Interview with Dr. Amber Hogan Mitchell, President and Executive Director, International Safety Center
To view this interview in the Safety First Magazine, click here.
Heather Monaghan (HM): Tell me a bit about your professional background and how you became involved in occupational and public health.
Dr. Amber Hogan Mitchell (AM): I love to share this with people, so thank you for asking. I grew up as an only child to a single mom who was a nurse who worked all hours of the night and day. After years of nursing, she ultimately became an HIV/AIDS nurse in New York City, and as a child I grew up sharing her with her patients - many who were sick and dying during the early AIDS epidemic. Unfortunately, my mom ended up passing away when I was in college and I guess it was then that my passion to keep people like her safe and well began to bloom.
After getting my Masters in Public Health from George Washington University and completing a post-graduate fellowship from the Uniformed Services University for the Health Sciences, I was hired as an industrial hygienist at the OSHA National Office in Washington DC. I ended up there in a time when the world was focused on infectious disease and bloodborne pathogens and when my growing passion for workplace safety was being nurtured. Preventing the spread of HIV, Hepatitis C, Hepatitis B, and other infectious diseases meant so much to me personally and professionally that it is something I stuck with even through my advanced doctoral training at the University of Texas School of Public Health.
HM: Have you always worked at the strategic/academic level, or do you have a background as a clinician?
AM: I am trained as a health educator and industrial hygienist with focus on preventing infection and illness in the workplace using the principles of epidemiology (finding the causes of injury, illness, and disease). I was a practicing industrial hygienist at OSHA and have academic training in occupational and environmental health at both the master’s and the doctoral level. Now, I work primarily on using occupational exposure surveillance data to build programs and interventions in healthcare facilities and to influence uptake of safer products, better practice, and robust policy to ensure that people are safe at work.
HM: When I looked into your background, I noticed you are the president of the International Safety Center. Can you tell me why the center was developed, and what are its main objectives?
AM: The International Safety Center was officially relaunched last year. Subsequently, it’s the next generation of the International Healthcare Worker Safety Center, which was born out of the terrific work done by Dr. Janine Jagger and her colleagues at the University of Virginia (UVA). It was created in the early 1990s because there was a general misrepresentation about the risks to healthcare workers who were exposed to blood and body fluids and subsequent infection or illness with bloodborne and infectious pathogens. EPINet® (Exposure Prevention Information Network) was created as a surveillance system to identify occupational exposures to blood and body fluids, whether it’s a needlestick, contaminated sharp, a splash, or a splatter, because there was little to no data—indicating to the world that potentially there was no problem. We know this is absolutely not true.
In 2014, we moved the Center activities away from UVA and it is now a stand-alone 501c3 nonprofit research and education center. There are several benefits to this model, allowing us to broaden our partnership with healthcare organizations, manufacturers and other academic institutions, and agility to improve and grow beyond bloodborne pathogens and into broader worker and patient safety issue areas, like exposure to chemical hazards, hazardous drugs, and to help improve overall healthcare quality.
HM: You mentioned EPINet, is that free to healthcare facilities?
AM: It is. Our model for the Center is to use the contributions, donations, and grants we receive from a number of different sources, to provide EPINet to hospitals around the world for free. Software, onboarding, and technical assistance are free for all. For our network hospitals that share their annual data with us to our aggregate, we also provide free customized report generation, continuing education, and training. This allows our network hospitals to have access to benchmarking data and current trends so they can work methodically to reduce injuries and exposures in their facilities. We stand true to giving hospitals the opportunity to take on something that is of no charge to them. We are always looking to expand our network of EPINet contributing healthcare facilities around the world. More data is more power to influence global policy and reduce occupational infections and illness. The Center’s CIO and VP, Ginger Parker tirelessly provides hospitals around the world, the support and expertise they need to keep EPINet going in their facilities.
HM: I think it is admirable that you are putting safety above the dollar, especially in this day and age when organizations are looking to make money from everything.
AM: That is exactly right, and it helps for us to have a free system which lends itself to educating legislators, policy makers, and administrators about an ongoing problem. If there were fees for service, it would limit the ability to bring on more and more facilities so they can compare their data to others and the US to other countries around the world. Don’t get me wrong, raising money is a constant challenge, but we are dedicated to the model.
HM: Are there any other tools that the International Safety Center is looking to offer healthcare organizations?
AM: EPINet is the only surveillance tool we have now, but it is used for endless outputs, including data analysis, customized reports, administrator presentations, continuing education, market research, policy analysis, and more. We help our facilities that are in the EPINet aggregate network compare specific endpoints to other hospitals. For example, in our EPINet system, we can compare injuries for professional groups (nurses, doctors, technologists, laboratorians, environmental service staff, etc.), location, procedure, device, safety implementation, personal protective equipment (PPE)use, and we can do all of this comparing potential changes over time. This gives healthcare facilities the evidence base they need to put an intervention into place or start an educational program, training program, or campaign. We are also looking to update and expand EPINet to match the expansion of patient care beyond hospitals and into clinics, doctors’ offices, outpatient surgery, pharmacies, and more.
HM: Does the data feed into one central bank where worldwide data can be collected, or is it data for individual organizations and they choose if they want to share?
AM: It’s a combination of both. We offer EPINet to any facility in the world for free, and it’s been distributed to about100 countries and translated in dozens of languages. Sometimes the countries will use EPINet within a certain number of hospital systems, and they will compare it on their own. Sometimes the hospital will just take it and use it to compare themselves to themselves over time, but one of our most powerful networks is the network we have in the United States. It has been ongoing for decades and shows an aggregate data set of injuries and exposures occurring in that network of hospitals that contribute their annual data to us. We collect and aggregate data (to maintain hospital confidentiality) and publish it on our internationalsafetycenter.org website. This summary data is available to the public. We are working toward building both types of networks all over the world so there are groups of hospitals that are contributing to a larger aggregate that we can then refine for that country, benchmark for that region, or identify changes related to policy over time.
HM: Are you able to connect with the ANCC (American Nurses Credentialing Center) in any way for benchmarks for bloodborne injuries or body fluid injuries?
AM: I would love to. As far as I know, they don’t utilize specific data on occupational injury or illness. It would be a wonderful group for collaboration, especially given their ability to influence creating the best working environments for nurses.
HM: Do you have any links with the American Nurses Association (ANA) and National Patient Safety Foundation?
AM: Yes, the ANA actually does have the Sharps Injury Prevention Stakeholder Group that I am member of. We also just finished publishing a series of three open access articles in ANA’s American Nurse Today. We do not currently have a link with the National Patient Safety Foundation, because our focus is worker safety and health. That being said, they would be a great new partner. With the movement toward culture or climate of safety, we are breaking down the walls between “what is healthcare worker safety and what is patient safety” and thinking about what is safety?
HM: I really like what you just said about breaking down the walls in patient and staff safety and just looking at “what is safety.” That is a core concept of building a safety culture.
AM: If I can make any change, it would be dissolving or breaking down the “us versus them” mentality (e.g., doctors vs. nurses, staff vs. patients, teaching vs. nonteaching hospitals). There is even this wall between infection prevention and occupational health professionals. It would be to move away from project- or issues-based healthcare to total health. I think this gets at that culture element which is a shift in value from the individual to the team.
One of my heroes is Paul O’Neill. He was the CEO of ALCOA, the largest aluminum company in the world for more than 100 years, based in Pittsburgh. He was the past Secretary of Treasury and has always rallied putting worker safety first. He has this concept built within a culture of safety that is called “discretionary energy”. People are willing to volunteer to gift you with their extremely valuable personal, discretionary energy only if they are treated with dignity and respect. If you run your organization with the collective understanding that if you work here, you will never get hurt here and we will treat you with dignity and respect - the pride in the organization swells, productivity increases and worker injuries decrease. I think by creating this value system built on teamwork, discipline, and humility, you have this focus on people wanting to give you their energy because you have built this place for them where they will not get hurt.
HM: Are there any areas of occupational safety you feel need to be regarded as high priority, either personally or for the International Safety Center in the future?
AM: I do. Regarding occupational safety and workplace exposure to blood and body fluids, globally emerging infections are a high priority. We learned with Ebola, and now Zika, that the globalization of travel is really blurring country and continent borders that used to geographically isolate infections and disease. There is now risk all around the world, even when your loved one travels and you stay put. We are also seeing reemerging diseases because of dips or declines in vaccination rates for diseases, such as measles. MRSA and other multi-drug-resistant colonization and infections are endemic. I think the expansion of policy initiatives and improving uptake of engineering controls (technology) to reduce illness and infections related to all kinds of infectious disease are really where we are focusing our movement now. Not just improving policy, but assessing the impact of current policy, improving technology and access to other engineering controls, and also improving the quality and impact and use of personal protective equipment.
HM: It has become a much cited example in nursing that despite all the education on phlebotomy, at the clinical level, some nurses still cut off the finger of the glove they use to palpate the patient’s vein prior to drawing the patients blood. Why do you think, when we know so much about the dangers of bloodborne pathogens and different illnesses people can get from bodily fluids, do nurses still deny the use of protective equipment for this task?
AM: They do, and I think it’s for a couple of different reasons. I think one reason is personal: old habits. When clinicians learn to palpate a vein without a glove, it just feels different when you have one on. For newer phlebotomists or newer med techs coming up in the field, they learn to palpate with the glove on, so the touch is different. The second reason is point of view: the viewpoint that the patient is first, and the patient is definitely first, but the patient can only be first when you are truly prepared to protect them from as much as possible. I think the conversation isn’t happening with the care provider and the patient. “I am wearing this to not only protect you from me but me from you. This is something that will help me do my job better and safer for both of our benefits.” Another reason is institutionalized: personal protective equipment - like gloves, gowns, or eye protection may not be immediately available in the right type and size, so compliance is difficult to achieve in these settings. There is a lot we have learned from Ebola that is important. The PPE you are choosing should have the right level of protection and need for whatever you are exposed to, whether that exposure is anticipated or not. I think medical device manufacturers have a lot of work to do to make PPE more comfortable, breathable, and effective; to ensure adherence to manufacturing and performance quality testing to prevent failures; and to help their customer facilities make it more easily accessible. When you incorporate all of these things, the care provider doesn’t have a choice but to wear something that is available to them, comfortable, works well, and does what it is expected to do. We are not there yet.
HM: How do you think we can change the culture of the nurses that have been taught to palpate the vein with their ungloved finger? How can we change their way of thinking so they realize it is not just the infection control staff saying you must do this for their benefit? It is a challenge in many different safety initiatives in healthcare.
AM: It really relates to what we were saying earlier—improving dignity and respect within the facility. If they take the finger off the glove to palpate a vein or tear off the safety feature of a syringe, and you want to change the behavior, you have to understand why the learned behavior is there. Again, the gloves may be the wrong size, they may be the wrong type, or they may not be within reach. Safety devices may not have been evaluated by a user, so they feel uncomfortable using it on their patient. Or workload may be too heavy and care providers are rushed to do more procedures than they should be doing and this is just an easier way. It is not all about getting workers to understand the risk, it’s about the institution understanding the circumstances their staff are placed in that is making them do something that isn’t safe. I don’t think it is at just the individual practitioner level, but from a broader team, system, institutional level. If, however, they are doing it because they have always done it and they don’t want to change their behavior to provide a safer environment for themselves and their patients, maybe they should be gearing toward a different job.
HM: I agree with you entirely. It’s not just about the individual; it’s about the whole organization. I guess it comes back to a systems approach to looking at things.
AM: It really comes back to that discipline piece, which is not just the discipline at the user or the clinical level; it’s the discipline in the organization. Going back to your example, I would bet if they are pulling the finger off the glove to palpate the vein, then they are doing other things wrong. The whole reason you are using a glove in the first place is to protect yourself from a patient, now your finger is on the person’s skin offering all kinds of opportunity for cross contamination, multi-drug-resistant organisms, and infection at the insertion site. What if they are using the same needle to inject multiple times? This is just the tip of the iceberg on a broader spectrum of why they are taking a shortcut.
HM: From your point of view what three factors are required to establish a culture of safety in a healthcare organization?
AM: I defer back to my hero, Mr. O’Neill - that focus on the discretionary energy that humans can give you or not give you. That energy is based on the general treatment of dignity and respect and encourages teamwork, humility, and discipline. The humility plays into the relationship of the hierarchy of healthcare workers between doctors and nurses, nurses and technicians, and administrators and staff. Everyone in the facility, no matter what their role, works with humility and shared responsibility. There is one more concept that describes something he calls habitual excellence and that involves asking every person three questions.
- Number one, can I say every day that I am treated with dignity and respect by everyone I encounter irrespective of pay rate or title?
- Number two, am I given the things that I need? Do I have the right education, right tools, the right PPE, and the right encouragement?
- Number three, am I recognized for what I do by someone I care about? When I am doing the right thing, are my supervisor, coworkers, or patients telling me that I am?
If the genuine answer to all three is yes, this is habitual excellence. Culture of safety in healthcare consists of these three concepts of respect, dignity (am I given the things that I need), and do the people I care about recognize me for doing the right thing. No need to come up with anything on my own, when someone like Mr. O’Neill lays the foundation graciously for all of us.
HM: Thank you, Dr. Mitchell. I think you have given our readers some very interesting points to consider.
About Amber Mitchell
Dr. Mitchell is the International Safety Center’s President and Executive Director. The Center distributes the Exposure Prevention Information Network (EPINet®) to hospitals to measure occupational sharps injuries and other blood and body fluid exposures. Dr. Mitchell’s career has been focused on public and occupational safety and health related to preventing infectious disease. She has worked in the uniformed services, public, private, and academic sectors. She holds committee positions within both APHA and SHEA.
Dr. Mitchell began her career as the first OSHA National Bloodborne Pathogens Coordinator and has received several Secretary of Labor Excellence Awards. She holds a Doctor of Public Health (DrPH) degree from the University of Texas School of Public Health and a Master’s in Public Health from The George Washington University. She is Certified in Public Health as a member of the very first CPH cohort offered by the National Board of Public Health Examiners.