Lessons from the Field

1. Lessons from the Field How to successfully coach a Positive Deviance Initiative ODN Conference Tuesday, 10/21/08 Session T18 3:00PM – 4:15PM Cathi Balboa Carlos Arce Sharon Benjamin

2. POSITIVE DEVIANCE: Different Process = Better Results We care about what works: we’re grounded in theory but responsible for SUCCESS Solutions to wicked problems CAN be found and success sustained Positive Deviance provides an important and different means of facilitating change Using Positive Deviance the emphasis shifts from finding the right answers to asking better questions People can change and success should be shared!

3. Positive Deviance helps us see solutions before our very eyes In every community or organization there are certain individuals or groups whose uncommon practices/behaviors enable them to find better solutions to intractable problems than their neighbors or colleagues who have access to the same resources

4. Positive Deviance (PD) Approach Engages the very people “whose behavior needs to change to solve the problem” to identify existing solutions from within Staff move from “Yeah, but….” to….. “I make the difference”

5. If we start by looking for existing solutions – and include everyone – especially unusual suspects – the solutions we discover vastly exceed our wildest notions in their elegance, simplicity, scope and speed of implementation. “NOTHING ABOUT ME WITHOUT ME”

6. PD Enables us to Act TODAY The presence of Positive Deviants demonstrates that it is possible to find successful solutions TODAY before all the underlying causes are addressed

7. Successful Applications of PD in All Walks of Life

8. When to use Positive Deviance Wicked, Important Problem Behavior needs to change NOT knowledge SOLUTIONS EXIST Progress is measurable Skilled facilitation is available

9. Focus onPracticeRather than Knowledge It’s easier to ACT your way into a new way of THINKING, than to THINK your way into a new way of ACTING

10. Discovery & Action PD findings are passed through a lens of “accessibility” Can everyone potentially adopt a behavior? Only behaviors/strategies accessible to all within a cohort or location are kept The rest are TBU….. ……True but Useless!!!

11. PD Exercise - Scenario You are a group of internal and external OD Consultants that work with an organization where the culture is known for its rampant “scope creep”. The facts that you know are: • 70%+ of their projects are labeled “Failures” • 80%+ are over budget and late • 50%+ are abandoned because resources are pulled. In small groups, designate a facilitator, scribe & participants Use the 6 PD questions to “discover” some solutions

12. PD’s Six Key Questions What would you like to know about this problem? What do youdo about it? What are the barriers that prevent you from doing the right thing 100% of the time? Who do you know who is doing the right thing or who has overcome these barriers? (the positive deviants) Who else needs to be in this conversation that isn’t here? (i.e. “Don’t decide about me without me”) How do we invite those people to be part of the action? What other ideas do you have?

13. CASE STUDY: WHY MRSA? • MRSA (Methicillin Resistant staphylococcus aureus) is a common bacterium that has quickly adapted to resist nearly all antibiotics. MRSA is a growing global crisis that causes unnecessary suffering, death and staggering expense. You are more likely to die from MRSA than AIDS. • It has spread across many barriers in part because of the iceberg effect – millions of people are colonized with only a small fraction showing visible symptoms. • There is evidence which suggests that when everyone gets involved the spread of MRSA can be stopped. Precautions are relatively simple but involve nearly everyone changing “autopilot” behaviors. • A fitting, creative challenge for complexity-inspired approaches, Plexus, and Positive Deviance.

14. Big questions facing hospitals • Is PD going to work for us? • How can we responsibly let go of control? • Is it safe to unleash wildly productive self-discovery? • Will it be effective to encourage local discovery & action? • Isn’t it our job to have the answers?

15. Big Results Clinical results: 35% average drop in MRSA infection rates (preliminary CDC results) The Billings Clinic incidence rate declined by 88% Albert Einstein Medical Center infections dropped 35% so, 57 people went back to their families, homes and lives. Expected organizational results Hand hygiene and gowns & gloves use improved at all sites Self-report data on performance & employee satisfaction improved Unexpected benefits • Improved nursing recruitment into tough units • Improved process for on-call scheduling

16. Coaching a PD initiative Carlos was on the inside and learned how an internal OD person can leverage PD Sharon was on the outside and learned how PD makes a big difference and leveraged existing OD initiatives Cathi mapped differences between PD and traditional change approaches We ALL saw it working!

17. What you might have heard... • Nothing will make a difference! • We’re doing everything we can do! • You’ll never get them to change! • Just tell us what to do! • Don’t tell me what to do! • We’ll always have transmissions!

18. Healthcare-associated MRSA Infections Housewide Incidence Rates January 1999 – June 2008 Incidence Rate = # cases / patient days X 1,000 Case is defined as healthcare-associated infection.

19. Healthcare-associated MRSA Infections ICU Incidence Rates January 2004 – June 2008 Incidence Rate = # cases / patient days X 1,000 Case is defined as healthcare-associated infection.

20. New Way to Act • Changed how we interact/how we solve problems • New Approaches: Confusing and Powerful • Reduced Transmissions • Increased Hand Hygiene compliance • Uncovered new leaders • Invited and recognized innovation

21. And, speaking of acting….

22. Harnessing Self-Discovery • We learn best when we discover things for ourselves • Unlocks the secrets of how innovative practices and behaviors enable some individuals to find successful solutions to common problems • With access to no special resources and within the same set of constraints; innovators are revealed right before our eyes!

23. Complex Lessons It takes courage and faith! • This is truly social science • Simple actions generate grand results • Data and need for certainty can be distracting… • “It’s weak”, “It’s a hoax”, “You don’t know for sure” • Shouldn’t keep us from improving • Movement created with limited formal leaders (Imagine what could be accomplished with more) • “Easier to act our way into a new way of thinking than to think our way into a new way of acting.”

24. How is PD different as a process?

25. Focus on PD Behavior We can’t (yet) clone people

26. Jasper Palmer discovered a better way to remove gowns and gloves 1 II V III But we canadopttheirsuccessful behaviors & strategies 1V

27. HOW does my role as an OD practitioner change? Paradigm shift - we move from expert to facilitator Requires comfort with uncertainty, power sharing & lack of control Mastering a subtle, elusive process with unusual metrics Learn to hug clouds Who’s doing what shifts & it’s labor intensive It’s a profoundly circular process – it’s not linear! Scaling up strategies change radically Uncovers & creates new problems…… and that’s the good news Inability to forecast all outcomes & consequences We move off stage Our answers are not relevant – our questions are

28. Selected Bibliography & Sources Cosgrove, S.E., (2006). The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin. Infect. Dis. 42: S82-9. Elixhauser, A.,& Steiner, C., (2007). Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005. AHRQ Healthcare Cost and Utilization Project, Statistical Brief #35, July. Klevens, R.M., Morrison, M.A., Nadle, J, Petit, S., Gershman, K., Ray, S., Harrison, L.H., Lynfield, R., Dumyati, G., Townes, J.M., Craig, A.S., Zell, E.R., Fosheim, G.E., McDougal, L.K., Carey, R.B., Fridkin, S.K., (2007). Active Bacterial Core Surveillance (ABCs) MRSA Investigators. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. Oct 17;298(15):1763-71. PMID: 17940231 Muto, C.A., Jernigan, J.A., Ostrowsky, B.E., Richet, H.M., Jarvis, W.R., Boyce, J.M., and Farr, B.M., (2003). SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infection Control and Hospital Epidemiology 24, no. 5:362-386. Tanner, R., Sternin, J. (2005). Your Company's Secret Change Agents. Harvard Business Review. May. Plsek, P.E., (2001). Appendix B: Redesigning Health Care with Insights. Science of Complex Adaptive Systems in Crossing the Quality Chasm. Institute of Medicine. Krebs, V., & Holley, J., (2006). "Building Network Weaving Through Smart Communities," http://www.orgnet.com/BuildingNetworks.pdf Photo credits: Keith McCandless, slides 2, 21, 25, 26 Positive Deviance Initiative/Jerry Sternin, slides 6, 7, 9

29. For More Information Carlos Arce carce@billingsclinic.org Sharon Benjamin, PhD sharon@sharonbenjamin.com Cathi Balboa cbalboa@earthlink.net Jerry & Monique Sternin www.positiveinitiative.org Jon Lloyd, MD www.plexusinstitute.org Margaret M. Toth, MD www.marylandpatientsafety.org