September 2021

Target zero harm with a 3-zone prevention strategy

How best practices, collaboration and culture can make it happen.

Infection Prevention 3 zone infographic

What does it take for pathogens to quickly spread and eventually cause a healthcare-associated infection (HAI)? Germs or pathogens need a place to live, a susceptible person and a way to be transmitted.

Transmission is rarely a dramatic event. A missed hand hygiene moment before changing a dressing. A room cleaned fast but not sanitized. An unmasked cough. A catheter that stays in too long.

In a typical hospital environment, 1 in 25 patients have an HAI. The Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) call these infections “never events,” meaning that the practice of evidence-based care should prevent them. But the reality is challenging and complex.

1 in 25

patients in US hospitals have at least one HAI1

With so many ill and compromised people in healthcare settings—both post acute and acute care—preventing infection can seem an overwhelming if not impossible task. But everyday routines and practices determine whether pathogens are spread or stopped—and everyone plays a role. That’s the challenge.

Targeting zero, lessons from COVID

In the past year, healthcare workers battled the worst infection daily—COVID-19. Overnight, infection preventionists became go-to experts on PPE, hand hygiene and all things infection-related.

As providing lifesaving care for COVID became the focus, the CDC suspended reporting of HAIs like CAUTIs and CLABSIs. But now there’s a back-to-basics movement to prevent infection—and COVID created a better understanding of the stakes.

Angela Zuick, Medline Director of Clinical Services

“There’s a belief that infection is, in some cases, inevitable. But now there’s evidence and literature that says no, we can do better.”

Angela Zuick, Medline Director of Clinical Services

Angela Zuick, Medline Director of Clinical Services, says, “It was hard for people to understand COVID because they couldn’t see it. And that’s the problem with pathogens and infection. You can’t see them.”

Zuick notes that even though awareness of infection prevention is higher today and that COVID helped people understand precautions like using PPE and hand hygiene, “There’s still a belief among some clinicians that infection is in some cases inevitable. But now there’s evidence and literature that says no, we can do better.”

A 3-zone strategy and targeting zero harm

For healthcare facilities, doing better means finding ways to get closer to achieving “zero harm,” a term that refers to the concept that no patients will be harmed by their interactions with a healthcare system. The Joint Commission, which is taking a strong stand in support of the journey to zero harm, says, “Zero harm doesn’t mean zero mistakes.” It does mean:

  • Developing systems and processes that reduce the likelihood of mistake
  • Creating a safety culture from leaders to frontline workers
  • Championing procedures that catch errors or unsafe conditions before they cause harm

One approach to targeting zero harm is to focus on three key zones or places where infection is transmitted:

  1. Environment of care
  2. Human-to-human contact
  3. Clinical practice

This 3-zone strategy covers the entire perimeter of risk and breaks down the overwhelming task of infection prevention into smaller, more manageable parts. The key to success? Making sure everyone at every level is involved, understands the 3-zone strategy and practices infection prevention, consistently.

Three zones of risk

“The zones are really a breakthrough,” says Zuick. “They help organizations look at every aspect of infection and get past the overwhelm so they can ask, ‘How can we improve best practices? What training and education do we need to close gaps? Which products will best support our people and keep everyone safe? How do all of these things come together to help us get closer to zero harm?’”

Angela Zuick, Medline Director of Clinical Services

“The 3-zone strategy covers the entire perimeter of risk and breaks down the overwhelming task of infection prevention into smaller, more manageable parts.”

Angela Zuick, Medline Director of Clinical Services

Christine Ninchich, Medline Clinical Resource Manager, was a risk and safety leader at a major hospital and helped develop the 3-zone strategy. She says, “So often infection prevention is thought of in silos: environmental services (EVS) here, clinicians there, and materials management elsewhere. But the three zones interconnect and cross over all the time.”

Christine Ninchich, Medline Clinical Resource Manager

“Because transmission happens in all three zones, to really impact infection prevention metrics, you have to empower and engage everyone. Shared accountability is key.”

Christine Ninchich, Medline Clinical Resource Manager

“In one interaction with a patient, you’re very likely to touch all three zones,” says Donna Matocha, Medline Clinical Resource Manager. “Let’s say, I’m a clinician putting in a central line at the bedside. If the EVS worker didn’t wipe down the bedrail and I put my gloved hand on it then touch the patient, all three zones had a failure there. The zones are always impacting each other.”

Ninchich notes, “Because transmission happens in all three zones, to really impact infection prevention metrics, you have to empower and engage everyone.” To do this, she says teams need to work together to create a culture of shared accountability. “The key is to inspire everyone to take ownership and help them understand the vital role they play in preventing HAIs across the organization. Shared accountability is key.”

The 3 zones of infection prevention, impacting acute and non-acute facilities

Zone 1 icon

Zone 1: Environment of care—keep it clean


of hospital floor sites tested positive for C. difficile 6

A patient or resident room and bathroom—or anywhere in the environmental zone—provides many places for germs to live happily on surfaces and in the air and water. From faucets to floors, bed linens to bed rails, and monitors to medical devices, proper cleaning and disinfection are critical to keeping everyone safe from infection.

EVS teams play a critical role in cleaning and disinfecting surfaces. Yet, EVS managers and staff face problems that can challenge their efficacy. One example is a lack of clear-cut guidelines on how to solve surface contamination. A way of solving this challenge is through an evidence-based cleaning and disinfecting program. These programs, Zuick says, can provide EVS workers training and education on evidence-based products that can help prevent the spread of germs.

EVS person cleaning patient room
Clean by Sequence Microfiber Cloths

Minimize cross-contamination

Clean by Sequence™ Microfiber Booklets ensure a separate cloth is used for each surface, so no surface is missed.

Improve compliance
Zone 2: Human to Human Transmission

Zone 2: Human-to-human transmission—pairing hand hygiene and PPE

Coughs, sneezes, touch. In the human-to-human zone of a healthcare setting, unchecked pathogens can easily cause infection through hand, face and bodily contact. Masks, gowns, gloves and hand hygiene products and practices protect patients, family, caregivers and staff against germs.

Only 40%

of healthcare workers adequately comply with hand hygiene practices5

“The number one way to help fight infection is simple: wash your hands,” says Zuick. “In fact, hand hygiene is fundamental to all zones. Everyone coming into the hospital—family members, delivery people and staff—has to practice proper hand hygiene in order to prevent transmission.”

Many device-related infections happen because people don’t practice hand hygiene or use PPE properly. And visitors and family often don’t realize their hands could contaminate their loved ones’ devices. But remaining vigilant about hand hygiene and the use of PPE can help minimize transmission within this zone.

Washing hands
IO Hand Hygiene electronic monitoring

Make it easier to track compliance and reduce HAIs

IntelObserve™ electronic hand hygiene monitoring is the answer.

Request a demo
Zone 3: Clinical practice

Zone 3: Clinical practice—eliminating CABSI, CLABSI and CAUTI


CLABSIs occur annually in hospitals and nursing homes2 with a patient mortality rate of 12-25%3


of all healthcare-associated UTIs are caused by an indwelling urinary catheter (IUC)4

In the clinical zone, catheters cause some of the most common HAIs. Central venous catheters (CVCs), peripherals (PIVs) and indwelling urinary catheters (IUCs) are access points and breeding grounds for germs that can lead to catheter and central line-associated blood stream infections (CABSIs and CLABSIs) and catheter-associated urinary tract infections (CAUTIs).

“When team members are stressed, distracted, rushed or tired inside the clinical zone, a simple oversight on a busy day can have serious infection consequences,” says Matocha.

Having a system of products, such as clinical kits for inserting catheters, can help nurses minimize risk of infection and error. Ninchich, previously a pediatric ICU nurse, says that clinical kits in particular can help nurses even when they’re busy. “With a kit that bundles everything a nurse would need in the right sequence, it makes it easier for them to do the right thing no matter how crazy their floor might be,” she says.

Insertion Bundle
VAM Dressing Change Bundle
IP VAM one layer tray

Matocha says bundles should be well-engineered from a human factor standpoint. “If you use the components in sequence you should be able to do the procedure correctly whether you’re a resident or experienced nurse. That’s a major step toward zero harm,” she said.

Men's Liberty Acute

45 seconds to freedom

Discover Men’s Liberty Acute External Catheter, designed to help prevent CAUTI.

Learn more

Build a culture of shared accountability

Infection prevention should ultimately belong to everyone in an organization. But how can you help people see their role in reducing HAIs? And how can you create a sense of shared accountability? It takes a culture shift.

Shifting the culture of an organization to promote greater accountability can help them be more effective at targeting zero harm, Ninchich says. To help people feel more empowered and become more engaged in shifting culture, she recommends organizations do the following:

  • Identify a champion in each unit, including in EVS, the lab, ancillary units and others across the continuum
  • Include the EVS director in cross-functional weekly rounds and monthly meetings, and do whatever it takes to build a collaborative relationship with them
  • Celebrate small successes together, such as a month of lowered infection rates, to build pride, ownership and accountability

“At the end of the day, everyone wants that magic zero number,” Zuick concludes. “It’s still a long journey to get there, but the good news is today there are more resources and evidence-based solutions to help you and your organization along the way.”

Want to learn more about infection prevention for your facility?

Contact a Medline Infection Prevention expert to see how a 3-zone strategy can help you drive consistent practice and prevent infection.

More strategies and insights to explore:

Discover a comprehensive approach to reducing CAUTIs and CLABSIs.

Explore best practices, training and products that help lower CAUTI rates.

Check out how an EVS program focused on infection prevention can impact HAIs at your organization.


  1. Magill, S.S., et al. Multistate Point-Prevalence Survey of Health Care-Associated Infections. The New England Journal of Medicine:
  2. National Healthcare Safety Network. Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection). Available at: Accessed January 17, 2021.
  3. Health Research & Educational Trust. Preventing Harm from CLABSI. Available at: Accessed January 17, 2021.
  4. Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP) Page last reviewed: October 16, 2015. Available at:
  5. Hand hygiene in healthcare settings – core slides. Centers for Disease Control and Prevention website. Available at: Accessed January 19, 2021.
  6. Desphande, A. et al. Are Hospital Floors an Underappreciated Reservoir for Transmission of Clostridium Difficile and Methicillin-Resistant Staphylococcus Aureus? Available at: