectional: leaders who display curiosity help build psychological safety, and psychological safety makes team curiosity visible in practice. In infection prevention, this translates into better detection of weak signals, more complete event reviews, stronger multidisciplinary learning, and less premature closure during investigations.

The leadership implication is direct: curiosity works best when leaders establish explicit non-blame norms and respond to concerns with gratitude rather than defensiveness.

Structured Inquiry and Systems Thinking converts curiosity into a method. In HAI work, this means shifting the framing from “Who caused this?” to “What conditions allowed this to happen?” Useful formats include after-action reviews (AARs), pre-mortems, safety-focused M&M conferences, structured multidisciplinary event review, and curiosity-based huddles and debriefs. The SEIPS model (Systems Engineering Initiative for Patient Safety) offers a particularly useful organizing framework — prompting leaders to examine person, tasks, tools and technology, organization, physical environment, and external environment as contributing factors in any HAI event.

Inclusive Leadership broadens whose questions get asked and whose perspectives inform the analysis. Research shows that inclusive, psychologically safe climates enable people to ask questions and take initiative, turning curiosity into change. In practice, this means actively seeking input from non-typical voices: environmental services, sterile processing, transport, informatics, patients, and families. Whether a multidisciplinary HAI review becomes genuine inquiry or ritual compliance depends almost entirely on whether leaders make room for real challenge.

What Gets in the Way

The session addressed the common blockers of curiosity honestly and without blame. Three systemic forces suppress inquiry in IP settings:

Hierarchy and fear — fear of retaliation for speaking up, deference to authority even when uncertain, and the belief that raising concerns changes nothing. These suppress social curiosity and uncertainty tolerance.

Workload, time pressure, and burnout — cognitive narrowing under pressure leads to less exploration and more reflexive certainty. Burnout depletes the very resources needed for curious inquiry: joyous exploration, knowledge-gap drive, and the tolerance for sitting with ambiguity.

Overconfidence and premature closure — accepting the first plausible explanation without exploring further. These are cognitive traps that are human and understandable, not blameworthy — but they suppress the drive to investigate further.

The critical insight: these blockers are systemic, not personal. The problem is not uncurious people. It is organizations that create conditions hostile to inquiry.

Practical Tools: PAAIL and Appreciative Inquiry

The session introduced two actionable frameworks for IP leaders. PAAIL (Preview, Advocacy, Advocacy, Inquiry, Listen) is a structured conversational approach drawn from the Harvard Center for Medical Simulation, useful when investigating unclear events, addressing resistance, de-escalating defensiveness, or exploring different interpretations of the same situation. Applied to the opening CLABSI case, a PAAIL conversation might begin: “Can we pause before deciding on education and walk through what may be contributing?” — moving through objective observation, personal perspective, open inquiry, and genuine listening before any intervention is chosen.

Appreciative inquiry offers a complementary reframe: rather than asking only what went wrong, leaders also ask when have we done this well, and what made success possible? Studying success — in high-performing units, successful interventions, and strong multidisciplinary partnerships — identifies system strengths worth spreading.

Disciplined Curiosity: The Guardrails Matter Too

The session was careful to name the risks of curiosity without discipline. Analysis paralysis, interrogation that feels like blame, distraction from urgent risks, and endless investigation without action can all undermine the very purpose curiosity is meant to serve.

The resolution is a simple formula: Curiosity + Structure = Better Action.

Guardrails for disciplined curiosity include time-boxing inquiry, clarifying the decision point in advance, separating learning from blame without avoiding accountability, inviting multiple perspectives, identifying what information would actually change the decision, and committing to closing the loop with teams after action is taken.

The principle: curiosity should make action smarter, not slower. The goal is not to ask questions forever — it is to ask better questions before action becomes fixed.

Five Key Takeaways

The session concluded with five behaviors that infection prevention leaders can begin practicing immediately:

Ask why before acting — resist the pull toward the first available explanation

Question data, not just accept it — interrogate what is being measured and whether the measurement is valid

Engage across disciplines — bring non-typical voices into investigation and review

Create psychological safety to speak up — respond to concerns with gratitude, not defensiveness

Stay open to new approaches and challenge the status quo — model uncertainty as a leadership strength, not a weakness

Summary assisted by AI.

Getting “Unscared”: Reframing Infection Prevention Rounding as Connection, Not Inspection

For many infection preventionists (IPs), the prospect of walking onto a unit to round can trigger real anxiety — worries about clinical credibility, being seen as “the compliance police,” or simply not knowing what to say. A session presented by Dina Conigliaro tackled that anxiety head-on, offering practical tools to help IPs approach rounding with more confidence and less dread. The session, titled “Terrified of Rounding? Get Unscared with Purposeful Infection Prevention (IP) Walkabouts,” combined behavioral science, communication strategy, and a healthy dose of humor to reframe rounding as a relationship-building exercise rather than a punitive check-in.

Why Rounding Still Matters

The session opened with a reminder of the stakes: an estimated 70% of healthcare-associated infections (HAIs) are considered potentially preventable. Rounding, Conigliaro argued, plays a distinct role in closing that gap because it catches risks that surveillance data alone can miss.

Three core benefits of routine rounding were highlighted:

•  Early warning detection — spotting risk before it becomes a reportable event

•  Relationship capital — visible IPs become trusted partners that frontline staff proactively bring concerns to

•  Behavioral reinforcement — real-time positive feedback can shape culture more effectively than after-the-fact correction

The framing throughout was pointed: rounding should be “not just inspection — connection.”

Naming the Fear, Then Reframing It

A central part of the session addressed the internal scripts that make rounding feel intimidating, pairing common worries with reframes:

•  “I don’t have a clinical background” → Recognizing infection risk is a transferable skill across care settings.

•  “I don’t want to seem like I’m policing staff” → IPs can own the narrative through curiosity rather than authority.

•  “I don’t know what to say if I’m asked something I don’t know” → Nobody knows everything; structured communication and practice help.

•  “I’m not sure what I’m looking for” → Rounding isn’t about catching everything — it’s about showing up consistently.

Confidence, the session emphasized, is a skill that can be deliberately built over time, not an innate trait.

Tools for Calming the Nervous System

Recognizing that rounding-related anxiety is a physiological as well as psychological experience, the session introduced several quick, in-the-moment regulation techniques IPs can use before or during rounds, including 4-7-8 breathing, five-finger breathing, the 5-4-3-2-1 grounding technique, and brief gratitude pauses — brief practices linked in the literature to improved mood and reduced physiological arousal.

Communication: Curiosity Over “Terminal Language”

Perhaps the most actionable portion of the session focused on language. Presenters contrasted “terminal language” — closed, directive statements likely to put staff on the defensive — with “curiosity language” that invites dialogue. For example, rather than stating “your hand hygiene compliance is 75% and needs to improve,” an IP might ask staff what barriers they see to hand hygiene and what would make compliance easier.

Structured communication frameworks, such as Situation-Background-Assessment-Recommendation (SBAR), were recommended as a way to deliver observations clearly without triggering defensiveness. Vulnerability was also highlighted as a trust-building asset: acknowledging when an IP doesn’t know something was framed as a credibility booster, not a liability.

Practical Rounding Infrastructure

Beyond mindset, the session offered concrete operational tools:

•  Risk-based prioritization — focusing rounds on units with more patients on precautions, unusual length-of-stay patterns, high device days, or rising standardized infection ratio (SIR) trends

•  The “5-minute round” — a reminder that brief, consistent rounding still delivers value even without extended time on a unit

•  Rounding trackers — simple paper or digital tools (“task minders”) to maintain consistency, with an emphasis on choosing a format the IP will actually use

•  Fidelity in follow-through — ensuring that any promised feedback is personally delivered, reinforcing trust over time

Resilience as a Practiced Skill

The session closed with a broader point about sustainability: resilience is described in the literature as directly mediating the relationship between nursing attitude and infection prevention and control (IPC) practice quality, with higher resilience associated with stronger IPC behaviors under stress. Presenters outlined a “foundation of resilience,” ranging from prioritizing rest and taking breaks to building connections, practicing mindfulness, and investing in professional development — positioning resilience, like confidence, as something built through consistent practice rather than an inherent trait.

Bottom Line for IPs

The session’s overarching message was that rounding is most effective — and most sustainable — when approached as intentional connection rather than a compliance checkbox. By pairing simple anxiety-reduction techniques with curiosity-driven communication and realistic, risk-based structure, IPs may find that rounding becomes less something to dread and more, as the session put it, “the best part of your day.”

Summary assisted by AI.

When Our Worlds Collide: How One Health System Built a Better Bridge Between Infection Prevention and Employee Health

A recap of the APIC 2026 session “When Our Worlds Collide: Infection Prevention & Employee Health Collaboration”

Healthcare workers care for some of the most vulnerable patients in the world — and in doing so, they accept a degree of personal risk that most people never consider. When a patient with unrecognized tuberculosis is admitted without airborne precautions, or a nurse with shingles continues working in a unit with immunocompromised patients, the consequences can ripple outward in ways that are costly, preventable, and deeply personal.

At APIC 2026, Kathryn Galvin, MS, MLS(ASCP), CIC, and Paul Anthony, MD, presented the session, “When Our Worlds Collide: Infection Prevention & Employee Health Collaboration,” a detailed look at how their health system — a large, multi-facility network operating across 500 locations with 44,000 colleagues — tackled a persistent problem: the gap between Infection Prevention (IP) and Colleague Health Services (CHS) in managing communicable disease exposures among healthcare workers. Their session was equal parts epidemiology primer, quality improvement case study, and practical blueprint for any IP team looking to strengthen its relationship with employee health.

Two Teams, One Mission — But Different Lanes

Despite sharing a commitment to preventing illness and protecting the people within a healthcare setting, IP and CHS have historically operated in parallel rather than in partnership. The session opened by laying out just how distinct — and yet interconnected — these two roles are.

Infection preventionists focus on HAI surveillance, outbreak investigation, hand hygiene compliance, and regulatory reporting through CMS and NHSN. Colleague Health Services, by contrast, manages employee health broadly: injury management, fitness-for-duty exams, OSHA compliance, drug and alcohol testing, immunizations, and the coordination of return-to-work after exposures.

When a communicable disease exposure occurs, both teams are activated — but from different directions. IPs identify the exposure, initiate contact tracing, and manage exposed patient follow-up. CHS handles employee baseline testing, prophylaxis, counseling, and ensures safe return-to-work. Both care about the outcome; neither can achieve it alone.

The stakes are real. Contact investigation for tuberculosis cost the U.S. an estimated $9.94 million in 2022 alone. Blood-borne pathogen exposures, airborne and droplet-transmissible diseases, and vaccine-preventable illnesses all represent ongoing, manageable risks — if the two teams are working from the same playbook.

What the Data Revealed

The presenters used a Plan-Do-Study-Act (PDSA) framework to describe how their IP and CHS teams came together to analyze the problem systematically.

The first step was simply pulling the teams into the same room to review exposure data together. What they found shaped everything that followed.

Looking at the types of exposures occurring across the system, varicella (chickenpox, transmitted via herpes zoster/shingles patients) accounted for 71% of all communicable disease exposures. TB exposures made up 25%, and meningitis accounted for the remaining 4%.

The root cause analysis was equally instructive: 56% of exposures were attributable to delayed identification of the infectious condition, and 42% resulted from incorrect isolation precautions being applied. Only 2% had no identifiable root cause.

This data pointed directly to the iceberg below the surface. The visible event — a colleague exposed to TB or varicella — was the product of deeper system failures: lack of clinical knowledge, misinformation, delayed identification and isolation, nonadherence to PPE and hand hygiene, and limited awareness of existing policies. The problem wasn’t individual carelessness. It was a system that made it too easy to miss.

The Two Highest-Risk Pathogens: A Refresher

The session dedicated time to reviewing the epidemiology of the two most common exposure sources — not because IPs don’t know this material, but because ensuring that bedside staff and clinical decision-makers understand it is half the battle.

Herpes Zoster (Shingles) spreads primarily through direct contact with vesicle fluid, but can become airborne in disseminated or immunocompromised presentations. It is infectious from rash onset until all lesions are crusted. A critical and frequently misunderstood point: shingles transmits varicella (chickenpox) to susceptible individuals — not shingles itself. Precautions range from Contact plus Standard for localized presentations to Contact plus Airborne for disseminated or immunocompromised cases.

A 2023 case report in Epidemiology & Infection illustrated the real-world risk vividly. An unimmunized healthcare worker cared for a patient with shingles without proper precautions, developed chickenpox 18 days later, and unknowingly transmitted varicella to a 31-year-old unimmunized patient who was already 80 days into a hospitalization. The chain ran from patient to HCW to patient. Prevention would have required three things: screening HCWs for varicella immunity, furloughing unimmunized staff post-exposure, and documenting patient immunity status at admission.

Tuberculosis spreads via airborne droplet nuclei so small — 1 to 5 microns — that they remain suspended in air and can travel across rooms and units when not properly contained. The infectious dose is very low, and infectiousness is highest in pulmonary or laryngeal TB, particularly in patients with cough, cavitation, or high bacterial burden. Containment requires placement in an Airborne Infection Isolation Room (AIIR) and cannot be safely managed with standard precautions alone.

Building the Exposure Workgroup

Recognizing that the old system — paper and email alerts sent from IP to CHS, disease by disease, without a standardized framework — was neither efficient nor reliable, the teams formed a joint Exposure Workgroup. The group’s objectives were sweeping in their ambition and deliberately specific in their targets: standardize IP and CHS workflows, standardize exposure criteria, standardize cluster and outbreak definitions, standardize notification templates, and standardize reporting to the Infection Control Committee.

The workgroup’s “Study” phase confirmed what the initial data suggested: varicella and TB were the priority targets, and mitigation had to address both the identification gap and the isolation gap simultaneously.

The resulting action plan had four components:

Interdepartmental Standard Work — a shared, written protocol (the Communicable Disease Exposure Standard Work) that defines exactly how IP is notified of a potential exposure, how the exposure window is set, who is responsible for each downstream action, how colleagues are queried regarding PPE and isolation, and how data is documented and reported. The process now flows in a defined sequence: IP identifies the isolation gap → refers to standard work → enters exposure details into an electronic database → an automated email alert goes to CHS → CHS prepares notifications and next steps → colleagues are queried → post-exposure recommendations are delivered → the case is reported to the Infection Control Committee monthly.

Clinical Decision Support — both varicella and TB isolation protocols were embedded directly into the electronic health record as order sets with built-in clinical guidance. When a provider orders shingles isolation, the order set immediately distinguishes between localized and disseminated/immunocompromised presentations, with clear criteria for each — including the requirement that localized lesions be covered with an occlusive dressing, and that disseminated or immunocompromised cases receive airborne plus contact precautions in a negative pressure room. The TB lab panel similarly pairs culture ordering with automatic initiation of airborne isolation, removing the gap between test ordering and room assignment.

Isolation Guidance Accessibility — rather than requiring staff to hunt through policy documents, a searchable “Directory of Infectious Diseases” was embedded directly into the EHR sidebar, accessible in one click during patient care. The directory covers isolation type, room requirements, transport requirements, duration of precautions, and comments for each condition.

An Education Campaign — exposure management content was integrated into the IP Champion program and the Nurse Residency program, using simulation, visual tools, and point-of-care reference materials. The campaign reinforced a specific and counterintuitive fact that drives many near-misses: a healthcare worker will come into contact with a patient or the contaminated room when crossing the threshold more than 90% of the time, even when not intending to provide direct care.

The education also introduced the “3 I’s” framework as a simple, memorable reminder for bedside staff: Identify (TB screening for all admissions and bronchoscopies; skin assessment on admission), Isolate (order isolation immediately — not after the clinical picture is clearer), and Inform (place isolation orders, set the infection flag in the EHR, post isolation signage).

Results

The intervention produced measurable results across both priority pathogens.

For TB, the number of colleagues possibly exposed dropped from 768 (January–June 2024) to 621 (January–June 2025), a 19.14% reduction year over year. Earlier and more reliable placement of patients in airborne isolation translated directly into fewer staff members in the exposure window.

For varicella, the total duration of colleague exposures decreased by 16% post-intervention. Faster identification and more correct isolation of herpes zoster patients shortened the window during which unimmunized staff and patients were at risk.

The presenters were candid about limitations: the outcome data comes primarily from the system’s largest hospital and may not fully reflect trends across all facilities. Sample sizes remain modest. Continued monitoring is needed before long-term conclusions can be drawn. But the direction of the findings — and the logic of the mechanism — is consistent and compelling.

Three Steps Toward Better Collaboration

The session’s closing message was aimed directly at IPs in the audience who may be working in organizations where the relationship between infection prevention and employee health remains informal, siloed, or reactive. The presenters identified three practical starting points:

Establish a joint forum. Regular, structured meetings between IP and CHS leadership — not just crisis calls when an exposure occurs — create the shared situational awareness needed to prevent the next exposure. Reviewing data together, not just handing it across, changes the nature of the relationship.

Standardize the workflow. Written standard work that both teams have agreed to, that is accessible at the point of need, and that defines roles and handoffs clearly is not bureaucracy — it is the difference between a near-miss and a missed exposure becoming an outbreak.

Embed guidance in the clinical workflow. Policies that live in PDFs are not policies that get followed under time pressure. Clinical decision support at the point of care — built into order sets, visible in the EHR sidebar, tied to the actions clinicians are already taking — removes the friction between knowing what to do and doing it.

The session’s underlying message was perhaps best captured by the data itself: most of these exposures are preventable. The gap is not in knowledge, and it is rarely in intention. It is in the systems and structures that either support or undermine the right behavior at the right moment.

Summary assisted by AI.

“Economic Armor”: As Margins Shrink, Infection Preventionists Are Told to Speak the Language of Finance

With hospital operating margins hovering near record lows and federal payment programs increasingly tying reimbursement to quality outcomes, infection prevention leaders are being urged to reframe their work in the one language that consistently gets budget approval: dollars and cents.

That was the core message of “Economic Armor: Making the Financial Case for Infection Prevention,” a session presented by Tim Kelly, senior director of health economics and outcomes research at BD Urology and Critical Care, at the APIC26 conference in Nashville.

A System Under Financial Strain

Kelly opened by painting a stark picture of hospital finances heading into the second half of 2026. Year-to-date hospital operating margins sat at just 1.9% in February, and 72% of health system CFOs and finance executives report margins of 2% or lower, according to a Becker’s Healthcare/LeanTaaS survey cited in the presentation. Compounding the pressure, the One Big Beautiful Bill Act (OBBBA) is projected to cut federal Medicaid funding by $1 trillion over the next decade, putting an estimated 400 hospitals at high risk of closing or cutting services.

Meanwhile, hospital expenses continue to climb. Labor still dominates hospital budgets at 60% of total expenses ($1,009 billion), but supply costs grew 9.9% and drug costs grew 13.6% in 2025 — both outpacing the 3.3% rise in hospital reimbursement rates. Of the expense growth hospitals experienced between 2019 and 2024, 45% was attributed to rising input costs such as labor, drugs, supplies, and equipment.

Against that backdrop, infection preventionists (IPs) are stretched thin. IPs work an average of 43.6 hours per week, and infection prevention and control citations remain among The Joint Commission’s most frequently cited compliance findings — even as programs face growing threats from emerging pathogens and antibiotic resistance.

Why HAIs Hit the Bottom Line Three Times Over

Kelly’s central argument was that healthcare-associated infections (HAIs) don’t just harm patients clinically — they hit hospital finances through at least three interlocking federal payment mechanisms:

• Hospital-Acquired Condition Reduction Program (HACRP): Established under the Affordable Care Act, HACRP docks Medicare payments for the worst-performing quartile of hospitals on a composite of six measures, five of which are HAIs — CAUTI, CLABSI, colon/hysterectomy SSI, MRSA bacteremia, and C. diff. More than 2,000 hospitals have been penalized under the program at least once, and 719 hospitals are sustaining a payment reduction in FY2026.
• Hospital Value-Based Purchasing (HVBP) Program: This program withholds 2% of Medicare payments, which hospitals can earn back — or lose — based on performance across four equally weighted domains, one of which (Safety) is built almost entirely around HAIs and the SEP-1 sepsis measure. Kelly noted this program affects essentially all hospitals, not just poor performers.
• Hospital Readmission Reduction Program (HRRP): In FY2026, 78.2% of all hospitals are paying some level of readmission penalty, with 240 hospitals losing more than 1% of payments. The connection to infection prevention is direct: published data show CAUTI patients are readmitted at nearly double the rate of matched controls (21.1% vs. 11.3%), and CLABSI patients are readmitted at double the rate as well (26% vs. 13%).

The clinical stakes are also significant. Research cited in the presentation found that among patients with select cardiovascular conditions, contracting an HAI during even part of an ICU stay was associated with an 8.9% increased risk of in-hospital mortality. Relative mortality risk was more than tripled for CLABSI (RR 3.52) and non-CLABSI hospital-onset bacteremia (RR 3.51).

The Real Cost of “Never Events”

Since 2008, CMS has refused to pay for a list of hospital-acquired conditions considered preventable “never events,” including catheter-associated UTIs, vascular catheter infections, and surgical site infections. According to research referenced in the talk, the incremental cost burden of these infections is steep:

Infection	Incremental Cost
CLABSI	$48,108
Non-CLABSI hospital-onset bacteremia	$42,095
Surgical site infection	$28,219
MRSA bacteremia (invasive, age 65+)	$23,301
C. difficile infection	$17,260
CAUTI	$13,793
Non-CAUTI hospital-onset UTI	$6,101

Critically, hospitals absorb a large share of these costs themselves. One study found that for bloodstream infections, Medicaid covers only 8% of excess costs and Medicare covers 29%, leaving hospitals to eat the rest. For private payers, hospitals recoup only about 27–28% of excess costs tied to bloodstream and urinary tract infections — meaning every prevented infection represents a direct financial recovery, not just an avoided penalty.

Length of Stay and the Overlooked Value of Patient Flow

Kelly emphasized that length of stay (LOS) reduction is one of the most underused arguments in an infection preventionist’s financial toolkit. Data presented showed CLABSI adds 15.6 to 17.4 incremental days depending on ICU status, while ventilator-associated pneumonia extends ICU stays by 4 to 10 days and surgical site infections add 8 to 9.5 days.

Because ICU beds cost roughly 3 to 5 times more per day than general ward beds ($11,304 vs. $6,055 in cited data, a difference of $5,249 per day), moving patients to lower-acuity settings faster — by preventing complications that prolong high-acuity stays — creates measurable savings independent of any payer penalty.

One of the more provocative figures came from a 613-bed academic medical center study using an “opportunity cost” framework: rather than comparing patients with and without an infection, the analysis calculated what a hospital loses in unrealized admissions when beds stay occupied longer than necessary. The finding: preventing a single HAI freed enough capacity to admit 4.62 additional patients, generating $1.5 million in gross revenue and $582,464 in additional profit.

A Word of Caution on Efficiency Claims

Not every efficiency argument lands the same way with hospital finance leaders, Kelly cautioned. Using illustrative (explicitly fictitious) examples of automated hand hygiene and surgical prep devices, he noted that time savings on nursing units are often unpersuasive to CFOs because clinical staff are typically treated as a fixed, sunk cost — saving a nurse 10 seconds per handwashing episode doesn’t change the labor budget. Time savings in the operating room, by contrast, can be more compelling because OR minutes are costly, throughput-limited, and tied to variable revenue opportunity. His recommendation: infection prevention advocates should pair any efficiency argument with a demonstrable clinical outcome, not present time savings alone.

Star Ratings and Patient Choice

The session also connected infection rates to CMS’s public-facing Overall Hospital Quality Star Rating, which weights Safety of Care and Readmissions at 22% each — both directly influenced by HAI rates — alongside Mortality (22%), Patient Experience (22%), and Timely & Effective Care (12%). A discrete choice experiment involving 1,025 Medicare beneficiaries found patients are willing to pay $1,698 out of pocket for a hospital with one additional star tied to clinical outcomes, $691 for patient experience, and $615 for safety — a reminder that reputational and market-share effects, not just CMS penalties, are at stake.

Building the Business Case

Kelly closed with a practical framework for IPs and hospital epidemiologists building funding requests: prepare an executive summary, identify a financial partner early, frame the problem, secure administrator or physician-leader buy-in, quantify avoidable costs, calculate financial impact, and then measure results after implementation. He also pointed attendees to resources such as the ISPOR Presentations Database — which returned 67 results for a simple search on surgical site infections — as a source of ready-made cost models and burden-of-disease data that can be adapted to a local business case.

The session also tied infection prevention to two adjacent institutional priorities that can strengthen a funding pitch: environmental sustainability (hospitals account for roughly 35% of the health sector’s 8.5% share of U.S. greenhouse gas emissions, and ICU care generates roughly three times the emissions and waste of acute-care beds) and alignment with The Joint Commission’s 2026 National Performance Goals, specifically Goal 5 (infection prevention and control) and Goal 2 (culture of safety).

The Bottom Line

As hospitals navigate thinning margins, Medicaid cuts, and an expanding web of value-based payment models, the session’s throughline was clear: infection prevention programs that can translate clinical outcomes into payer-specific financial terms — HACRP penalties avoided, HRRP readmission exposure reduced, ICU days converted to ward days, star ratings protected — are far better positioned to compete for scarce hospital resources than those relying on clinical rationale alone.

Summary assisted by AI.

Water Matters: Why Building Water Systems Are Becoming a Standard of Care in Infection Prevention

Water management is emerging as a defined standard of care in U.S. healthcare facilities, according to a presentation, “Water Matters: A Critical Factor in Infection Prevention,” delivered at APIC26 by Sylvia Garcia-Houchins, RN, MBA, CIC, AL-CIP, principal at Gordon & Rosenblatt, and Jeff Holland, MBA, senior global director of life sciences at Xylem. The session outlined how water system design, maintenance, and testing are increasingly scrutinized by accrediting bodies — and why infection preventionists need a working knowledge of the standards driving that scrutiny.

From Public Utilities to Premise Plumbing

Historically, waterborne illness in the U.S. — cholera, typhoid, dysentery — traced back to contaminated public water supplies. That changed in the 1920s, when Abel Wolman helped make science-based chlorination of public water nearly universal, largely eliminating traditional waterborne disease.

Today’s threat looks different. Public drinking water is not sterile — it carries a rich, diverse microbial community, including low levels of pathogens such as Legionella, Pseudomonas, and non-tuberculous mycobacteria (NTM). Most modern waterborne disease now originates not from the municipal supply itself, but from what happens to that water after it enters a building: premise plumbing and cooling towers, where sediment, temperature, water age, and disinfectant residual (the “STAR” factors) can allow opportunistic pathogens to proliferate. When contaminated water exits a building system — through showers, ice machines, or humidifiers — susceptible patients can be exposed.

The financial burden is substantial. CDC estimates put direct annual U.S. healthcare costs at $402 million for Legionnaires’ disease, $667 million for Pseudomonas pneumonia, and $1.53 billion for NTM infection.

ASHRAE 188 Set the Framework

ANSI/ASHRAE Standard 188-2015 was the first industry consensus standard for risk management of building water systems, establishing a methodology many other guidance documents now echo: assemble a multidisciplinary team, document the system, conduct a risk assessment, implement control measures and monitoring, define corrective actions, and confirm results through verification and validation — all supported by documentation.

According to the presenters, ASHRAE, AAMI, CDC, CMS, and The Joint Commission (TJC) now broadly agree on the key elements of water management in healthcare facilities, and all align with the ASHRAE methodology. CDC recommends that facilities implement comprehensive, ASHRAE-aligned water management programs (WMPs) covering both general environment-of-care systems (premise plumbing, cooling towers, irrigation) and special-purpose departments such as dialysis, respiratory care, and sterile processing.

Sterile Processing Comes Into Focus: ANSI/AAMI ST108

A significant driver of recent attention is ANSI/AAMI ST108:2023, which sets minimum requirements for water quality and steam purity used to clean, disinfect, and sterilize reusable medical devices. Using the wrong water in device reprocessing can damage equipment, stain or corrode instruments, reduce the efficacy of cleaning chemistries or sterilization processes, and introduce endotoxins or waterborne pathogens — all of which carry direct infection-control and patient-safety consequences.

The standard defines three water types relevant to sterile processing departments (SPDs):

• Utility Water – used for flushing, washing, and intermediate rinsing. It is not the same as tap water; tap water typically needs treatment to consistently meet ST108’s Table 2 specifications, and most SPD water problems trace back to Utility Water.
• Critical Water – used for final rinses after high-level disinfection, final rinses of critical devices before sterilization, and as feedwater for steam production. Critical Water isn’t inherently “better” — ST108 itself warns that using it at every stage can damage water systems or processing equipment.
• Steam – its quality is judged by testing the condensate against Utility Water specifications, though condensate quality alone doesn’t guarantee the feedwater won’t damage steam-generating equipment.

Notably, compliance with ST108 is not yet required by CMS or TJC, and the presenters emphasized that, by itself, ST108 does not constitute the standard of care — though its influence is clearly growing.

Water Chemistry Affects Cleaning Product Performance

The presentation also highlighted a frequently overlooked variable: the pH and alkalinity of dilution water directly affects the performance of enzymatic cleaners, detergents, and disinfectants. Chlorine bleach was offered as an illustrative example — its active disinfecting species, hypochlorous acid (HOCl), dominates at lower pH (about 50% at pH 7.5) but essentially disappears at pH 9.5. Because ST108 permits both Utility and Critical Water for diluting cleaning products (subject to manufacturer instructions), facilities need to verify the actual pH of their diluted use-solutions rather than assume compliance based on water type alone.

Sampling Plans: The Most Overlooked Requirement

Presenters described the development of a comprehensive water sampling plan (ST108, Section 9.3) as one of the standard’s most important — and most commonly under-executed — requirements. Initial testing calls for a “Phase 1” Performance Qualification: daily sampling across the entire system, including the facility and SPD water supply, every treatment step for both Utility and Critical Water, all points of use throughout the SPD, and steam condensate. Only after this qualification phase is evaluated through a risk assessment should facilities transition to routine sampling — and Tables 2 and 5 of ST108 do not capture every analyte a facility may need to test; additional analytes depend on facility-specific factors such as whether the municipal supply uses chlorine or monochloramine as a secondary disinfectant.

For target organisms, ST108 offers limited specificity, but ISO T/S 5111 identifies three clinically significant pathogens that should always be included in SPD sampling plans: Pseudomonas aeruginosa, atypical Mycobacterium species (NTM), and Legionella species. Molecular methods such as quantitative PCR (qPCR) were cited as particularly useful for multi-pathogen validation testing, with additional method guidance available in ANSI/ASHRAE Standard 514-2023.

What This Means for Infection Preventionists

The presenters framed “standard of care” as an evolving concept shaped by rules and regulations, peer-reviewed literature, evidence-based guidance, and consensus standards — with peer adoption often the ultimate determinant of when a practice becomes expected rather than optional. Their message to IPs: accreditation surveyors, including long-term care surveyors, increasingly expect a documented, facility-wide water management plan — covering premise plumbing, specialty departments, and sterile processing alike — complete with a risk assessment and testing protocols, available for review on demand.

Disclosures: Sylvia Garcia-Houchins is a Principal at Gordon & Rosenblatt, a water management consulting firm. Jeff Holland is an employee of Xylem, a manufacturer of water purification equipment used in healthcare. Both relevant financial relationships were disclosed and mitigated for this presentation. This article summarizes conference presentation content current as of June 17, 2026, and is not a substitute for direct review of ANSI/ASHRAE 188, ANSI/AAMI ST108, or facility-specific regulatory guidance.

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From Data to Action: CDC Data Shows Nearly All U.S. Hospitals Have Water Management Programs — But Gaps in Execution Persist

The session, “From Data to Action: Practical Tools and Insights to Strengthen Water Management Programs,” was presented by Christine Yount, MPH, REHS, and Jacqueline Woodring, BS, of CDC’s Division of Healthcare Quality Promotion, Health Systems Strengthening, Resilience & Training Branch.

Nearly all U.S. acute care hospitals now report having a water management program (WMP) — but according to new CDC survey data and outbreak investigation findings presented at APIC 2026, having a plan on paper is not the same as having one that actually protects patients. The session paired national surveillance trends with lessons from real-world outbreak investigations and introduced new tools, including a nine-element implementation framework and a frontline staff training series, aimed at closing the gap between adoption and execution.

Why Water Is a Patient Safety Issue

Presenters opened with a reminder that tap water is not sterile, and water used throughout a healthcare facility can harbor organisms capable of causing disease in vulnerable patients — including those who are immunosuppressed, have cystic fibrosis or pre-existing lung damage, are in the ICU, or have non-intact skin or open wounds. Medical devices themselves can also serve as vectors for transmission.

Water use in healthcare settings is extensive and touches nearly every part of facility operations:

• Facility systems — HVAC, cooling towers, fire suppression, irrigation
• Consumption — drinking water, ice, food preparation
• Patient care — hygiene, aqueous medical products, medications, ventilators, neonatal isolettes, dental water
• Procedures — dialysis, surgery (including cardiopulmonary bypass), burn wound debridement, ECMO
• Cleaning and reprocessing — automated endoscope reprocessors, instrument washers, steam generation (autoclaves), environmental cleaning

Premise plumbing — the large, complex distribution systems inside healthcare facilities — creates conditions conducive to biofilm formation: high surface-to-volume ratios, intermittent stagnation (including in “dead legs,” sections of pipe with no flow or circulation), low residual disinfectant, and warming cycles. Water quality within a building may drift from the standards set at the point of entry under the Safe Drinking Water Act.

Opportunistic Pathogens of Premise Plumbing (OPPP)

These conditions favor a specific category of organisms known as Opportunistic Pathogens of Premise Plumbing, or OPPP — microbial residents of drinking water distribution systems characterized by slow growth, biofilm formation, tolerance of temperature swings, resistance to disinfection, and the ability to survive at low oxygen levels. Examples cited include:

• Legionella species
• Gram-negative non-fermenters such as Pseudomonas, Acinetobacter baumannii complex, Burkholderia cepacia complex, Elizabethkingia species, and Stenotrophomonas maltophilia
• Nonfecal Enterobacterales, including Enterobacter, Klebsiella, Pantoea agglomerans complex, and Serratia species
• Nontuberculous mycobacteria (NTM)
• Fungi such as Aspergillus fumigatus, Fusarium, and Phialemonium
• Protozoa including Acanthamoeba and Naegleria fowleri

Since 2017, CMS has required that facilities, at minimum, conduct a risk assessment for Legionella and other OPPP, develop and implement a WMP, and define testing protocols, control limits, and corrective actions — though CMS does not mandate routine Legionella or OPPP testing itself.

What National Surveillance Shows

Drawing on the National Healthcare Safety Network (NHSN) Annual Acute Care Hospital Survey, presenters traced WMP adoption from 78% of reporting hospitals in 2017 to 96% in 2022, and 97% in the most recent 2025 survey (n=5,175) — indicating that formal program adoption has become close to universal.

But adoption doesn’t tell the whole story. Among hospitals with a WMP in the 2025 survey:

• 95% reported having conducted an environmental assessment, while only 81% reported completing a Water Infection Control Risk Assessment (WICRA)
• Monitoring rates varied sharply by parameter: 93% reported monitoring temperature, but only 61% reported monitoring pH and just 79% reported monitoring disinfectant residual
• On the validation side, 63% reported heterotrophic plate count testing, while only 28% reported routine Legionella testing

WMP teams most commonly include facilities engineering, environmental health, epidemiology, infection prevention, management and operations, laboratory, and external partners.

Outbreaks Reveal Where Programs Fall Short

A CDC-led root cause analysis of 14 Legionnaires’ disease outbreak investigations from 2015–2019 — spanning five hospitals and five long-term care facilities — used environmental assessments to identify contributing factors and expose recurring water management gaps, reinforcing that the presence of a WMP does not guarantee it is functioning as intended.

CDC’s broader review of acute care hospital WMPs found several elements commonly missing:

• Attention to OPPP other than Legionella
• Coverage of key endpoints, including healthcare equipment and wastewater/drains
• Infection prevention practices such as risk assessment integration, sink hygiene, splash avoidance, and use of the appropriate water type for a given task
• Adequate documentation

Infection preventionists surveyed about their greatest WMP challenges pointed to cross-departmental collaboration and cooperation; buy-in from leadership, facilities staff, and multidisciplinary partners; limited time and funding; knowledge gaps; and aging infrastructure.

A Nine-Element Framework for Implementation

To help close these gaps, CDC introduced a Framework for Healthcare Water Management Program Implementation, intended to supplement — not replace — existing standards by adding emphasis on risk assessment, multiple water endpoints, infection control practices, and staff training and education. The nine elements are:

1. Assembling and maintaining a diverse and accountable team
2. Assessing risks for patients
3. Enhancing risk awareness through education
4. Monitoring water quality
5. Mitigating conditions that promote OPPP growth
6. Reducing patient exposures
7. Communicating risk
8. Applying continuous program improvement through verification and validation
9. Effectively documenting program activities

CDC described the framework’s goal as providing a more holistic picture “from plumbing to patients,” rather than treating water management as a narrowly technical or engineering-only function.

Lessons from Infection Control Assessment and Response (ICAR)

The presenters also drew on findings from CDC’s Infection Control Assessment and Response (ICAR) program, which conducts collaborative, on-site assessments of infection prevention practices. Water-focused ICAR modules examine sink hygiene, cleaning and disinfection of fixtures, and general staff awareness of water as an infection risk. The framing presenters used was a shift “from risk assessment to action”: risk assessments examine water sources, transmission pathways, patient exposure, and preparedness, while frontline training tools — described next — help staff recognize where water is used, understand how germs spread, identify risky practices, and follow correct procedures.

Project Firstline: Turning Data Into Frontline Training

A central practical takeaway from the session was CDC’s Project Firstline, a national infection control education and training collaborative aimed at frontline healthcare workers. Content is designed to be accessible, adaptable, and practical for on-the-job use, grounded in educational best practices and CDC science, with the broader goal of building a culture of infection control expertise among frontline staff.

Project Firstline reaches healthcare workers through micro-learns, job aids, posters, fact sheets, training toolkits, short videos, and interactive scenarios, disseminated via partner networks, the web, newsletters, social media, and virtual events.

Water micro-learns are bundled educational packages — each including a user guide, discussion guide, and job aid — designed for short, focused trainings such as just-in-time sessions or pre-shift huddles, and can be led by infection preventionists, charge nurses, or other experienced staff. The water micro-learn series covers four topics specific to healthcare settings:

• Germs and Water in Health Care — an overview of infection risks associated with water
• Sinks — preventing the spread of germs from sinks
• Drains and Biofilms — preventing the spread of germs from drain biofilms
• Ice — keeping patients safe from germ spread through ice

These resources have also been translated into Spanish to reach a broader segment of the frontline healthcare workforce.

What Facilities Can Do Tomorrow

The presenters closed with a short list of concrete, near-term actions for facilities looking to strengthen their programs:

• Engage leadership early and directly
• Review the existing WMP and current practices against the nine-element framework
• Identify high-risk patient populations within the facility
• Assess staff knowledge gaps around water-related infection risk
• Deploy micro-learns for quick, low-lift training wins

Resources Cited

• CDC Environmental Infection Control Guidelines: cdc.gov/infection-control/hcp/environmental-control/water.html
• Considerations for Reducing Risk: Water in Healthcare Facilities: cdc.gov/healthcare-associated-infections/php/toolkit/water-management.html
• Legionella Water Management Program Training: cdc.gov/control-legionella/php/training/index.html
• Germs Live in Water and Wet Surfaces Factsheet (Project Firstline)
• Project Firstline Training Resources: cdc.gov/project-firstline/hcp/training/

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