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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.
The Robert Wood Johnson Foundation (RWJF) supported this project with a grant of $292,250 from January 2006 to January 2008.
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:
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.
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.
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:
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 six institutions Plexus chose to pilot the Positive Deviance MRSA Prevention Partnership were:
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:
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:
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.
Some examples of positive deviants with innovative strategies for MRSA prevention included:
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:
Specific hospital units achieved the following results:
From 2006 to 2008 five of the six hospitals reported hospital-wide reductions in MRSA infection rates:
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:
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.
Reducing methicillin-resistant Staphylococcus aureus infections in hospitals by using the positive deviance approach to organizational change
Plexus Institute Inc. (Bordentown, NJ)
Curt C. Lindberg, M.H.A., D.Man.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
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.
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.
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.
"Social Network Mapping," Plexus Institute, fielded March 2007.
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.
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.
Report prepared by: Gina Shaw
Reviewed by: Richard Camer
Reviewed by: Marian Bass
Program Officer: Rosemary Gibson
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