November 2009

Grant Results

SUMMARY

From 2006 to 2008, investigators with the Plexus Institute developed a pilot program at six hospitals to control and reduce the rate of infections of methicillin-resistant Staphylococcus aureus (MRSA), one of the most virulent hospital-acquired infections in the United States.

Investigators used an approach called positive deviance, which identifies individuals and groups within an organization or community who have overcome seemingly intractable problems and spreads their solutions throughout the organization.

Key Results

  • Six institutions participated in the pilot project:
    • Albert Einstein Medical Center, Philadelphia, Pa.
    • Billings Clinic, Billings, Mont.
    • Franklin Square Hospital Center, Baltimore, Md.
    • University of Louisville Hospital, Louisville, Ky.
    • The Johns Hopkins Hospital, Baltimore, Md.
    • VA Pittsburgh Healthcare System, Pittsburgh, Pa.
  • MRSA rates declined by 73 percent in four of the six pilot units (Albert Einstein, Billings Clinic, Franklin Square Hospital Center and the University of Louisville Hospital Center). Two of the six institutions did not report unit-level data (The Johns Hopkins Hospital and VA Pittsburgh Healthcare System).
  • The aggregate rate of MRSA infections per 1,000 patient days dropped from 4.36 in 2006 to 1.17 in 2008 among the four pilot hospital units that reported.
  • Three of the six hospitals expanded the approach from the initial pilot units to at least one other unit (The Johns Hopkins Hospital, Franklin Square Hospital Center and University of Louisville Hospital).
  • Three hospitals adopted the project throughout their entire institutions (Billings Clinic, VA Pittsburgh Healthcare System and Albert Einstein Medical Center).
  • The results achieved by the pilot institutions spurred 53 additional hospitals in the United States, Canada and South America to adopt the positive deviance approach in their drives to prevent MRSA transmission.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project with a grant of $292,250 from January 2006 to January 2008.

 See Grant Detail & Contact Information
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THE PROBLEM

Between 5 and 10 percent of all hospital patients contract an infection during their hospital stays. Despite campaigns in hospitals to increase the rates of hand-washing and other antiseptic techniques, these hospital-acquired infections have risen significantly in recent years. According to the Centers for Disease Control and Prevention (CDC), about 1.7 million people acquire an infection while in a U.S. hospital every year, and nearly 100,000 die as a result of their infections. Hospital-acquired infections cost an estimated $6.5 billion in additional health care every year.

A growing cause of hospital-acquired infections is methicillin-resistant Staphylococcus aureus (MRSA), a virulent strain of bacteria resistant to commonly used antibiotics. The CDC reports that nearly 95,000 people developed MRSA infections associated with their hospital care in 2005, and approximately 18,650 of them died as a result. The United States now has the second highest MRSA infection rate in the world.

Researchers have documented effective techniques for preventing the transmission of MRSA. Some U.S. hospitals and hospital units, and countries such as Denmark, Finland and the Netherlands, have successfully brought MRSA rates under control using similar protocols, such as those described below:

  • Active surveillance cultures to identify all patients with MRSA and isolation of all patients colonized or infected with MRSA.
  • Barrier precautions (such as the use of gloves, gowns and disposable equipment) on all patients colonized and infected with MRSA.
  • Strict hand hygiene before and after every patient contact.
  • Environmental cleaning.

But traditional strategies designed to persuade hospital staff to adopt these practices and adhere to them faithfully—such as educational campaigns, initiation of best practice programs and other quality improvement initiatives—have not been effective. Although the necessary interventions are low-tech and inexpensive, they require changing behavior rather than recalibrating machines, and successful implementation is therefore much more variable. The problem is not lack of knowledge about control and prevention techniques, but the difficulty, and sometimes the inability, to translate that knowledge into social and behavioral changes within the complex structures of hospitals and health care systems.

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RWJF STRATEGY

According to RWJF's 2005 Annual Report, "[t]he Pioneer Portfolio supports innovative projects that can lead to fundamental breakthroughs in the health and health care of Americans. We seek to invest in high-return ideas that could have major impact in the future, even though the probability that projects will lead to such breakthroughs is uncertain.…

"In 2005, the Pioneer Portfolio pursued this objective through a mix of projects aimed at helping us think more precisely about the trends and strategies that may define the future of health and health care.…

"Our immediate focus is to develop a strategic approach that will attract new ideas and breakthrough innovations. Our longer-term objective is to assess and steer our investments toward projects that are most likely to result in breakthrough advances in health and health care."

RWJF issued its grant to the Plexus Institute for research on methods to reduce hospital-based transmission of MRSA (methicillin-resistant Staphylococcus aureus) in 2005. To read more about RWJF's interest in this subject, please visit the Pioneer blog.

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THE PROJECT

The Plexus Institute, a nonprofit organization that uses "complexity science" to tackle problems in health care organizations and other institutions, developed a pilot program employing positive deviance to reduce methicillin-resistant Staphylococcus aureus (MRSA) infection at six U.S. hospitals. The project had three goals:

  • Reduce MRSA infection rates in pilot nursing units by 75 percent.
  • Expand MRSA prevention efforts in participating hospitals beyond the initial pilot units.
  • Spread the positive deviance methodology for MRSA prevention to other hospitals.

What Is Positive Deviance?

Positive deviance is based on the observation that, in most communities, there are certain individuals or groups—positive deviants—whose special practices or strategies help them to find better solutions to prevalent, seemingly intractable problems, than do their peers, who have access to the same resources.

Through a process of facilitated small group interactions called discovery and action dialogues at the study institutions, participants identified these individuals and their strategies, and highlighted the strategies in order to spread them throughout the organization. The approach enables the very people whose behavior needs to change to discover effective solutions that already exist within their institution or community. Rather than imposing externally defined best practices, as is common in many quality-improvement initiatives, organizations using the positive deviance approach generate solutions from within. And because they come from within, these solutions are less likely to be rejected as impractical, too difficult or inappropriate for a particular institution's culture.

The positive deviance approach has been used around the world to generate solutions to complex health care problems, including childhood malnutrition, infant mortality and morbidity, poor pregnancy outcomes and the spread of HIV.

The Pilot Institutions

The six institutions Plexus chose to pilot the Positive Deviance MRSA Prevention Partnership were:

  • Albert Einstein Medical Center, Philadelphia, Pa.
  • Billings Clinic, Billings, Mont.
  • Franklin Square Hospital Center, Baltimore, Md.
  • University of Louisville Hospital, Louisville, Ky.
  • The Johns Hopkins Hospital, Baltimore, Md.
  • VA Pittsburgh Healthcare System, Pittsburgh, Pa.

These sites agreed to use positive deviance to engage staff in determining how to consistently employ the following evidence-based precautions in at least one pilot unit:

  • Active surveillance MRSA cultures on all patients on admission/discharge/transfer.
  • Hand hygiene before and after every patient contact.
  • Barrier precautions (such as the use of gloves, gowns and disposable equipment) on all patients colonized or infected with MRSA.
  • Environmental cleaning.

Project leaders at each hospital launched the intervention with a kick-off event attended by staff members from all hospital departments. Project leaders described the problem of MRSA infection and the positive deviance approach to reducing it. Patients told stories of their experiences with the infection. Project leaders then called for volunteers to help identify a pilot unit at each hospital where MRSA reduction techniques uncovered with the positive deviance approach could be introduced.

To identify positive deviant practices, the hospitals held discovery and action dialogues with hospital staff members. These small, facilitated group discussions, which included diverse front-line health care workers, ranging from physicians and nurses to lab technicians, housekeepers, unit secretaries, social workers, chaplains, food service staff and patient transporters, fostered wide networks and increased conversation. Facilitators asked staff members questions such as:

  • What steps do you take to prevent transmission of MRSA?
  • What prevents you from taking these steps all the time?
  • Do you know of anyone who has overcome those barriers?

Project team members trained hospital staff to facilitate the sessions. They participated as coaches at first, and then transitioned out as the staff members became more adept at facilitation. The staff who led the sessions varied; they included nurses, infection control specialists, quality control personnel and organizational development staff.

Pilot hospitals held numerous dialogue sessions, at different times of day and on different days of the week so that all staff had an opportunity to participate. Once group members identified a new positive deviant (PD) practice during the discussions, facilitators called for volunteers to step forward to take on the spread of the innovation. Participants also created PD practices.

In addition to the small, group dialogues, the hospitals identified positive deviant approaches using statistics. If a hospital had a particular unit with much lower MRSA rates than the others, staff involved in the pilot project would visit that positive deviant unit and observe its practices to find out what its staff was doing differently.

The pilot hospitals supported one another and shared innovations through biweekly conference calls, as well as regular, informal e-mails and phone calls between participants. They also held regular, face-to-face meetings to share experiences, ideas and data.

Positive Deviants in Action

Some examples of positive deviants with innovative strategies for MRSA prevention included:

  • Jasper Palmer, a patient transport worker at Albert Einstein Medical Center, became concerned that gowns were overwhelming hospital trash cans and spilling out of disposal bins, ending up on the floor and increasing contamination. Palmer created a method for taking off a gown, rolling it into the size of a baseball, and pulling his gloves over the gown to contain it. A nurse noticed his approach and spread it around as part of the positive deviance project. In most hospitals, surgical procedures are named after the surgeons who create them; this de-gowning approach was dubbed the Palmer Method. Hospital staff created a YouTube video of Palmer's technique. At a regional workshop on MRSA prevention, Einstein sent Palmer, a unit secretary and a nurse to speak.
  • A patient transport worker at Albert Einstein Medical Center realized that guidelines from the CDC did not address specific situations he experienced in transporting isolation patients to support services. He and his colleagues worked with clinicians to develop precautions that included performing hand hygiene and donning gloves and gowns before moving the patient onto a gurney and wrapping the patient in a clean sheet. They then remove their protective garments, sanitize their hands and the hand rail, place a previously prepared clean plastic bag containing clean gloves, gowns and a small bottle of hand gel on the gurney, and transport the patient. The receiving department gets verbal instructions and the necessary supplies to adhere to precautions. This process is now part of everyone's routine.
  • Staff members at the VA Pittsburgh Health System found that two patients who had become MRSA-positive during their stay had occupied the same room. Wondering if there had been contamination in the room that routine cleaning had missed, housekeeping staff observed room cleaning procedures and discovered they were highly variable. They designed, refined and tested a cleaning checklist that consisted of color photos of the room with black dots on areas requiring daily cleaning and red dots on areas requiring cleaning when a patient checks out.
  • Walter Fairfax, M.D., a critical care physician at the Billings Clinic stopped wearing ties to the hospital, since ties can transmit MRSA. After he did this, medical students cultured ties and found a variety of organisms, so many medical staff members stopped wearing neckties, white coats and long sleeves.

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RESULTS

Reduction of MRSA Rates

Between 2006 and 2008, the Positive Deviance MRSA Prevention Partnership significantly reduced the rate of methicillin-resistant Staphylococcus aureus (MRSA) infections in the pilot units:

  • MRSA rates declined by 73 percent in four of six pilot units reporting. These were Albert Einstein, Billings Clinic, Franklin Square Hospital Center and the University of Louisville Hospital Center. The Johns Hopkins Hospital declined to report MRSA infection rates after running afoul of federal reporting requirements on another project. The VA Pittsburgh Healthcare System began its positive deviance MRSA prevention program on a facility-wide basis and did not pilot test.
  • The aggregate rate of MRSA infections per 1,000 patient days dropped from 4.36 in 2006 to 1.17 in 2008 among the four pilot hospital units that reported.

Specific hospital units achieved the following results:

  • The surgical intensive care unit at Albert Einstein Medical Center achieved a 70 percent drop in the rate of hospital-acquired MRSA infections from 2006 to 2008, yielding a 2008 rate of 0.81 infections per 1,000 patient days.
  • The intensive care unit at Billings Clinic achieved a 100 percent drop in the rate of MRSA infections from 2006 to 2008, yielding a 2008 rate of 0.00 infections per 1,000 patient days.
  • The intensive care unit at Franklin Square Hospital Center attained a 100 percent drop in the rate of MRSA infections from 2006 to 2008, yielding a 2008 rate of 0.00 infections per 1,000 patient days.
  • The intensive care unit at University of Louisville Hospital realized a 65 percent drop in the rate of MRSA infections from 2006 to 2008, yielding a 2008 rate of 4.33 infections per 1,000 patient days.

From 2006 to 2008 five of the six hospitals reported hospital-wide reductions in MRSA infection rates:

  • Albert Einstein Medical Center—35 percent reduction.
  • Billings Clinic—89 percent reduction.
  • Franklin Square Hospital Center—49 percent reduction.
  • University of Louisville Hospital—36 percent reduction.
  • VA Pittsburgh Healthcare System—33 percent reduction.

Expanding Beyond the Pilot Units

  • Three of six pilot hospitals expanded their initial efforts beyond the pilot unit to at least one other unit in the hospital.
    • University of Louisville expanded to four units.
    • Franklin Square Hospital Center expanded to two units.
    • The Johns Hopkins Hospital expanded to three units and to another hospital in its system.
  • Three hospitals adopted the project throughout their entire institution. These were:
    • Billings Clinic.
    • VA Pittsburgh Healthcare System.
    • Albert Einstein Medical Center.

Online MRSA Surveillance System

  • Creation of the nation's first online MRSA surveillance system, in partnership with the Centers for Disease Control and Prevention (CDC).
    • Initially developed to help the pilot sites evaluate their performance, the system has now been incorporated into the CDC's National Healthcare Safety Network (NHSN), making it available to all hospitals in the United States.

Expansion to New Hospitals

According to the project team, the results achieved by the pilot institutions spurred 53 additional hospitals to adopt the positive deviance approach in their effort to prevent MRSA transmissions. These included:

  • Five Department of Veterans Affairs hospitals.
  • Some 35 health care facilities participating in a statewide collaborative led by the Maryland Patient Safety Center and the Delmarva Foundation.
  • Six hospitals participating in a regional MRSA collaborative led by Indiana University.
  • Two hospitals in Colombia, South America.
  • Six hospitals in a MRSA collaborative sponsored by Ontario Agency for Health Protection and Promotion (OAHPP) in Canada.

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LESSONS LEARNED

  1. Engagement of front-line staff is even more essential than leadership support in changing behavior. Senior leadership were actively involved in initiating the positive deviance process at their hospitals, established a supportive climate and dealt quickly with systematic barriers to good infection prevention practices. Nonetheless, positive deviance did not gain real traction in the pilot sites until unit and other hospital staff became engaged. (Project Director/Lindberg)
  2. More intensive, early coaching would speed the implementation of positive deviance. Pilot site leaders and their coaches said that more intense coaching in the beginning of the effort would have helped the process move along more rapidly. (Project Director/Lindberg.)
  3. Use of selected positive deviance process measures, such as the number of discovery and action dialogues held and the diversity of participants (referred to in positive deviance parlance as unusual suspects), would also have supported more rapid uptake of the approach and would have served as indicators of progress. "Attention in the beginning of the process was on outcome data (methicillin-resistant Staphylococcus aureus [MRSA] infections and transmissions) and infection control process (hand hygiene, gloving, gowning). Upon reflection, this should have been coupled with attention to process measures," said project director Lindberg. (Project Director/Lindberg)
  4. Be patient and let the plans emerge from the staff. "We called it 'go slow to go fast,'?" project director Lindberg said. "Infection control is dependent on the actions of literally hundreds of staff members. They have to be engaged in some way at some time, but once they do get engaged, then it begins to cook. In our hospitals, it took about a year for things to really start moving." (Project Director/Lindberg)

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AFTER THE GRANT

Jon Lloyd, M.D., a retired surgeon who served as the coordinator of the Pittsburgh (methicillin-resistant Staphylococcus aureus) MRSA Prevention project, joined Plexus as senior clinical advisor, MRSA prevention, to help maintain and expand the network of organizations devoted to positive deviance and MRSA prevention.

Plexus was slated to serve as a major subcontractor, on a $1.8 million grant to Indiana University for MRSA prevention and research, from the federal Agency for Healthcare Research and Quality.

Plexus is assisting six Canadian hospitals in a positive deviant MRSA prevention collaborative sponsored by the Ontario Agency for Health Protection and Promotion.

The Centers for Disease Control and Prevention (CDC) awarded a grant to the Delmarva Foundation (a national, not-for-profit organization with a mission to improve health in the communities they serve) to develop and implement a protocol for social network analysis (SNA) in hospitals using positive deviance in MRSA prevention efforts. Plexus planned to partner with Delmarva on this $300,000 grant, which is renewable for four years.

Plexus engaged the New York-based National Executive Service Corps to develop a business plan for expanding its positive deviance MRSA initiative nationally.

Plexus planned to publish a book on the project, co-written with help from individuals at the pilot institutions.

Plexus was invited by The Joint Commission to submit an article on the PD MRSA initiative. The article was submitted October 3, 2009.

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GRANT DETAILS & CONTACT INFORMATION

Project

Reducing methicillin-resistant Staphylococcus aureus infections in hospitals by using the positive deviance approach to organizational change

Grantee

Plexus Institute Inc. (Bordentown,  NJ)

  • Amount: $ 292,250
    Dates: January 2006 to January 2008
    ID#:  055726

Contact

Curt C. Lindberg, M.H.A., D.Man.
(609) 298-2140
curt@plexusinstitute.org

Web Site

http://www.plexusinstitute.org/complexity/index.cfm?id=3

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Buscell P. "Mapping the Positive Deviance/MRSA Prevention Networks at Pennsylvania and Montana Health Care Facilities Shows Promise." Prevention Strategist, 41–45, Autumn 2008.

Cohn J. "Positive Deviance Model Keeps MRSA at Bay," Occupational Health and Safety Online, January 23, 2008. Available online.

Lindberg C, et al. "Letting Go, Gaining Control: Positive Deviance and MRSA Prevention." Clinical Leader, in press.

Lloyd J, Buscell P and Lindberg C. "Staff Driving Cultural Transformation Diminishes MRSA." Prevention Strategist, 10–15, Spring 2008.

Reports

Buscell P. More We Than Me, How the Fight Against MRSA Led to a New Way of Collaborating at Albert Einstein Medical Center. Bordentown, NJ: Plexus Institute, January 2008. Also available online.

MRSA Tumaround Document: Description of New Approaches That Have Evolved During the Course of the PD/MRSA Initiative to Combat Health Care Acquired Infection. Bordentown, NJ: Plexus Institute, August 2008.

Singhal A and Buscell P. From Invisible to Visible: Learning to See and Stop MRSA at Billings Clinic. Bordentown, NJ: Plexus Institute.

Singhal A and Greiner K. Do What You Can, With What You Have, Where You Are: A Quest to Eliminate MSRA at the VA Pittsburgh Healthcare System. January, 2008. Available online.

Audio-Visuals and Computer Software

Antibiotic Resistant Bacteria, a 60-minute audiotape of presentation and community discussion. Bordentown, NJ: Plexus Institute, February 15, 2008. Available online.

Positive Deviance in the Fight Against MRSA, a 60-minute audiotape of presentation and community discussion. Bordentown, NJ: Plexus Institute, June 6, 2008.

MRSA Attack Plan. A 2-minute video produced with Medstar television about the positive deviant MRSA project at Johns Hopkins. Bordentown, NJ: Plexus Institute.

Survey Instruments

"Social Network Mapping," Plexus Institute, fielded March 2007.

World Wide Web Sites

http://PDMRSA.blogspot.com. Created by Plexus Staff member Tuyen Tran for member discussion and information and contribution by invited bloggers.

www.plexusinstitute.org/complexity/index.cfm?id=3. Web page devoted to positive deviance and methicillin resistant Staphylococcus aureus, includes stories and articles from several sources about this work.

Presentations and Testimony

Jon Lloyd, "Positive Deviance and MRSA Prevention," at the International Society of Microbial Resistance Policy Forum George Mason University on February 9, 2007, Fairfax, VA. Proceedings available online.

Jerry Sternin and Monique Sternin, "Positive Deviance and MRSA," at the Association of Professionals in Infection Control (APIC) National Conference, June 24, 2007, San Jose, CA. Conference proceedings available online.

Jon Lloyd, "Update on Healthcare-Associated Infections Part 1: The Changing Face of MRSA in the Hospital and the Community," for the Voluntary Hospital Association, October 23, 2007. Live satellite broadcast and webcast.

Jon Lloyd, "Update on Healthcare-Associated Infections Part 2: Building a Culture of Safety," for the Voluntary Hospital Association, October 23, 2007. Live Satellite broadcast and webcast.

Jon Lloyd and Margaret Toth, "Engaging Your Team: Advanced Collaboration Techniques; Who to Include and How to Get Buy-in From the People That Matter Most," for Voluntary Hospital Association VHA Accelerated Improvement Network: Eliminating MRSA—Wave 2, Session #1 November 2007 webinar.

Jon Lloyd, "Positive Deviance: How a Unique and Innovative Approach Is Making a Difference," at Annual Safer Healthcare Now! Conference, April 1–2, 2008, Winnipeg, Canada. PowerPoint® presentation available online.

Curt Lindberg, "Positive Deviance: Tools and Application," at Safer Healthcare Now Western Node MRSA Collaborative Meeting, October 27–28, 2008, Calgary, Canada. Proceedings are available online.

Jon Lloyd, Curt Lindberg and John Jernigan, "Positive Deviance: A Different Process, Better Results," at the IHI Annual Forum, December 8, 2008, Nashville, TN.

Nancy Iversen, et al, "Billings: Hospital-Wide Decrease in Methicillin-Resistant Staphylococcus aureus (MRSA) After an Intervention in a Community Hospital," CDC analysis was presented at a special late-breaker session during the Society for Healthcare Epidemiology of America's 19th Annual Scientific Meeting on, March 21, 2009. The CDC team concluded that successful implementation of the multifaceted MRSA prevention program using positive deviance resulted in significant MRSA reduction with sustained decreases demonstrated over time. Abstract available online.

Katherine Ellinson, et al, "Multi-Center Prevention Effort Significantly Cuts MRSA," CDC analysis was presented at a special late-breaker session during the Society for Healthcare Epidemiology of America's 19th Annual Scientific Meeting on, March 21, 2009. The CDC team concluded that successful implementation of the multifaceted MRSA prevention program using positive deviance resulted in significant MRSA reduction with sustained decreases demonstrated over time. Abstract available online.

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Report prepared by: Gina Shaw
Reviewed by: Richard Camer
Reviewed by: Marian Bass
Program Officer: Rosemary Gibson

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