Positive Deviance: Uncovering Solutions to Intractable Problems from the Inside

1. The Dartmouth Institutefor Health Policy & Clinical Practice Coaches Retreat and Reunion wMay 3-4, 2009 Positive Deviance: Uncovering Solutions to Intractable Problems from the Inside Jon C Lloyd, M.D., Senior Clinical Advisor, Plexus Institute Advisory Board, Positive Deviance Initiative

2. Road Map • Background • MRSA epidemic in US • RWJ/Plexus Beta site experience 2. Establish the rationale for using a Social Change approach for addressing MRSA and other seemingly intractable challenges 3.Describe the first practical use of Positive Deviance in Vietnam 4.Describe the broad application of Positive Deviance to MRSA. 5. What’s next?

3. Number of MRSA Infections Reported In US Hospitals MRSA Overview 1993 2,000 2005368,000 AHRQ Healthcare Cost and Utilization Project, Statistical Brief #35, July 2007

4. MRSA Overview >90,000 MRSA Infections annually 87% HA-HO or HA-CO 1 in 5 Patients with invasive MRSA infection will die JAMA. 2007 Oct 17;298(15):1763-71

5. 5.1 million people were asymptomatic MRSA carriers in 2005 …up from 2.4 million in 2001. That’s an increase of 130%! It’s a NATIONAL EPIDEMIC

6. Prevalence of Methicillin-Resistance Among S. aureus Infections, Denmark and US, 1960-2004 Denmark, Finland, and the Netherlands have been able to lower the percent of S. aureus resistant to methicillin to <1% using rigorous transmission-based control policies that include: surveillance cultures, standard and contact precautions. Muto, et al. SHEA Guidelines. CDC. Natioinal Nosocomial Infectious Surveillance System (NNIS). 2005

7. Reducing MRSA Infections by Using the Positive Deviance Approach to Behavior and Social Change

8. Positive Deviance Collaborative • In 2006, 6 hospitals partnered with The Plexus Institute and CDC to prevent MRSA • Strategies: evidence-based recs (hand hygiene, Contact Precautions, environmental cleaning selective application of active surveillance testing) • Implementation: Positive Deviance • Hospitals shared electronic data for evaluation

9. Novel Approach: Positive Deviance • Applied to intractable problems • Uncommon but effective practices • Utilizing existing resources • Scale up to change group behavior • In healthcare settings • Staff uncover, create, and diffuse effective IC strategies • All employees participate

10. “While national rates of MRSA HAI’s go up,RWJ/Plexus PD beta site rates are going down.” John Jernigan, MD, MPH

12. The “system” for ordering/administering Tylenol 3 (Assessment by Pittsburgh Regional Healthcare Initiative)

13. MRSA is a TOUCHERSproblem and is spread when people, coming in contact with patients who are infected orcolonizedwith MRSA, spread the germ to others by way of their hands, clothes and shared equipment. As a result, the opportunities for transmission exist on a scale of millions. EVERYONE in the facility is a potential source of transmissions andsolutions.

14. HAI’s are a complex problem requiring behavior and social change • We already know what to do – Hand hygiene and barrier precautions were introduced 160 ago. Resistant pathogens and active surveillance emerged 50 years ago • Traditional best practice, industrial approaches and regulation & enforcement alone either fail outright or tend to work temporarily without spreading within or between healthcare institutions • Sense of urgency - Scope of MRSA problem is massive and more complex than previous patient safety initiatives, e.g. VAP, CLAB, etc. • Time is ripe for a solution that matches the complexity and nature of the challenge.

15. Brenda Zimmerman: Complexity and Creativity in Orgnizations

16. Brenda Zimmerman, York University Simplicity Plan then act Explicit plans Look for agreement Limit type of action Clockware Complexity “Act-learn” at the same time Generative relationships Multiple actions Swarmware When In The Zone Of...

17. Infection Prevention is Everyone’s job! In general, lots of people are smarter than a few people... especially front line staff

18. The “Awareness” Iceberg This internationally acclaimed study conducted by Sidney Yoshida, was initially presented at the International Quality Symposium, Mexico city, 1989. It indicated how management's failure to understand its processes and practices from the perspective of its customers, suppressed the company's profits by as much as 40%.  Problems known to top managers 4% 9% Problems known to middle managers 74% Problems known to supervisors 100% Problems known to front line staff & managers

19. Business as usual Leadership: powerful, few. Make decisions about how work is done Middle managers: implement decisions Front line workers- experts at the work they do: carry out decisions, rarely engaged in deciding HOW work is done

20. Front line workers: experts at the work they do, decide HOW to do work, & foster self-discovery among peers Leadership and middle managers support and filter ideas, and remove barriers for implementation of practices from frontline workers PD

21. S0… The questions we must ask ourselves are: • If front line staff (touchers) are in the best position to • know where, when and how (MRSA) transmissions occur • in their work area and how to prevent them, how are we • going to unleash their secrets? • What are we going to do once the transmission sites • and causes have been exposed and solutions have been • proposed by those who know best? • What can we start doing today to address these issues? • .

22. Sternins Introduce PD, Vietnam, 1991Childhood Malnutrition www.positivedeviance.org

23. The POWER of Positive Deviance Solutions before our very eyes The Premise: In every community there are certain individuals whose uncommon practices/behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources

24. Why Positive Deviance for HAI Prevention? Because solutions to MRSA and other HAI’s already exist in every hospital !

25. Where are the shrimps, crabs & greens in healthcare?!

26. Positive Deviance Steps Design & Do Discover Determine Define

27. Define & Determine: Kick-Offs Day 1—Kick-Off (2-3 hours) Senior Leader Introduction MRSA overview Personal Stories Reflection The Positive Deviance (PD) Story Reflection Examples of PD used for MRSA Reflection Invitation to Volunteer Meeting Day 2—Volunteers Meet Organize for action Launch Expanded Discovery and Action Groups Plan Measurement Plan Communication 27

28. Volunteers meet after the Kick Off

29. Discovery & ACTION DialogueBe genuinely curious – the answers are in the room

30. Discovery & ACTION Dialogs Facilitator starts with basic questions: • How do you know whether your patient has MRSA? • In your own practices, what do you do to prevent spreading MRSA to other patients or staff? • What prevents you from doing these things all the time? • Is there anyone who has a way of doing things that helps them to overcome these barriers? • Do you have any ideas? • Any volunteers?

31. Design & Do - Front line staff act on and own their solutions

32. All healthcare workers are created different and equal in their desire and capacity to make contributions to the health and safety of others.

33. Before & After Bible Hygiene

34. Albert Einstein Medical CenterPhiladelphia, PA

35. Jasper Palmer A gown and gloves removal artist at work! 1 V II Thousands of small changes are unleashed, engaging unusual suspects in improving safety and effectiveness. III 1V

36. Transporting patient in contact precautions John Ringdal

37. Pre-Op Decolonization- Vascular Surgery Stacy Love

39. “We dance around in a ring and suppose, while the secret sits in the middle and knows.” — Robert Frost Eddie Yates

40. What PD Tells Us – that is different Solutions imported from external sources – result in a “social” immune response in the same way our bodies reject foreign bodies. BEST PRACTICES “IMPORTED” FROM THE OUTSIDE – ARE NOT AS DURABLE OR SCALABLE AS LOCAL “BEST PRACTICES” DISCOVERED FROM THE INSIDE.

41. Buy–In vs Ownership *Buy-In: Someone else has developed the idea, made the decision, designed an action plan and then asks and needs the staff to implement it. Ownership: Front line staff develops the idea, makes the decisions, designs the action plan and acts on it. * Buy-in is the opposite of ownership and a danger signal that tells you that your development and implementation process are missing the essential ingredient of involving everyone who needs to be.

42. Bathed in Data

43. Quantitative & Qualitative Measures • In-House Data • MRSA Surveillance System- NHSN • Clinical Incidence Density Data • Social Network Mapping • Stories

44. University of Louisville Hospital

45. Einstein MRSA HAI Rate Facility Wide Billings Clinic HA-MRSA Infections 1999-2007

46. MRSA and Other Resistant Organism Healthcare-associated Infection VAPHS-UD In-Patient Units

47. Partnership with CDC / NHSN MRSA Surveillance System Data

50. Clinical Incidence Density Data Clinical incident MRSA isolates identified by positive non-surveillance cultures obtained >48 hours after admission from patients with no positive MRSA cultures in the previous year (Huang).