Stopping the Line: A Tale of 2 Hospitals

Infection preventionists (IPs), you are on the front lines, fighting an unseen enemy every day. It's a battle that demands constant vigilance, but what happens when you spot a critical flaw in the defenses? Do you feel empowered to act, or are you held back by the fear of disrupting essential workflows or creating friction with colleagues and leaders?

For too many, the answer is the latter. Yet, there is a powerful principle that can change that dynamic. It's a concept born from the assembly lines of Toyota and refined for health care environments in the 1990s: the "Stop the Line" principle.

What It Means to "Stop the Line"

Simply put, "Stop the Line" is a commitment to a culture of high reliability. It’s a proactive step that allows anyone, regardless of their position or experience, to pause a process to ensure safety and prevent a potential disaster. In health care, this means stopping to correct a process gap immediately to prevent harm to employees or patients.

This isn’t about blaming individuals. It's about empowering everyone to be a safety advocate. By putting a temporary halt on a procedure, you create a space to evaluate what's happening and make the necessary corrections on the spot. This is followed by a formal documentation of the incident, ensuring it's not a one-and-done fix, but a catalyst for systemic change.

The Barriers to Action

While the concept is simple, implementing it is anything but. Several cultural and logistical barriers can prevent an IP from feeling empowered to act.

• Hierarchical Cultures: In some organizations, a rigid hierarchy makes it feel like "stopping the line" is a challenge to authority. This can be especially true in cultures that are conflict-avoidant.
• Blame Culture: If a team's performance is focused on individual metrics rather than a collective effort, an IP might fear being blamed for disrupting workflow or causing delays. This can lead to a culture where people hesitate to speak up, fearing they'll be seen as “killing the messenger,” and this fear directly contributes to IP burnout, leaving critical patient safety gaps unaddressed.
• Lack of Resources: Understaffing, insufficient equipment, and pressure to keep things moving can all contribute to the feeling that stopping the line is a luxury a department can't afford. This puts immense pressure on IPs, forcing them to compromise safety or shoulder an impossible burden alone.
• Poor Communication: Without a clear, documented path for escalating safety concerns and leaders who actively reinforce these escalations, IPs can feel their efforts will be dismissed or, worse, result in professional repercussions.

An incomplete or unaddressed 'stop the line' is as bad as not acting at all; it can lead to a demoralized staff and a perception that reporting issues is futile, contributing to burnout and compromised patient safety.

A Tale of 2 Systems

To truly understand the power of "Stop the Line," let’s look at 2 scenarios, one in a less reliable organization and one in a “Highly Reliable Organization” (HRO). An HRO in a hospital is one that consistently delivers safe, high-quality patient care and operates without serious errors, even in the face of immense complexity and high-stress situations. These organizations have a culture that is obsessed with anticipating and preventing failure, not just reacting to it. They achieve this by fostering a deep sense of psychological safety, where staff feel empowered to speak up about potential problems without fear of retribution, and by continuously learning from both near-misses and mistakes.

Scenario 1: The Non-HRO Hospital System

As an IP, you're auditing high-level disinfection (HLD) and discover multiple breaches: scopes aren't pretreated at the bedside, transport containers are unapproved, and cleaning logs are missing. You recognize the need to "stop the line," but when you raise the issue, you find little support. The department leader doesn't see it as their accountability. They tell you to just deal with it.

You and the staff educator are left alone to fix the problem, without the resources to order proper supplies or the authority to mandate immediate training. Despite the obvious risks, the department continues to operate, providing substandard care. The lack of leadership engagement and accountability effectively neuters your efforts, reinforcing the idea that your role is to identify problems, but not to fix them.

Scenario 2: The HRO Hospital System

You’re auditing HLD and find similar significant breaches. Immediately, you "stop the line," and the process for reprocessing scopes ceases. You bring in trained employees from another department to handle the backlog while you, the team, and leaders meet to debrief. You lay out your findings, discuss the key risks, and engage the leaders to create a clear action plan.

The leaders don’t just agree, they show up. They ensure staff are immediately trained, that the correct supplies are on hand, and that the new, safer procedure is followed. They hold themselves accountable, with regular reports on the progress of the action plan. You document the findings in the incident reporting system, and the entire organization works together to ensure this never happens again.

This is the key difference: In the HRO, stopping the line is not a burden; it’s a shared responsibility that saves lives.

Empowering the Future of Infection Prevention

How do you, as an IP or a department leader, build a culture that supports this critical principle?

For department leaders, it starts with strengthening your program. The APIC Competency Model provides an excellent roadmap for this, focusing on staffing, training, and standardized protocols.^1,2 Leverage technology and data to identify risks and track progress. Most importantly, empower your IPs to speak up. Support them and back their decisions, reinforcing that "Stop the Line" is a collective good, not an individual act.

For the IP, your greatest tool is the audit. By proactively auditing high-risk processes, you can identify safety non-compliance before it becomes a catastrophe. Auditing with leaders is crucial; it turns a solo effort into a shared accountability, creating buy-in and a direct line to those who can enact systemic change.

As an IP, you can begin by taking these three actions:

• Conduct a focused risk assessment. Identify one high-risk process in your department, such as high-level disinfection or central line care. Use a standardized audit tool to assess compliance.
• Schedule a "safety walk" with your leader. Frame it not as an inspection, but as a collaborative effort to proactively identify process gaps and shared accountability for patient safety.
• Suggest a simple escalation pathway. Propose a clear, two-step process for stopping the line: (1) an immediate pause to address the breach, and (2) a scheduled debrief with leaders to document and create a long-term fix.

The 'Stop the Line' principle isn't just a process; it's a culture of unwavering commitment to safety that transforms individual vigilance into collective protection.

As an IP, you hold a vital key to this culture shift. What bold step will you take this week to audit a high-risk process and spark a life-saving conversation with your leaders about safety?

References:

1. Garcia R, Barnes S, Boukidjian R, et al. Recommendations for change in infection prevention programs and practice. Am J Infect Control. 2022;50(12):1281-1295. doi:10.1016/j.ajic.2022.04.007.
2. Billings C, Bernard H, Caffery L, Dolan SA, Donaldson J, Kalp E, Mueller A. Advancing the profession: an updated future-oriented competency model for professional development in infection prevention and control. Am J Infect Control. 2019;47(6):602-614.