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Letter to the Editor
Successful model of shared medical directorship in Hospital
Epidemiology
Christina Liscynesky MD , Shandra R. Day MD , Nora E. Colburn MD, MPH and Susan L. Koletar MD
Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, Ohio
To the Editor—Healthcare Epidemiology programs are a require-
ment of the Joint Commission and the Centers for Medicare &
Medicaid Services.1,2The nationally recommended ratio for
infection preventionists (IPs) is 1 IP per 69 inpatient beds.3The
amount of necessary physician support is less clear. Should it be
delineated based on inpatient bed number, ambulatory clinic
numbers, or geographic area?
Traditionally, a single medical director oversees the department
of Hospital epidemiology, and depending on the size and needs of
the institution, associate medical directors (AMDs) may be needed
as well. We report our successes in challenging that classic
framework with a co–medical-director model.
Background
The Ohio State University Wexner Medical Center is an academic,
quaternary health system with ∼1,600 beds, comprising University
Hospital (Level 1 trauma/burn center/liver & kidney transplant),
the James Cancer Hospital (bone marrow transplant unit), Ross
Heart Hospital (heart and lung transplant), East Hospital
(orthopedic surgery) as well as ∼200 clinics including 4 ambulatory
surgery centers.
Creation of co–medical-director model
The hospital epidemiology department historically had 1 medical
director until 2012, when an AMD was added to provide oversight
to the James Cancer Hospital. In 2014, another AMD was recruited
with oversight at East Hospital. The medical director fielded
emergency calls from IPs and leadership 24/7, presented at
leadership forums, and approved all decisions. The enormous job
scope left minimal opportunity for preparedness or clinical work.
In January 2018, the longtime medical director retired,
providing the opportunity to reassess the traditional top–down
leadership model. The AMDs worked as a team to identify
operational needs, for example, starting the Influenza Workgroup.
For the next 18 months, we continued with our primary
epidemiology responsibilities and split the remaining responsibil-
ities based on clinical obligations; the hospital leadership
responded with supplemental pay. An added benefit was seamless
coverage for each other while on leave (vacation or medical).
Efficiency improved because approval and guidance was only
needed from 1 physician, which allowed real-time decision
making. The dyad leadership success built upon interpersonal
trust, constant communication, meticulous organizational skills,
and task delegation to the IPs. Our IPs grew in their roles as experts
as we empowered them to make decisions. We created protocols
for common exposures such as Norwegian scabies, led outbreak
investigations for pathogens including group A Streptococcus, and
created institutional guidance for emerging pathogens such as
Ebola. The benefits of excellent team communication, increased
availability for collaboration, and preplanning were quickly
realized and acknowledged with increased institutional support.
In August 2019, the Ross Heart Hospital funded a third AMD.
Experience during the COVID-19 pandemic
As hospital epidemiologists, we were at the center of the medical
center’s response to the global crisis. We collectively led the
COVID-19 Clinical Care Workgroup (CCWG), a multidiscipli-
nary team responsible for protocol and guideline creation. In the
setting of a new virus, compounded by panic from the press, family
and coworkers, this amount of work was clearly untenable for 1
person. Our prior transition to a shared leadership model
facilitated quick group decision making. Individual strengths
and differences (ie, personalities, experiences, and risk tolerances)
allowed us to challenge each other on policies prior to roll out. This
model allowed us to remain active on the infectious diseases (ID)
consultation services, providing us frontline experience to ensure
practical polices as we literally went from the bedside to the
boardroom for daily meetings with leadership. Importantly, we
took scheduled breaks, including vacations and medical and
maternity leave to avoid burnout. Our team has come out of the
pandemic stronger, more cohesive, and with the respect of hospital
leadership. The 3 AMD titles have been transitioned to medical
director titles, underscoring the triumvirate leadership mode.
Current organization
The current department is composed of 3 medical directors; 1
associate medical director; 1 administrative director; and 20 IPs
with diverse subject-matter expertise, including 5.5 IPs dedicated
to ambulatory, 1 data manager, 1 planning analyst, and 5 high-level
disinfection analysts (Fig. 1). We built a collaborative, dynamic
department that functions at its peak performance regardless of
which medical director is available. The medical directors each
Author for correspondence: Christina Liscynesky, MD, Division of Infectious
Diseases, Wexner Medical Center, N1147 Doan Hall, 410 West 10th Avenue, Columbus
OH 43201. E-mail: Christina.Liscynesky@osumc.edu
Cite this article: Liscynesky C, Day SR, Colburn NE, Koletar SL. Successful model of
shared medical directorship in Hospital Epidemiology. Infect Control Hosp Epidemiol
2023. doi: 10.1017/ice.2023.228
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under the
terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original
article is properly cited.
Infection Control & Hospital Epidemiology (2023), 1–2
doi:10.1017/ice.2023.228
https://doi.org/10.1017/ice.2023.228 Published online by Cambridge University Press
have salary support of ∼0.5 full-time equivalent (FTE), with the
associate medical director at 0.35 FTE.
Discussion
A key component to our success is that it allows for continued
patient care, providing balance, clarity, and the privilege of
managing interesting ID cases. The consultation service allows us
to experience the environment we are safeguarding, to interact
with the frontline staff, and to teach our trainees at the bedside and
as rising healthcare leaders.4
Patient care is not interrupted with administrative questions
because an off-service medical director is available. This flexibility
advances infection control initiatives by not delaying meetings—for
example, rapid institutional rollout of new Clostridiodes difficile
testing and permanent presence on device-related infection rounds.
The biggest challenge to this model is minimizing work duplication
and ensuring efficient use of everyone’s time. Efficiency requires
constant communication to ensure that we are abreast of current
issues and that we prioritize the determination of who is leading an
initiative. Having a systemwide administrative director is key to
maintaining this balance and providing consistent communication
across the health system. We are also very conscientious about the
challenge of providing conflicting guidance, and we work closely to
provide a clear and unified message.
In conclusion, the creation of a hospital epidemiology
co–medical-director model has allowed for a sustainable program
able to withstand the challenges of the pandemic while allowing
time to balance personal and professional goals. The key to the
success of our model is continued communication and staunch
institutional support.
Acknowledgments.
Financial support. No financial support was provided relevant to this article.
Competing interests. All authors report no conflicts of interest relevant to this
article.
References
1. The Joint Commission. Infection prevention and control (IC.01.01.01: the
hospital identifies the individual(s) responsible for the infection prevention
and control program). The Joint Commission Resources website. https://
www.jointcommission.org. Accessed October 9, 2023.
2. Infection prevention and control and antibiotic stewardship programs
(§482.42 conditions of participation). Centers for Medicare & Medicaid
Services website https://www.cms.gov/regulations-and-guidance/guidance/
manuals/downloads/som107ap_a_hospitals.pdf. Published 2020. Accessed
October 9, 2023.
3. Bartles R, Dickson A, Babade O. A systematic approach to quantifying
infection prevention staffing and coverage needs. Am J Infect Control 2018;
46:487–491.
4. Day SR, Sobhanie MM, Colburn NE, Liscynesky C. Experiential learning and
mentorship as the foundation of clinical epidemiology training during
infectious diseases fellowship: Response to “Training infectious diseases
fellows for a new era of hospital epidemiology.”Antimicrob Steward Healthc
Epidemiol 2022;2:e59.
Figure 1. Epidemiology department.
2 Christina Liscynesky et al
https://doi.org/10.1017/ice.2023.228 Published online by Cambridge University Press