Human Factors Engineering and Positive Deviance

1
Human Factors Engineering and Positive Deviance

• to
• Stop Hospital Acquired Infections (HAI)
• Will Sawyer MD
• APIC SW Ohio
• May 13, 2008

2
Audience participation during this presentation

• Identify 2-3 other HCWs in this room and note
  how many times they touch their mucus membranes
  during this presentation.
• (Positive Deviance behavior).
• Possible colonizer of MRSA.

3
Objectives

• 1.Convert you to the practice of Hand
  Awareness (Hand hygiene and Respiratory
  Etiquette and cross contamination).
• 2. You understand the necessity for
  establishing a culture of safety in the
  healthcare environment.
• 3. You accept that the drastic situation of
  HAI requires drastic measures to make the change
  to protect both the patient and HCW from
  infectious disease (patient safety shield).
• 4. To understand that is transmission of HAI
  that is most important to reducing HAIs.
• 5. To understand that the Champion
  Handwasher Hospital Campaign will help your
  hospital accomplish the first 4 objectives.

4
Who is Dr.Will
traditional medical role

• Solo practice Family Medicine, 1986 to present,
  Cincinnati, Ohio
• Trihealth Hospital System Patient Safety
  Committee, 2004-present.
• Bethesda North Hospital Med. Executive Committee,
  2000-07.
• Bridges to Excellence Pay for Performance
  Program, founding member, 2003-2005(NCQA, CMMS,
  GE, Humana et al).
• Clean Hands Coalition, founding member and
  partner of CDC,
• 2003 to present.
• Henry the Hand Foundation, founder 1999.
• Henry the Hand Champion Handwasher, creator,1996.
• Influenza Sentinel Network for CDC,member, 2003
  to present.
• Ohio Carrier Advisory Committee for Medicare
  Co-chair,
• 1994 to present.
• Ohio Medicaid Advisory Committee member
  1995-2004.
• Patients Choice, founder and President/CEO,
  1993-2003, 450 physician
  IPA
• AMA OMSS, delegate, 1999 to 2007.

5
Who is Dr.Will Positive Deviance
Strategist

• Solo practice Family Medicine, 1986 to present,
  Cincinnati, Ohio
• Bridges to Excellence Pay for Performance
  Program, founding member, 2003-2005(NCQA,
  CMMS, GE, Humana et al).
• Clean Hands Coalition, founding member
  (partnership of CDC, USDA, ASM, SDA, industry and
  universities) 2003 to present.
• Influenza Sentinel Network for CDC, one of 100
  sites,member, 2003 to present.
• Hand Awareness presentations
• Non Pharmaceutical Approach to Prevent
  Human Illness and Transmission of Emerging
  Pathogens
• NEHA 2006,
• NAHEC 2006 and
• USDA Food Safety Conference, 2006.
• Human Factors Engineering
• Stopping Hospital Acquired Infections,
  TapRoot(Root Cause Analysis) Conference 2007
• Champion Handwasher Hospital Campaign
  presentations
• John Muir Health System 2006
• Thompson Health System 2006

6
A Hospital System can drastically reduce HAI by
looking in the mirror. Of the 98,000
preventable deaths each year 90,000 are due to
infectious disease, according to IOM.

7
This Tool Kit will help meet the Elements of
Performance for JCAHO IC.4.10

• 1. Interventions are designed to incorporate
  relevant guidelines for infection prevention and
  control activities.
• Interventions are implemented which include the
  following (EPs 2 and 3)
• 2. A hospital wide hand hygiene program that
  complies with current CDC hand hygiene guidelines
  (National Patient Safety Goal 7, requirement 7a.)
• 3. Methods to reduce the risks associated with
  procedures, medical equipment, and medical
  devices, including the following Appropriate
  storage, cleaning, disinfection, sterilization,
  and/or disposal of supplies
  and equipment.

8
The Tool Kit meets the National Patient Safety
Goal 7

• Reduce the risk of health care-associated
  infections.
• Requirement 7A Comply with current CDC hand
  hygiene guidelines. note This requirement is
  scored at standard at IC.4.10,EP 2.
• Requirement 7B Manage as sentinel events all
  identified cases of unanticipated death or major
  permanent loss of function associated with a
  health care-associated infection.

9
The Powerof 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
10
Lets admit to the Public that HCWs need to make
changes to prevent the spread of HAI.

• As HCWs, we are interested in a culture of
  safety in the hospital to achieve a zero
  denominator for HAI.

11

• Evidence-based medicine and infection
  prevention measures can go no where without our
  ability to influence decision-makers to support
  our efforts and to persuade healthcare teams to
  adopt safe behaviors.
• Denise Murphy RN, BSN, MPH, CIC,
• VP, Chief Patient Safety and
  Quality Officer
• Barnes-Jewish Hospital
• Washington University Medical
  Center

12
Culture of Safety

• It is only through genuine communication
  and accountability for ones behavior in the
  hospital community, that we will foster a
  culture of safety, that will help prevent the
  spread of infectious disease, hence HAI.
• A key component to the Champion Handwasher
  Hospital Campaign success is based upon ones
  personal awareness and personal accountability
  not age, educational accomplishments or level of
  authority in the hospital
  community.

13
Human Factors Engineering

• We need to apply the same evidence based medicine
  approach to empower HCWs that the Power of
  Infection Prevention is in their hands! They
  simply need more Hand Awareness practice.

14
Hand Awareness

• Knowing where your hands are and what they are
  doing AT ALL TIMES.
• Scientifically stated it is the integration of
  Hand Hygiene, Respiratory Etiquette and
  cross-contamination awareness in a best practice
  model.

15
How New is Hand Awareness?

• John Snow MD(1854) Broad Street pump handle and
  Cholera epidemic.
• Ignaz Semmelweis MD (1847) Perinatal mortality
  reduced by using a dilute chlorine solution rinse
  between the morgue and LD suite.
• Although it took 20 years for acceptance of both
  their discoveries now described as Positive
  Deviance.
• Will Sawyer MD(1999) The 4 Principles of Hand
  Awareness as primary infection prevention.
• Lets not wait 20 years to accept and
  miss the opportunity to prevent many
  HAIs.

16
Preventing transmission is an important part of
MRSA control

• Entire healthcare-associated MRSA problem caused
  by spread of a few clones
• Preventing widespread colonization minimizes
  circulating pool of resistance genes that can
  contribute to cycle of increasing multi-drug
  resistance (e.g. VRSA is likely a product of
  widespread colonization with VRE and MRSA)
• Improving antibiograms helps ease pressure for
  broad spectrum antibiotic use and preserves
  effectiveness of preferred antimicrobial agents
• Preventing colonization helps prevent infections
• Including those that might happen post-discharge
  (newly colonized patients have up to 30 risk of
  infection in the ensuing year).
• Prevention and Control of Healthcare-associated
  MRSA, John Jernigan MD, Division of Healthcare
  Quality Promotion, CDC and Prevention April 29,
  2008.

17
So what do we need to change today to prevent HAI?

• STOP TRANSMITTING by OUR HANDS!!!
• 1. Practice the 4 Principles of Hand Awareness.
• 2. Stop keyboard and RFID gun cross
  contamination
• during patient care.
• 3. Remove neck ties that are causing cross
• contamination.
• 4. Stop using cell phones in the midst of
  patient care
• that are contributing to cross
  contamination.
• 5. There will be more suggestions to better
  engineer
• the patient care process.

18
PD Focus on Practice Rather than Knowledge

• Its easier to ACT your way into a new way of
  THINKING, than to
• THINK your way into a new way of ACTING

19
The 4 Principles of Hand Awareness

• 1. Wash your hands when they are dirty and before
  eating.
• 2. Do not cough into your hands.
• 3. Do not sneeze into your hands.
• 4. Above all, do not put your fingers into your
  eyes, nose or mouth.
• Endorsed by the AMA and the AAFP (2001)
• referred to as individual ideas for flu
  prevention by CDC, but not packaged as an
  integrated concept.

20
The 4 Principles of Hand Awareness

• 1. Wash your hands when they are dirty and before
  eating.
• 2. Do not cough into your hands.
• 3. Do not sneeze into your hands.
• 4. Above all, do not put your fingers into your
  eyes, nose or mouth.
• Endorsed by the AMA and the AAFP (2001)
• referred to as individual ideas for flu
  prevention by CDC, but not packaged as an
  integrated concept.

21
The 4 Principles of Hand Awareness

• 1. Wash your hands when they are dirty and before
  eating.
• 2. Do not cough into your hands.
• 3. Do not sneeze into your hands.
• 4. Above all, do not put your fingers into your
  eyes, nose or mouth.
• Endorsed by the AMA and the AAFP (2001)
• referred to as individual ideas for flu
  prevention by CDC, but not packaged as an
  integrated concept.

22
The 4 Principles of Hand Awareness

• 1. Wash your hands when they are dirty and before
  eating.
• 2. Do not cough into your hands.
• 3. Do not sneeze into your hands.
• 4. Above all, do not put your fingers into your
  eyes, nose or mouth.
• Endorsed by the AMA and the AAFP (2001)
• referred to as individual ideas for flu
  prevention by CDC, but not packaged as an
  integrated concept.

23

• We ALL know or have heard of someone who went
  into the hospital contracted MRSA,VRE, C.
  difficile or other infectious diseases causing
  illness or death!
• Which health systems are consistantly 75
  compliant with CDC Hand Hygiene guidelines?
• Correct, none!

24
The emergence of MRSA has been due to
transmission of relatively few clones, not de
novo selection
Hiramatsu, et al. Trends in Microbiology
20019486
25
HCWs are a Petri Dish for many diseases in the
hospital.

• Remember as long as we do not introduce the
  infectious disease into our mucus membranes then
  the disease will less likely spread in and out of
  the hospital.

26
Which Behaviorsare we talking about?

• Nose picking and rubbing
• Eye rubbing
• Nail biting, finger licking, etc.
• Curtailing these habits,
• Is a simple solution
• to a complex problem
• of HAI.

27
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!

28
Perhaps we should institute wearing a Patient
Safety Shield, as a safety device?

• Creating a physical barrier to prevent
  inoculation and colonization of MRSA and other
  germs to reduce Hospital Acquired Infections
  (HAI).

29

• It is our duty to our Patients, their
  families and healthcare workers
• Let us move forward together!
• Each of us can make a difference a small but
  significant effort from all of us.
• Sir Liam Donaldson Professor Didier Pittet
  MD
• Clean Hands reduce the burden of disease.
  
  
  
• Lancet366185-86, 2005
  

30

• There are several models talking about the
  Culture of Safety hospital wide
• Cleanyourhands Campaign in the U.K.
• Clean Care is Safer Care by the WHO
• Champion Handwasher Hospital
• Campaign in the U.S.

31

• Hospitals are still functioning in silos in OUR
  communities.
• Collaborating to teach a consistent message can
  help protect the public, our patients, from HAI.
• Introducing friendly competition between
  hospitals in a region will help initiate the
  culture of safety in your region.

32
Most Healthcare-Associated Invasive MRSA
Infections Have Their Onset Outside of the
Hospital
28
14
59
Source ABCs Population-based surveillance
System, Klevens et al. JAMA 2007
33

• In December, 2006
• IHI (Institute for Healthcare Improvement)
  initiated the 5 million Lives Campaign which asks
  hospitals to develop simple techniques to prevent
  MRSA infections in the hospital. And asks their
  Boards to Get on board!
• The 4 Principles of Hand Awareness.

34

• SHEA (Society for Healthcare Epidemiology of
  America) just finished their Annual Congress
  where they devoted much of their program to
  discussing programs to prevent MRSA infections.
• The 4 Principles of Hand Awareness.

35
Amazing preventable statistics in the US from
the CDC and Prevention!

• 90,000 patients die each year from Hospital
  Acquired Infections (HAI)
• 2,000,000 HAI occur each year, at a cost of 6.7
  billion
• 5,000 people die from food borne illness
  annually,
• 76,000,000 cases of food borne illness annually
• More than 300,000 hospitalizations due to
  food borne illness
• 33,000,000 hospital admissions annually

36
More preventable statistics in the US from the
CDC and Prevention!

• 52,000,000 Upper Respiratory Infections occur
  each year,
• 164,000,000 days lost from school due to illness,
• 22,000,000 days lost from school due to the
  common cold
• 36,000 people die from the Flu and flu-like
  illness annually
• 800,000,000 patient visits annually

37
What are the 10 most deadly weapons?
38

• Our Fingers
  and Thumbs!

39
HCWs Nares organism found in several patients
mediastinal site infections on the same floor,
1989.

• Reduction of Surgical site Infections in
  Cardiothoracic Surgery by Elimination of Nasal
  Carriage of Staphylococcus Aureus, Jan, AJ et al,
  Infection Control and Hospital Epidemiology,
  November 1996.

40
Other Evidence that the colonized HCWs are the
source for Staph aureus outbreaks

• Boyce JM, Opal SM, Potter-Bynoe G, Medeiros AA.
  Spread of MRSA in a hospital after exposure to a
  HCW with chronic sinusitis. Clin Infect Dis
  199317496-504.
• Boyce JM. Preventing Staphylococcal Infections by
  Eradicating Nasal Carriage of Staphylococcus
  aureus Proceeding with Caution. Infect Control
  and Hosp Epidemiol 199617775-779.
• CoovadiaYM, Bhana RH. Johnson AP, Haffejee I,
  Marples RR. A laboratory confirmed outbreak of
  rifampin-methicillin resistant Staphylococcus
  aureus (RMSA) in a newborn nursery.. J Hosp
  Infect 198914303-312.
• Gaynes R, Maroska R, Mowry-Hanley et al.
  Mediastinitis following coronary artery bypass
  surgery a 3 year review. J Infect Dis
  1991163117-121.
• Meier PA, Carter CD, Wallace SE, Pfaller MA,
  Herwalt LA. Eradication of MRSA from the burn
  unit at a tertiary medical center. Infect Control
  Hospital Epidemiol 199617798-802.

41
Perhaps we should institute wearing a Patient
Safety Shield, as a safety device.

• Since there is insufficient compliance with
  the CDC hand hygiene guidelines, creating a
  physical barrier to prevent inoculation and
  colonization of MRSA and other germs in nares
  would reduce HAI. (Positive Deviance strategy)
• Prevention and Control of Healthcare-associat
  ed MRSA, John Jernigan, MD April 29,2008

42
Hand Awareness

• People who are Hand Aware are much less likely
  to contaminate themselves, another person,
  patient, device or surface.
• Why would anyone knowingly give themselves E.Coli
  0157H7, MRSA,VRE, Shigella, Pertussis, Croup,
  Meningitis,TB, Flu, Strep, Impetigo, Pink Eye,
  hepatitis A and many others?

43
Respiratory Etiquette

• Principle 2 and 3.
• Do not Cough or sneeze into your hand. Use a
  sleeve, kleenex, crook of your elbow, etc.,
  anything except a bare hand. Very few people are
  running to the sink to wash their hands after
  coughing or sneezing.
• Pertussis, viral illness, pneumococcus,
  meningococcus, SARS, Mumps, Measles, Rubella,
  and many similar diseases would be prevented by
  diligent practicing of the
  4 Principles of Hand Awareness.

44
Respiratory Etiquette
45
Hand Hygiene

• Principle 1 and 4.
• Handwashing is publicly discussed.
• Mucus membrane contact has NOT been publicly
  discussed as it should be, to prevent
  inoculation and colonization.

46
Hand Hygiene
47
The Hand is quicker than the eye!

• Unfortunately the single act of handwashing or
  sanitizing alone does not prevent
• cross-contamination!

48

• Bacterial counts on surfaces
• 2.7 million bacterial cells/ square inch on a
  drinking fountain.
• 33,800 bacteria/sq. inch on a cafeteria tray.
• 3,200 bacteria cells/sq. inch on a toilet seat.
• 260 bacterial cells/sq inch on key boards.
• 740 bacterial cells/sq inch on ear phones.
• National Sanitation Foundation, www.nsf.org

49
The Hand is quicker than the eye!

• People unknowingly touch a contaminated
  surface, then transmit the organism to another
  surface, themselves or a patient due to
  unconscious personal habits.

50
How soon after starting to work in the hospital
do HCW nares become colonized with MRSA?

• 2 weeks? 6 weeks? Who is checking?
• Does your pre-employment interview ask if you
  comply with the 4 Principles of
  Hand Awareness?
• Or are you a nose picker, nail biter,
  finger licker, eye rubber,
  etc.?
• 20-30 of HCWs are colonized with
  MRSA at any one time - Boyce,1996

51
When did the CDC and Prevention first address the
issues of mucus membrane colonization, self
inoculation and cross contamination?

• 1983

52
Guideline for Infection Control in Hospital
Personnel Walter Williams MD.MPH, Hospital
Infections Program, National Center for
Infectious Diseases, CDC and Prevention July
17,19831-43

• Staph aureus If certain personnel are linked
  epidemiologically to an increased
  number of infections,
  these personnel can be cultured
  and, if positive, removed from
  patient contact until carriage
  is eradicated.

53
Is any hospital following this guideline?

• None that we know!
• Concern, there may not be enough staff to care
  for the patients, is the usual response.
• So why dont we do a better job of preventing
  ourselves from being colonized and potentially
  infectious?
• Its just a habit! Not a good enough reason.

54
Most Invasive MRSA Infections Are
Healthcare-Associated
N 8,987

• In the US in 2005 there were
• 94,360 invasive MRSA infections
• 18,650 associated deaths

14
86
Source ABCs Population-based surveillance
System, Klevens et al. JAMA 2007
55
How best to prevent MRSA Transmission in
Healthcare Settings?

• Controversial subject
• standard precautions versus standard plus barrier
  (i.e. contact precautions)?
• Should contact precautions be used only on those
  identified by clinical cultures?
• Due to iceberg effect, many colonized patients
  unrecognized base on clinical cultures alone
• Should active surveillance be used to identify
  carriers?
• If so, in what settings?
• Prevention and Control of Healthcare-associated
  MRSA, John Jernigan MD Division Health Care
  Promotion, CDC and Prevention April 29, 2008.

56
Guideline for Infection Control in Hospital
Personnel Walter Williams MD.MPH, Hospital
Infections Program, National Center for
Infectious Diseases, CDC and Prevention July
17,19831-43

• Viral respiratory infections Masks probably will
  not completely protect personnel from patients
  with respiratory illnesses because large
  particles and aerosols may still reach the eyes,
  and self-inoculation from contaminated
  hands can still occur by
  touching the eyes.

57
Legislation necessary?

• Seat belts have been estimated to save 15,000
  lives per year and prevent 132,000 injuries per
  year.
• Adhering to the 4 Principles of Hand Awareness
  could significantly reduce the 90,000 estimated
  preventable HAI deaths per year.

58
(No Transcript)
59
MRSA is not walking out of the hospital.

• Staff, patients, visitors, vendors and others are
  carrying disease out on their hands, in the
  nares, clothing, equipment, etc.
• How many of us decontaminate entering or
  leaving the hospital?
• Why not?

60
Decontaminating upon entering the hospital
facility,
if you do not want to carry any disease into the
facility
61
Decontaminating upon leaving the hospital
facility,

• if you do not want to carry any disease out of
  the facility.

62
Decontaminating upon entering home or work,

• to minimize the chance of bringing in disease.

63
So How do you change HCWs habits?

• CDC, SHEA and many notable scientists put
  together a review in the MMWR in 2002.
• First, you draw the HCWs attention to
  what is your (their) habit?
• You will need to invoke a Positive
• Deviance technique!

64
So How do you change Peoples habits?

• You help them change it by a few simple
  techniques (Positive Deviance) which help them
  stop the health risk behavior i.e. touching
  their eyes, nose or mouth (mucus membranes). Wear
  a Patient Safety Shield. The barrier method is a
  great for prevention!

65
Perhaps we should institute a Patient Safety
Shield, as a teaching tool.

• Creating a physical barrier will help teach us
  to prevent inoculation and colonization of MRSA
  and other germs, which will reduce HAI.

66
Guideline for Hand Hygiene in Health-Care
Settings J.M. Boyce and D. Pittet MMWR,
2002,51(RR16)1-44

• Factors necessary for change include
• 1. dissatisfaction with current situation
• 2. perception of alternatives, and
• 3. recognition, both at the individual and
  institutional level, of the ability and potential
  to change.
• The first two necessitate a system change
  and the latter requires education.

67
Guideline for Hand Hygiene in Health-Care
Settings J.M Boyce
and D. PittetMMWR, 2002,51(RR16)1-44

• Factors necessary for change include
• 1. dissatisfaction with current situation
• 2. perception of alternatives, and
• 3. recognition, both at the individual and
  institutional level, of the ability and potential
  to change.
• The first two necessitate a system change
  and the latter requires education.

68
Guideline for Hand Hygiene in Health-Care
Settings J.M Boyce and D. Pittet MMWR,
2002,51(RR16)1-44

• Factors necessary for change include
• 1. dissatisfaction with current situation
• 2. perception of alternatives, and
• 3. recognition, both at the individual and
  institutional level, of the ability and potential
  to change.
• The first two necessitate a system change
  and the latter requires education.

69
Most importantly, an improvement in Infection
Control practices requires

• Questioning basic beliefs
• Continuous assessment of the group (or
  individual) stage of behavioral change
• Interventions with an appropriate process of
  change
• Supporting individual and group creativity
• Because of the process of change, single
  interventions often fail. Thus, a multimodal,
  multidisciplinary strategy is likely necessary.

70
Key Prevention Strategies

• Prevent infection
• Diagnose and treat infection effectively
• Use antimicrobials wisely
• Prevent transmission

Clinicians hold the solution!
71
Lets Get Started

• Lets admit to ourselves that humans are
  responsible for transmitting disease and
  contaminating surfaces in the community setting.
• Lets agree that we each have personal habits that
  may be contributing to the spread of infectious
  disease.
• Lets agree to not take offense when someone
  comments to us about our Hand Awareness
  technique.
• Lets agree that we are ALL sensitive about our
  personal habits and we agree to accept more
  public accountability that we want to protect our
  family and friends.
• Lets agree that this process makes each and
  everyone of us a little nervous.

72
Predicted Number of EMRSA-15 Outbreaks During
1993-98, United Kingdom
900
800
700
600
EMRSA-15 outbreaks 1993-1998
500
400
30 Duration
300
30 transmission
200
100
30both
100
80
60
40
20
Source Austin JID 1999179883
of Facilities Implementing Intervention
73
Identify the Champion Handwasher Officer

• The purpose is to have one individual (Coach) who
  is responsible for coordinating the efforts of
  the healthcare team ensuring that this Campaign
  succeeds to benefit the patients in your
  hospital.
• They are the contact point to the media.
• Also to promote periodic reinforcement
  activities in the hospital to maintain a high
  level of compliance for the team, to ensure the
  hospitals success.

30both
74
Champion Handwasher Hospital Campaign

• It requires team work and true collaboration
  to improve the outcome.

• It is human behavior habits and
  administrative barriers that need to be overcome
  to achieve a culture of safety.

• We need to promote genuine communication
  across levels of authority to be successful.

75
Champion Handwasher Hospital Campaign

• It requires team work and true collaboration
  to improve the outcome.

It is human behavior habits and
administrative barriers that need to be overcome
to achieve a culture of safety.

• We need to promote genuine communication
  across levels of authority to be successful.

76
Champion Handwasher Hospital Campaign
to Prevent HAI.

• It requires team work and true collaboration
  to improve the outcome.

• It is human behavior habits and
  administrative barriers that need to be overcome
  to achieve a culture of safety.

• We need to promote genuine communication
  across levels of authority to be successful.
• Every successful team requires a Coach.
  Physicians are more like professional athletes
  than employees

77
OK

• This Positive Deviant Strategy sounds
  plausible.
• How do we get started?

78
To begin select a few phrases (slogans) to be
used that tells a fellow HCW they did not wash or
sanitize correctly, or breached one of the
4 Principles of Hand Awareness. (Positive
Deviance)

• Statement(s) that will not be offensive, and
  instead, reward our peers and other observers for
  their correct observation.

79
Sample Phrases

• Are you a Germinator?
• Dont touch the T zone?
• I do not think you washed before touching that
  patient.
• Hey Bozo watch those digits!
• You just broke one of the
  4 Principles.

80
Goals

• Each HCW understands, practices and promotes the
  4 Principles of Hand Awareness to their patients,
  colleagues, friends and family.
• Each HCW will have a couple of simple
  non-threatening phrases to use when they notice
  another HCW breaches one of the 4 Principles of
  Hand Awareness.

81

• Prepare you to launch the Champion Handwasher
  Hospital Campaign which will jump start the
  culture of safety initiative in the hospitals
  in your region?
• Complying with CDC Hand Hygiene guidelines alone
  will not allow us to reach zero denominator for
  HAI.
• We need to communicate and stop cross -
• contaminating!

82
Opportunities for MRSA Prevention Research

• Impact of focusing on high risk units
• Use of topical antimicrobials/antiseptics for
  eradicating or suppressing S. aureus colonization
• Chlorhexidine bathing of patients (targeted to
  colonized patients versus high-risk groups)
• Use of topical antibioitics for decolonization
  (e.g. mupirocin)
• Risk factors for healthcare-associated,
  community-onset (HACO) MRSA
• Impact of hospital-based prevention programs on
  HACO
• Use of mathematical modeling to understanding
  inter-facility transmission dynamics and
  implications for prevention
• Novel techniques for changing organization
  culture as a means to improve adherence
• Prevention and Control of Healthcare-associated
  MRSA, John Jernigan MD, Division of Healthcare
  Quality Promotion, CDC and Prevention April 29,
  2008.

83
Conclusions

• The burden of MRSA remains high in US healthcare
  settings
• Community-associated MRSA (CA-MRSA) infections
  are emerging rapidly in many areas, but
  population-based estimates suggest that most MRSA
  infections are healthcare-associated
• Epidemic strains of MRSA originally associated
  with the community have emerged as important
  causes of hospital-acquired infections
• MRSA infections and transmission can be
  prevented, even in endemic settings in the US
• Effective control programs must be multifaceted,
  and broad institutional commitment, including
  measurement of impact, is required for successful
  implementation
• Prevention and Control of Healthcare-associated
  MRSA, John Jernigan MD, Division of Healthcare
  Quality Promotion, CDC and Prevention April 29,
  2008.

84
Champion HandwasherHospital Tool Kit

• Reinforcement Tools for the Campaign,
  enlisting multimedia strategies (social
  marketing), that help break through traditional
  human defenses Positive Deviance
• Animation
• Music
• Visual prompts
• Participatory demonstrations

85
Champion HandwasherHospital Tool Kit
86
Champion Handwasher 1 stickers
87
Champion Handwasher 2 stickers
88
Champion Handwasher Spray bottle Germ Potion
89
Champion Handwasher 1buttons
90
Champion HandwasherCD DVD
91
Champion Handwasher Sink Reminders
92

• Henry the Hand Champion Handwasher is prepared to
  be the National Coach,
• make the Campaign fun and to improve our
  success to benefit OUR patients!

93
Prevention and Control of Healthcare-Associated
Methicillin-Resistant Staphylococcus aureus

• John A. Jernigan
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention
• April 29, 2008

The findings and conclusions in this
presentation/report are those of the authors and
do not necessarily represent the views of the
Centers for Disease Control and Prevention
94

• Positive Deviance Approach
• For Behavior Social Change
• Funded through the Ford Foundation
• Tufts University

95
TRADITIONAL VS POSITIVE DEVIANCE
PROBLEM SOLVING APPROACH

• POSITIVE DEVIANCE
• Internally Fueled
• (by people like us,
• same culture and resources)
• Down-up, Inside-out
• Asset Based Whats 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)

• TRADITIONAL
• Externally Fueled (by experts
• or internal authority)
• Top-down, Outside-in
• Deficit Based Whats wrong here?
• Begins with analysis of
• underlying causes of PROBLEM
• Solution Space limited by
• perceived problem parameters
• Triggers Immune System
• defense response

96
A Few CA-MRSA Strains Cause Most Community
Outbreaks
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