Big Problems + Small Interventions = Big Change Lisa Kimball lisa@plexusinstitute

1. Big Problems + Small Interventions = Big Change Lisa Kimball lisa@plexusinstitute.org Plexus Institute

2. The P o w e rof 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

3. The Vietnam Story The future is already here… but it is not at all well distributed.

4. Number of MRSA Infections Reported In US Hospitals 1993 2,000 2005 368,000 MRSA Overview • AHRQ Healthcare Cost and Utilization Project, • Statistical Brief #35, July 2007

5. MRSA Overview 1 in 5 Patients with invasive MRSA infection will die JAMA. 2007 Oct 17;298(15):1763-71

6. Positive Deviance (PD) Approach • The very people “whose behavior needs to change to solve the problem”identify existing solutions from within • Thereby suppressing the “immune rejection response”

7. Positive Deviance Inquiry Establishes community behavioral norms related to the problem to be addressed Enables community to discover successful uncommonbehaviors/ strategies practiced by the Positive Deviants

8. Analyzing PD Findings PDI findings are passed through a conceptual “accessibility sieve” PD Behaviors Behaviors Behaviors Only those behaviors/strategies accessible to all are kept Accessible to All The rest are “TBU,” True but Useless (i.e. not accessible to all) and are discarded

10. MRSA Prevention & Eradication

11. “While national rates of MRSA HAI’s go up, RWJ/Plexus PD beta site rates are going down.”

12. Typical Beta Site Results Incidence Rate = # cases / patient days X 1,000 Case is defined as healthcare-associated infection.

13. PD Focus on Practice Rather 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”

14. PD Enables us to Act TODAY Although most problems have complex, interlinked underlying causes . . . The presence of Positive Deviants demonstrates that it is possible to find successful solutions TODAY before all the underlying causes are addressed!

15. Traditional vs PD Problem Solving Approach PD Flows from identification and analysis of successful solution to problem solving Traditional Flows from problem analysis towards solution Actual Problem Parameters Fixed Solution Space Actual Problem Parameters Expanded Solution Space Expanded Solution Space Perceived Problem Parameters Perceived Problem Parameters Perceived Problem Parameters Actual Problem Parameters

16. 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 The “Awareness” Iceberg 4% 9% Problems known to middle managers 74% Problems known to supervisors 100% Problems known to front line managers

17. 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

18. Theatre In the Round A diverse audience, from many units across the clinic, assembles in the conference room… now an inpatient medical room. For the next 60 minutes, no one knows what to expect.

19. PD - Complex Adaptive System Through addressing a discrete part of a complex problem (.. a fractal of the whole) … we impact all the underlying structural issues.

20. PD: Crossing The “Knowledge/Behavior Change Gap” • Social proof • Perceived advantage • Opportunity for practice Behavior change Knowledge

21. TRADITIONAL Externally Fueled (by “experts” or internal authority) Top-down, Outside-in Deficit Based “What’s wrong here?” Begins with analysis of underlying causes of PROBLEM Solution Space limited by perceivedproblem parameters Triggers Immune System “defense response” POSITIVE DEVIANCE Internally Fueled (by “people like us”, same culture and resources) Down-up, Inside-out Asset Based “What’s right here?” Begins with analysis of demonstrably successful SOLUTIONS Solution Space enlarged through discovery of actual parameters Bypasses Immune System (solution shares same “DNA” as host) Contrasting Approaches Adapted from Jerry Sternin

22. When to use the PD approach • Problem requires behavioral or/and social change (adaptive challenges versus technical challenges) • Seemingly “intractable” problem – compelling enough to require a new approach • Presence of Positive Deviants (individuals/ groups exhibiting desired outcome) • Leadership commitment to address issue : “PD champions” • Skilled facilitation

23. PD & The Diffusion of Innovation Life-Cycle Communityparticipatesin discovery of innovation Thereby jumping the “early adopters/early majority” chasm Geoffrey A Moore. Crossing the Chasm.

24. PD ~ a Network Phenomenon 2005 2007 VA Pittsburgh

25. D&A Dialogues • What do you know/think about ________? • What do YOU do about ______________? • What keeps you from doing that all the time? • Who/Where have you seen overcome those barriers? • What other ideas do you have about removing barriers? (or supporting desired behavior) • What has to happen next to make that happen? • Who will do what when next?

26. PD and MRSA—Now Nearly 50 additional facilities are involved, most are hospitals, a few long term care facilities and outpatient hemodialysis centers—Maryland Patient Safety Center, Veterans Administration, Indiana University, AHRQ ACTION Network. Rockefeller Foundation funding global expansion of PD for MRSA and other healthcare problems.

27. Current Applications of Positive Deviance

28. Contact Lisa Kimball lisa@plexusinstitute.org http://plexusinstitute.org