harnessing positive deviance to reduce mrsa infections at the billings clinic
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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
2000
4000
6000
8000
10000
12000
14000
16000
18000
Jun-03
Aug-03
Oct-
03
Dec-0
3
Feb-0
4
Apr-04
Jun-04
Aug-04
Oct-
04
Dec-0
4
Feb-0
5
Apr-05
Jun-05
Aug-05
Oct-
05
Dec-0
5
Feb-0
6
Apr-06
Jun-06
Aug-06
Oct-
06
Dec-0
6
Feb-0
7
Apr-07
Jun-07
Aug-07
Oct-
07
Dec-0
7
Feb-0
8
Apr-08
Jun-08
Aug-08
Oct-
08
Dec-0
8
Month
Gowns/
Month
The Power of “Improv”
• Experiential• Allows self-discovery• Creating sustainable behavior
change• Enjoyable and highly effective
learning experience
Questions ?
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