Harnessing Positive Deviance

to Reduce MRSA Infections at the Billings Clinic

Nancy Iversen, RN, BSN, CICDirector, Patient Safety & Infection

ControlBillings Clinic

Not-for-profit, community owned and governed

Integrated Delivery System

3400 employees

230+ employed physicians representing 35 specialty departments

272-bed hospital, 90-bed nursing home

7 regional branch clinic locations

Multi-state management affiliations and support services

POSITIVE DEVIANCE A Different PROCESS

Better RESULTS

Incidence Rate = # cases / patient days x 1,000

Our Experience: MRSA Incidence Rates

MRSA Incidence Rates(Healthcare-associated Infection Only)

0.13(6 peopleinfected)

0.77(34 peopleinfected)

0.85(38 peopleinfected)

0.75(33 peopleinfected)

0.44(20 peopleinfected)

0.34(14 peopleinfected)

0.21

0.15(4 peopleinfected)

0.32(9 peopleinfected)

0.30(14 peopleinfected)

0.00

0.20

0.40

0.60

0.80

1.00

1999 2000 2001 2002 2003 2004 2005 2006 2007 CY 2008Jan-Dec

May 2006 PD/MRSA

Project began

2005-2007 65%

decrease

2006-2007 55% decrease

J an 1, 2005-Dec 31, 2008 84% reduction in Healthcare-associated MRSA Infections

p < 0.001

2007-CYTD 2008 57% decrease

Active Surveillance began in ICU

J an '07

Active Surveillance began in IPM

Nov'08

CertaintyClear Evidence

Agre

em

en

tA

mong P

art

icip

ants

Close to Far from

Far

from

Clo

se to Simple

Chaotic

Complex

Complicated

Following a recipe

Sending a rocket to the moon

Raising a teenager

Waiting out a storm

Lean - Six Sigma

Positive Deviance - MRSA

What is Positive Deviance?

• An approach used to solve problems requiring social and behavioral change

• Achieves sustainable results by changing cultural norms

Positive Deviance (PD)

Key Principles• Community Ownership• Self-Discovery• The people are “the experts”• Immediacy of action• Emphasis on practice• On-going measurement

reinforcing change

Key Interventions ~

The “Science” Bundle

• Hand hygiene

• Decontamination of the environment and equipment

• Contact precautions for infected and colonized patients

• Active surveillance cultures (ASCs)

MeasurementsMeasurements

• Prevalence Study

• Active Surveillance – nares culture on admission, discharge, transfer or death

• MRSA Infections

• Adherence to hand hygiene and contact isolation

The “Cultural” Bundle

• Make the invisible, visible

~ chocolate pudding to simulate contamination ~

• Reinforce with Feedback

• Solutions that are co-created and owned~ ownership vs. buy-in

~ discovery & action dialogues ~

• Act your way to a new way of thinking ~ create experiences that allow self-

discovery ~

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.

Gown UseJune 2003 – December

2008Gown Usage

June 2003 through December 2008

0

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14000

16000

18000

Jun-03

Aug-03

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Dec-0

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Feb-0

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Feb-0

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Feb-0

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08

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8

Month

Gowns/

Month

The Power of “Improv”

• Experiential• Allows self-discovery• Creating sustainable behavior

change• Enjoyable and highly effective

learning experience

Questions ?