Overcoming Limitations in a Low-Resource Facility: Spotlight on the Navajo Nation

Infection Control TodayInfection Control Today, May/June 2024 (Vol. 28 No.3)
Volume 28
Issue 3

Sage Memorial Hospital, Navajo Health Foundation in Arizona tackles health care and infection control challenges through innovative strategies and cultural sensitivity, serving the Navajo community with respect and resilience.

nterior of a somber hospital room.  (Adobe Stock 764272114 by gassh)

Interior of a somber hospital room.

(Adobe Stock 764272114 by gassh)

As health care disparities continue to exist in many areas globally, particularly in health care deserts, Sage Memorial Hospital, Navajo Health Foundation, serves as a positive example by providing health care to the Native American community in Ganado, Arizona, and beyond.1 Like many health care facilities in the US and the world, Sage Memorial Hospital faces limited resources, services, and infrastructure. Despite these limitations, the Sage Memorial Hospital remains committed to providing accessible, quality health care to its diverse patient population.

Infection Control Today (ICT) spoke with Sage Memorial Hospital leader­ship again to learn more1 about the hospital and its community’s unique challenges and innovative strategies, which sheds light on its journey toward excellence in health care delivery and serves as an example of how these types of challenges can be overcome. ICT spoke with Christian Bigwater, BSBA, director of public relations and marketing, and Tiyarra Wauneka, environmental services supervisor.

ICT: Please provide an overview of your hospital and its specific challenges in providing health care services to the Native American community.

CHRISTIAN BIGWATER, BSBA: Sage Memorial Hospital1 is a 25-bed** facility in Ganado, Arizona, in the Navajo Nation. It serves as the primary health care provider for over 20,000 members of the Navajo community and surrounding areas. Our main challenge is ensuring access to quality health care services for all community members. The remote location of many Navajo communities makes it difficult for patients to travel to our hospital for care, and there are also limited resources, services, and infrastructure in the area to support health care needs. We work hard to address these challenges and provide the best possible care for our community. The completion of our new hospital will help address some of these challenges.

**This is a correction. The print version said 45 beds. Although the new hospital will have the shell space for it, there is no plan yet for that many.

ICT: How does the hospital address language barriers when serving a diverse Native American population with various tribal languages and dialects?

CB: Our facility has collaborated with Diné College Navajo language instructors to provide Navajo language medical terminology training for interested staff.2,3 The course is over several days and certifies health care workers to be Navajo-English translators. This helps ensure that our patients can communicate effectively with diverse staff. It is also part of our culture here at Sage Memorial Hospital to teach our staff of other nationalities simple and basic Navajo words used in everyday life. This could include words such as “hello,” “thank you,” “yes,” or “no,” “grandma,” “grandpa,” or “Where does it hurt?” Our leadership team highly encourages respect, beauty, and sacredness among all who enter the facility through K’é [kinship].1,2 This practice brings the unity of all diverse cultures into one, and we practice that each day.

ICT: Native American hospitals are often located in remote or rural areas. What logistical challenges does this location pose for infection control and the delivery of health care services?

CB: Sage Memorial Hospital serves several rural communities; we call them chapters. Most patients we serve live miles off the main US highways on dirt roads. Our biggest challenge is ensuring that our patients can be transported to the hospital for service, and our facility is making efforts to do home visits as needed. Although we have advanced in infection control practices, our patients still face the challenges of having no running water, no electricity, and sometimes poor living conditions. Our hospital, quality department, and behavioral health [services] have significantly addressed these issues. Because of these challenges, we have implemented innovative practices such as UV robot technology3-5 to enhance disinfection protocols and reduce the risk of hospital-acquired infections.

ICT: How do cultural practices and traditions influence infection control measures and health care delivery in your hospital?

CB: Our hospital is guided by our mission, vision, and values. Our core values include respect, sacredness, beauty, kinship, and unity. These values are rooted in our Navajo culture and guide all our decisions and practices. This extends to health care delivery and infection control measures as well. For example, the notion of “K’é [kinship] and Hózhó [beauty/balance]” is a reflection of what we want our patients to see in us once they leave the hospital. We strive to create a clean, safe, and comfortable environment for our patients.

ICT: Can you share any innovative strategies or programs your hospital has implemented to overcome the unique challenges related to infection control in a Native American health care setting?

Sage Memorial Hospital's Environmental Service Department in front of the new facility.   (Photo credit: Christian Bigwater)

Sage Memorial Hospital's Environmental Service Department in front of the new facility.

(Photo credit: Christian Bigwater)

TIYARRA WAUNEKA: Our hospital will be implementing a new software called SmartFacility. This advanced software is designed to optimize the team’s efficiency by helping to determine the adequate number of environmental services [EVS] staff per square foot to meet our facility’s demands. It will also provide real-time requests for areas of concern for infection control. The software has a built-in step-by-step process for EVS to follow to reduce the amount of human error. Our facility has considered electronic hand hygiene dispensers that will track staffing efforts and the importance of hand hygiene before and after service is given to our patients. It will help infection control to target clinical areas of high traffic. These innovative solutions will further enhance our infection control practices and streamline our processes, ultimately improving the quality of care we provide to our community.

ICT: Native American hospitals may encounter financial constraints. How do these limitations impact the ability to invest in infection control resources and initiatives?

TW: Financial limitations will always be a part of any health care facility and impact our hospital’s operations. As Native Americans, it is in our nature to persevere, adapt, and improvise. For infection control specifically, we have worked very closely with our grant writer to research and secure funding for infection control remediation. I have also built well-rounded, professional relationships with the vendors I work with to establish ways of securing new equipment and tools to aid in infection control most cost-effectively. We are committed to trying new equipment and sharing our experience with vendors as part of the promotion of products.

ICT: Have there been any partnerships or collaborations with tribal organizations, government agencies, or other health care providers that have helped address the challenges related to infection control and health care delivery?

TW: The EVS team recently had the chance to build relationships with the Association for the Health Care Environment through training in best practices for the EVS staff. This helps standardize all processes to limit human error and ensure that infection control processes are efficient. We have already trained using the CHEST [American College of Chest Physicians]6 training, which focuses on cleaning procedures in inpatient rooms. We have also trained in CNACC [Certificate in Non-Acute Care Cleaning Program], focusing on high-risk areas such as behavioral health, offices, and mobile health clinics.7 Our facility will soon include the Association for the Health Care Environment Certified Surgical Cleaning Technician8 training focusing on surgical suite cleaning. I have also contacted surrounding facilities and shared experiences and best practices on infection control. San Carlos Apache Healthcare in Graham County, Arizona, and Chinle Comprehensive Health Care Facility, part of the Indian Health Service program in Chinle, Arizona, have been great partners to work with to progress with infection control remediation.

ICT: How has the COVID-19 pandemic affected infection control practices and resources in your hospital, and what lessons have been learned from managing infectious diseases during this time?

TW: The COVID-19 pandemic has significantly impacted infection control practices in our hospital. It has helped us realize how quickly infection can spread and the importance of understanding how pathogens are transmitted. The EVS team has now taken more time to understand how common pathogens impact health, and we are more aware of emerging pathogens. We have become more prepared by having a plan of action, understanding the disinfecting solutions we use, and utilizing best practices that The Joint Commission, the American Hospital Association, and the Association for the Health Care Environment recommend. It is about creating a network with other EVS professionals and collaborating on what works best through experience. Overall, this pandemic has reinforced the importance of infection control measures in protecting the health and well-being of our patients and staff.

ICT: Looking ahead, what are your hospital’s priorities and strategies for improving infection control while continuing to address the unique needs of the Native American population it serves?

TW: Our new facility will heavily work off technology. Infection control effort demands a lot of manual work; however, with new technology, such as electronic floor scrubbers, robotic floor sweepers, UV robots,5 and consistent training, our facility can accomplish the highest level of care. The EVS team’s goal is to become proficient in knowing the correct tools, disinfecting chemicals, and having the knowledge of pathogens to accomplish our goals for infection control. It is amazing to see our hospital go from limited technical operation to full operation on technical systems. This, for us, is a win in innovative strategies.


  1. Navajo Health Foundation - Sage Memorial Hospital. Accessed April 25, 2024. https://sagememorial.com/
  2. Navajo medical terminology & interpreter course. Navajo Health Foundation - Sage Memorial Hospital. Accessed April 25, 2024. https://sagememorial.com/2023/05/15/navajo-medical-terminology-interpreter-course-june-7-9-800-a-m-500-p-m/
  3. Whitacre Martonicz T. Infection prevention department displays Navajo traditions. Infection Control Today. June 22, 2023. Accessed April 25, 2024. https://www.infectioncontroltoday.com/view/infection-prevention-department-displays-navajo-traditions
  4. Whitacre Martonicz T. Providing infection prevention on the Navajo Nation. Infection Control Today. June 2, 2023. Accessed April 25, 2024. https://www.infectioncontroltoday.com/view/providing-infection-prevention-navajo-nation
  5. Whitacre Martonicz T. Increasing infection prevention in the Navajo Nation with UV-C robots. Infection Control Today. June 15, 2023. Accessed April 25, 2024 https://www.infectioncontroltoday.com/view/increasing-infection-prevention-navajo-nation-uvc-c-robots
  6. CHEST - American College of Chest Physicians. Accessed April 25, 2024. https://www.chestnet.org/
  7. Certificate in Non-Acute Care Cleaning Program (CNACC). Association for the Health Care Environment. Accessed April 25, 2024. https://www.ahe.org/cnacc
  8. Certified surgical cleaning technician (CSCT) training model & resources. Association for the Health Care Environment. Accessed April 25, 2024. https://www.ahe.org/csct-training-model-and-resources
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