The Dartmouth Institute for Health Policy

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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

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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. Whats next?

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Number of MRSA Infections Reported In US
Hospitals
MRSA Overview

• 1993 2,000
• 2005 368,000

AHRQ Healthcare Cost and Utilization Project,
Statistical Brief 35, July 2007
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MRSA Overview
gt90,000 MRSA Infections annually 87 HA-HO or
HA-CO 1 in 5 Patients with invasive MRSA
infection will die
JAMA. 2007 Oct 17298(15)1763-71
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5.1 million people were asymptomatic MRSA
carriers in 2005 up from 2.4 million in 2001.
Thats an increase of 130!
Its a NATIONAL EPIDEMIC

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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 lt1 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
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• Reducing MRSA Infections by Using the Positive
  Deviance Approach to Behavior and Social Change

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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

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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

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While national rates of MRSA HAIs go up,
RWJ/Plexus PD beta site rates are going down.

John Jernigan, MD, MPH
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The system for
ordering/administering Tylenol 3
(Assessment by Pittsburgh Regional Healthcare
Initiative)
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• MRSA is a TOUCHERS problem and is spread when
  people, coming in contact with patients who are
  infected or colonized with 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 and solutions.

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HAIs 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.

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Brenda Zimmerman Complexity and Creativity in
Orgnizations
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When In The Zone Of...

• 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

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• Infection Prevention is Everyones job!
• In general, lots of people are smarter than a few
  people...
• especially front line staff

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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
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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
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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?
• .

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Sternins Introduce PD, Vietnam, 1991Childhood
Malnutrition
www.positivedeviance.org
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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
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Why Positive Deviance for HAI Prevention?

• Because solutions to MRSA and other HAIs already
  exist in every hospital !

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Where are the shrimps, crabs greens in
healthcare?!
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Positive Deviance Steps
Design Do
Discover
Determine
Define
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Define Determine Kick-Offs

• Day 1Kick-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 2Volunteers Meet
• Organize for action
• Launch Expanded Discovery and Action Groups
• Plan Measurement
• Plan Communication

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Volunteers meet after the Kick Off
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Discovery ACTION DialogueBe genuinely
curious the answers are in the room
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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?

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Design Do - Front line staff act on and own
their solutions
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• All healthcare workers are created different and
  equal in their desire and capacity to make
  contributions to the health and safety of others.

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Before After Bible Hygiene
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Albert Einstein Medical CenterPhiladelphia, PA
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Jasper Palmer
A gown and gloves removal artist at work!
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V
II
Thousands of small changes are unleashed,
engaging unusual suspects in improving safety
and effectiveness.
III
1V
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Transporting patient in contact precautions

• John Ringdal

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Pre-Op Decolonization- Vascular Surgery

• Stacy Love

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We dance around in a ring and suppose, while the
secret sits in the middle and knows. Robert
Frost

• Eddie Yates

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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.

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BuyIn 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.

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Bathed in Data
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Quantitative Qualitative Measures

• In-House Data
• MRSA Surveillance System- NHSN
• Clinical Incidence Density Data
• Social Network Mapping
• Stories

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University of Louisville Hospital
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Einstein MRSA HAI Rate Facility Wide
Billings Clinic HA-MRSA Infections 1999-2007
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MRSA and Other Resistant Organism
Healthcare-associated Infection
VAPHS-UD In-Patient Units
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Partnership with CDC / NHSN

• MRSA Surveillance System Data

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Clinical Incidence Density Data

• Clinical incident MRSA isolates identified by
  positive non-surveillance cultures obtained gt48
  hours after admission from patients with no
  positive MRSA cultures in the previous year
  (Huang).

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A Successful Multi-Center Intervention to Prevent
Transmission of Methicillin-resistant
Staphylococcus aureus (MRSA)
K Ellingson1, N Iversen2, JM Zuckerman3, D
Borton3, L Goss4, K Lloyd4, P Chang1, J
Stelling5, A Kallen1, M Sternin6, C Lindberg7, J
Lloyd7, and JA Jernigan1 for the Positive
Deviance MRSA Prevention Partnership
1CDC, Atlanta, GA 2Billings Clinic, Billings, MT
3Albert Einstein Healthcare Network,
Philadelphia, PA 4University of Louisville
Hospital, Louisville, KY 5Brigham and Womens
Hospital, Boston, MA 6Positive Deviance
Initiative, Boston, MA 7Plexus Institute,
Bordentown, NJ
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Conclusions

• Decrease in transmission and resistance in
  hospitals using Positive Deviance approach
• Decrease in MRSA clinical incidence
• Intervention-associated reduction in MRSA
  clinical incidence (p-value 0.001)
• Reduction sustained in post-intervention period
• Improvement in S. aureus antibiogram
• Reduction sustained in post-intervention period

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PD a Network Phenomenon
2005
2007
VA Pittsburgh
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Potential Network
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POSITIVE DEVIANCE Growing National Network
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PD and MRSANow

• 60 additional facilities are involved, most are
  hospitals, a few long term care facilities and
  outpatient hemodialysis centersMaryland Patient
  Safety Center, Veterans Administration, Indiana
  University, AHRQ ACTION Network.
• Rockefeller Foundation funding global expansion
  of PD for MRSA and other healthcare problems.

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The DNA of PD

• Solutions for complex problems requiring social
  change already exist in your hospital- Inside
  Job
• Front line staff are on site experts
• Find out from staff whats working or could work
  and enable them to amplify it, do it
• Solutions are co-created, owned sustained by
  the staff
• The whole process is bathed in information- data,
  social network maps, stories
• PDs Values
• Everyone wants to make a contribution that adds
  value
• Everyone is capable of making value-adding
  contributions
• Everyone is treated with respect dignity every
  day

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A New Health System for the 21st CenturyIOM 2001

• Appendix B
• Redesigning Health Care with Insights from the
  Science of Complex Adaptive Systems
• Paul Plesk

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Developing an Epistimology of Approaches to
Improvement

• Defect-Based

• Asset-Based (PD)

• Subject Experts
• K?A?P
• Knowledge Transfer
• Outside-In Best Px
• Roll Out
• Buy-In
• Empower
• Solutions

• Front Line Staff Gurus
• P?A--gtK
• Behavior Transfer
• Inside-Out Best Px
• Peer-to-Peer Spread
• Ownership
• Unleashing Power
• Relationships

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Acknowledgments

• The Staff and Patients at PD/MRSA Beta Sites
  Special Thanks to
• Bob Muder, MD, MS, VA Pittsburgh Healthcare
  System
• Cheryl Squier, RN, ICP, VA Pittsburgh Healthcare
  System
• Rajiv Jain, MD, VA Pittsburgh Healthcare System
• Heidi Walker, RN, former PD/MRSA Prev. Coord.,
  VAPHS
• Candace Cunningham, RN VA Pittsburgh Healthcare
  System
• Cheryl Creen, RN, MSN, VA Pittsburgh Healthcare
  System
• John A. Jernigan, MD, MS, Centers for Disease
  Control Prevention
• Jerry and Monique Sternin, Positive Deviance
  Initiative
• Curt Lindberg, Plexus Institute
• Margaret Toth, MD, CQO, Delmarva Foundation
• Robert Wood Johnson Foundation, Beta Sites and
  their Coaches

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Thank You