Change the culture, protect the patient using 'positive deviance' to prevent MRSA
Empowering workers to make change that lasts
"Maybe the problem is that you can't import change from the outside in. Instead, you have to find small, successful but 'deviant' practices that are already working in the organization and amplify them. Maybe, just maybe, the answer is already alive in the organization — and change comes when you find it."
— Jerry Sternin, director of the Positive Deviance Initiative, www.positivedeviance.org.
An increasing number of hospitals are applying an exotic-sounding philosophy to solve an all too ordinary problem: patient infections with methicillin-resistant Staphylococcus aureus (MRSA). It's called "positive deviance" (PD) and it is not an insult. It is, infection preventionists say, a potentially dramatic breakthrough to culture change for hospitals that still are taking a business-as-usual approach while MRSA kills more patients every year than HIV.
PD is not a one-bug intervention, and indeed has been used to attack problems ranging from hunger in Third World villages to high school dropout rates in the United States. The essence of the PD approach is that the answer lies within the community with the problem. In health care, for example, somebody may have found a solution that eluded the typical top-down management approach. To give but one example, a nurse who never forgot to culture for MRSA on patient discharge — unlike many of her colleagues — simply taped a swab on the patient door that day. Unknown barriers may exist to — or even be created by — carefully worded policies and mandated practices. Workers must routinely overcome those barriers in individual units or recurrent situations. Some stop at the barrier and the original goal is lost. Others solve the problem in their own way. Can their answers be applied systemwide? First, you have to look for your 'positive deviants,' those that have taken a different path and found solutions that were not necessarily in the manual.
"It was a little odd at first," says Dorothy Borton, RN, BSN, CIC, infection control practitioner at Albert Einstein Healthcare Network in Philadelphia. "Most of the time [deviance] has a negative connotation, but it helped people think outside the box. It's not so much 'buying in' as already owning it. We're used to giving everybody the answers and telling everybody what to do, but I am not the one providing care every day and I don't know all the nuances of what they do."
Another PD key is to bring health care workers of every stripe into the conversation about problems and solutions, which can come from some unlikely places, she says. "When we started talking to folks about trying to stop transmission of MRSA, there was a lot of blending of personnel and positions in those conversations," Borton tells Hospital Infection Control. "Anybody was welcome. It could be a medical clerk, housekeeper, an aide, an RN, a physician, a dietitian. 'Unlikely suspects' is a term we use a lot in PD. Folks that you would not think of as the first person that would have the answer. Sometimes it was very clear to them. They would make a suggestion and others would say, 'That's it.'"
'Nothing about me without me'
A common PD saying is, "Nothing about me without me," she says. "In other words, you can't talk about somebody else or assign them a responsibility unless they are at the table to discuss it with you."
Borton became intrigued by the potential of PD when she and a colleague attended a conference on using this novel approach to reduce MRSA. They were excited and convinced that the PD process could be applied to the growing MRSA problem. After a kickoff in May 2006, four units volunteered to be PD pilot units. Using the PD process, the staff in the communities (units) identified barriers to compliance with evidence-based practices of hand hygiene and contact precautions: complaints that isolation gowns were hot and often unavailable upon entry to isolation rooms, hand sanitizer dispensers weren't as available as staff desired, isolation signs were confusing and hard to read, and communication about patients in isolation was poor.
The staff then suggested ways to remove barriers, and interventions and improvements were under way. As a result, MRSA in the pilot units decreased from 0.7 infections/1,000 patient days in FY '07 to 0.5 infections/1,000 patient days in the first quarter FY '08. "I think we can do better," Borton emphasizes. "Those data were coming in when not all of our units were up and doing PD. We now have all of our med/surg units, critical care units and step-down units involved in the process. We anticipate those numbers will go lower because everyone is coming into the process."
Role-playing, grass-roots solutions
In addition, hand hygiene compliance has dramatically increased from the 50% range it was hovering around. For example, some workers said they washed their hands when they went into a patient room but did not feel comfortable reminding others to do so. Others that knew the danger such workers posed to their patients would speak out, but then found themselves in uncomfortable, combative situations. However, a couple of nurses said they were successful in addressing the problem through diplomatic, gentle reminders and modeling behavior of good hand hygiene. As a result the other workers did some role-playing exercises to prepare for such situations while a physician "champion" volunteered to spread the good word to his peers, she says. "Once they had success, then it would feel better the next time."
The PD program included MRSA surveillance cultures on admission, transfer and discharge in certain units to determine if transmission was occurring. "Initially, people were having difficulty remembering to get their swabs," Borton says. "Some had a pretty good record while others were forgetting all the time."
One approach was recommended by the aforementioned nurse who taped the swab on the door on the day of transfer or discharge. "Someone else on a different floor said a clerk had a list of everybody who was being discharged and would ask the nurses if they swabbed the patients," she says. "These are things that only insiders to the unit would think about."
In an unusual example that emphasizes how much support the hospital gave the workers, several alternative gowns were considered to replace a gown that was "too hot" when used routinely for isolation rooms. Ultimately, the workers decided to go back to the original gown after finding other problems in alternative models "The grass isn't always greener, but the value of that whole exercise is now they are not fussing about the gowns being hot," Borton says. "They know they're hot but they say, 'We checked and there's nothing better out there.'"
Workers also said protective equipment in general was too difficult to access, thus a one-stop station by the door was added to hold such items as gloves, gowns, and masks. "The hardest thing for many of us at first was to let go and trust that people can work this out," she says. "Leadership's role is to remove the barriers."
Pittsburgh VA leads the way
The first hospital to try the PD approach to reduce MRSA was the Pittsburgh VA in 2005. They had already had success — a 50% reduction in two units using an industrial model to standardized practice. However, they wanted to take it a step further, says Jon Lloyd, MD, who originally worked with the hospital as a liaison for the Centers for Disease Control and Prevention. They heard about the Positive Deviance Initiative (http://www.positivedeviance.org/). PD pioneer Jerry Sternin was showing that the approach could solve all kinds of problems, but reducing health care infections had not been one of them at that point. "We looked to this approach because of the failure of traditional approaches," says Lloyd, who now is coordinator of the national MRSA prevention network and senior clinical advisor for the Plexus Institute in Bordentown, NJ.
"Health care workers have known about the efficacy of standard and contact precautions for quite a few years," he says. "[Hand washing] since 1847. It's not primarily a knowledge gap. Every hospital has infection control guidelines. They are in a manual and we all know that everyone reads them, commits them to memory, and adheres to them religiously. It is a total fantasy. As a result of the failure of the traditional approaches, we are involved in a national [MRSA] epidemic."
Albert Einstein Medical Center and several other hospitals followed Pittsburgh's lead and a beta network was born that now has led to a national movement. "There's been more than a 50% reduction in all 14 units at the VA since 2005," Lloyd says. "The pooled data from the five other sites show a 2.9% reduction per month over a year period, so it is about a 35% drop in the one year's worth of data that we have."
In implementing the program, Lloyd looked for solutions and suggestions among all staff, including ministers that console patients in isolation rooms. Explaining how MRSA can be transmitted by vectors such as stethoscopes, he stumbled on a saintly source that could only come from a minister. They dutifully gowned and gloved before going into contact isolation rooms, but they carried the Good Book from patient to patient, often letting them hold it to read passages. "'I think we may be passing on more than the good word with our scriptures,'" Lloyd recalls one told him. "So they started performing Bible hygiene."
Some used a vinyl cover that could be decontaminated between patients, while others used disposable OR hats as a book cover between patients, he noted.
Another unlikely source to MRSA prevention was the housekeeping staff. Some said they had independently adopted their own cleaning methods in some cases because the hospital cleaning protocol was hard to follow, was written only in English, and did not use any illustrations. They worked with infection preventionists to review every area of a room that should be cleaned between patients. The process included a little "Glo Germ" to show them spots they were missing. As a result, they came up with their own cleaning checklist.
"They were so proud of that they laminated it and put it on every cleaning supply cart," Lloyd says. The housekeepers had seen doctors and nurses using checklists to insert central lines and now took pride in preventing infections rather than just cleaning rooms. "They were thinking of their job as an infection control procedure, not just cleaning up a room when a patient goes home," he says. "To me, that is one of the most eloquent examples of PD's simplicity. The housekeepers really owned it. The closer these solutions are to the people who actually do the work, the simpler and less expensive they are. And since they create them, they don't turn their backs on them. I think that these solutions are much more likely to endure than those that come from the top down."
Indeed, a hospital CEO might balk at enforcing MRSA infection prevention solutions that come from ministers and housekeepers, but PD spreads rapidly among peer groups without being mandated from the top. "Once they work, staff tend to want to share them peer to peer," Lloyd adds. "So housekeepers on one unit that have had a breakthrough will share that with each other. The solutions spread like a virus. You create the freedom and opportunity for the frontline workers to share their ideas and make decisions. Enabling them to act on their ideas, we found, led to some impressive reductions in transmission."
That said, the success should not lead to some national mandate, which would, after all, run counter to PD's principles, he notes. Better to let it arise and flourish in hospitals that see it as an attractive alternative. "It's for hospitals that are interested in learning how to listen actively to their staff, who believe that it's easier to act your way into a new way of thinking than to think your way into a new way of acting," Lloyd says.
However, PD doesn't stand for "panacea delivered." It's too early to tell whether it will have widespread implications for infection prevention, but simply bringing in workers from all levels and specialties to solve problems may yield benefits. "I don't know that it fits every facility, but it is a great fit for us," Borton says.
An increasing number of hospitals are applying an exotic-sounding philosophy to solve an all too ordinary problem: patient infections with methicillin-resistant Staphylococcus aureus (MRSA).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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