Acting against MRSA

Jon Lloyd begins the series of guest blogs from the front line. Jon is a retired surgeon and is currently the Coordinator for the Southwest Pennsylvania MRSA Prevention Collaborative for the federal Centers for Disease Control and Prevention and the Veterans Administration Pittsburgh Healthcare System. In this entry, he recounts the experience of using improvisation [inspiration from Keith McCandless and the Billings Clinic team] as a tool for opening dialogue between staff on a unit and orthopedic residents on infection control practices:

Improv with 4West staff and Ortho Residents


Like most hospitals, we have struggled with infection control. Like everyone else, we have tried evidence-based, knowledge-based, technically oriented approaches. We’ve had educational sessions, campaigns on hand hygiene and power-point presentations. We’ve made supplies readily available and put soap dispensers everywhere. We’ve used active surveillance with high tech molecular testing. But all these efforts haven’t made much change in physician behavior. So we decided to approach infection control as a cultural problem, and try to create a fun and safe way to mirror physician behavior back to them, to enable staff to discover their current practices and create their own innovative ways of improving those behaviors. Using improv followed by discussion and refreshments, staff identified problems and came up with four specific solutions, all in less than 40 minutes. Briefly and bulleted, here’s what happened in our 8-9-07 exercise:

• Setting and participants: 4West (a mixed surgical Unit), mock isolation room with debrief room directly across the hall. Isolation room "bugged" with GermGlo everywhere. In addition to 4W staff, the Chief of Orthopedic Surgery and his 5 house staff ("Super Chief," senior and junior residents and intern) were present along with staff from the Ortho Clinic.

• Scene 1: Dressing change on patient in contact isolation precautions for MRSA SSI following ORIF. The patient is played by a male aide. Role switches, by the way, are instructive and invigorating. In an earlier improve, residents and housekeepers and escorts played RNs. Orthopedic residents, their Chairman, Peter Cohen, M.D. and several 4West staff observed. Patient Escort served as director and Charge Nurse facilitated. Director explained that what they were about to see is a condensed, only slightly exaggerated version of what goes on every day. The intent of the improv is to foster safe and fun group learning by doing.

• Action: Entourage of house staff players entered isolation room provoking the RN rounding with them to insist that they come back out and perform HH and don gowns and gloves. Super Chief (SC) says: "We'll only be a minute, just have to change a dressing, gotta get down to the O.R." Without washing his hands, SC put arms in to a gown and gloves and the entourage followed without taking any precautions. SC greeted patient, took scissors out of lab coat pocket and cut through MRSA soaked dressing then put scissors back in pocket. SC’s gown was dangling off his wrists and his tie was flopping around in the wound. When his cell phone rang (the call was staged) SC grabbed the phone from his lab coat, talked, then put it back in his coat. After completing the dressing change, SC threw pus-soaked dressing and contaminated gloves in regular garbage can and placed the soiled gown on hook on back of the door. RN encouraged SC to discard gown. SC replied: "I may return or some one else can use it...just tryin' to save the hospital a little money."

• Debrief: Across the hall in a room with coffee and cookies the facilitator asked, "Based on what we all know about infection prevention precautions, do any of you have concerns about what you just saw?” The junior resident immediately commented on SC’s failure to perform hand hygiene and other house staff entering room with no precautions. The senior resident burst in with commentary on the scissors and cell phone circus. SC, not to be out done, recited the remaining litany of precaution violations: sloppy gowning, improper disposal of contaminated dressing, and hanging used gown on door so that it could be re-used. He also noticed the food tray on the over bed table next to a urinal and used Kleenex. We then turned the lights off and illuminated GermGlow on the hands, face, clothing, cell phone and scissors used by play acting SC. This elicited the usual shock of recognition from the observers.

• Scene 2: Facilitator asked the two residents who are notoriously least compliant with transmission-based precautions to go and change the dressing the right way. They both did everything perfectly; HH, gown/glove, sterile scissors to remove bandage, cell phone unanswered, proper disposal of dressing in the red can, proper removal and disposal of gowns/glove, HH, etc. We returned to the debrief room for more cookies and coffee. This provided an opportunity for the house staff to reflect on what they had seen and done, which led to a rich sharing of their ideas. These included:
(1) Scissors the house staff carry in their lab coats are the ones they use in the O.R., but they are not available on the nursing units. The residents carry them because they are sharper, one blade is blunt and slides under bandage without cutting skin, and they can be autoclaved and re-used. So why can't the nursing units provide them with these scissors?
(2) The gowns suck; it's a nuisance to have to tie them around your neck, so they end up dangling off our wrists. Aren't there gowns with neck loops you can just put your head through?
(3) Put a handle to hang the urinal on the side of the over bed table. That way the urinal isn't vulnerable to tipping over and spilling on the food and other items on the table.
4) Put a coat hanger outside isolation rooms next to the hand hygiene dispenser so we can hang our lab coats up, perform hand hygiene and put on a gown which is kept on a door hanger in an easy, efficient sequence.
Following this flow of terrific ideas, we turned the lights off and shined the UV lamp on the hands, clothing, and personal items of everyone who entered the mock isolation room during the improve. Again, horrors… GermGlow every where. The improv started at 3:30 pm and ended at 4:10 pm. 4W staff and ortho residents lingered for another 15 minutes for more cookies and chatter. Most of the talk was about how fast their ideas would be implemented.
Residents and staff filled out an “Improv Critique Sheet” (see below).

• Outcomes:
(1) A supply of scissors preferred by ortho residents was ordered from central supply. They were available the next morning and the residents used them.
(2) Requisitions for coat hooks on the wall next to the hand hygiene dispensers and handles on the sides of all over the bed tables to hang urinals were filled out, signed by Dr. Jain, Chief of Staff and submitted as urgent requests. These will be available next week.
(3) RNs on 4W found a small supply of gowns with neck loops that fit over the head and don’t need to be tied. They also have thumb holes to facilitate gloving without contamination. Unfortunately they’re plastic and too hot if worn for more than a few minutes. The ideal would be gowns with neck loops and fabric that breathes. The director of supplies has been asked if such a gown is available and if not to ask suppliers to make them. They would sell like hot cakes.
(4) Improvs are planned for the nursing staff on each of the units, medical house staff and attendings and will undoubtedly spread to out patient clinics and support services. As improve actors, we all leave the stage to act our ways into new ways of thinking.
• Learnings:
(1) The apparent amnesia that physicians manifest during patient rounds regarding 158 year old evidence-based infection prevention precautions can be overcome by the dynamic of safe, fun group learning using improvisation.
(2) Knowledge alone does not change behavior.
(3) Bringing knowledge to the surface and learning by doing as a group evokes a desire to change things and simple innovative ideas most of which can be acted upon quickly by expanding the use of existing resources

Jon C. Lloyd, MD, on behalf of front line workers on 4W and the Dept. of Orthopedic Surgery, VAPHS who did all the “work” (fun) on this improv and do the work on a daily basis and who came up with all the great ideas and started acting on them immediately.

“I love acting. It’s so much more real than life.” Oscar Wilde

A note... from the boss

In July, my boss, Curt, was asked to write a blog entry for our funder the Robert Wood Johnson Foundation Pioneer Portfolio to highlight the completion of the first story on PD/MRSA at the Pittsburgh VA Hospital. I thought I would share it here also:

At Plexus Institute I’ve had the chance to be involved in an effort to bring the social change process Positive Deviance (PD) into the healthcare quality improvement world. One aspect of this work deals with the challenge of MRSA. With support from RWJF’s Pioneer Portfolio we’ve organized a network of hospitals to learn about and use PD to reduce MRSA rates. With a bit of experience under our belts now we have our first story, written by Arvind Singhal, a communications scholar at Ohio University and a long-time collaborator with Everett Rogers, about the PD MRSA work at the VA hospital in Pittsburgh, one of our Beta Site hospitals. As you read through this story I think you will pick up a sense for some of the key elements of PD:

- Broad engagement of staff and patients, meaning involvement of more than the “usual suspects”.
- Discovery by the staff of practices by colleagues in the organization who have achieved better results (these are the PD people and practices).
- Encouragement of conversations and connections among a diverse group of people who ordinarily do not work on quality issues together but whose work bears on the problem (like hospital clergy, environmental workers, unit secretaries, nurses, transport staff in the case of MRSA). In the VA story you’ll see that some environmental service workers became real MRSA prevention heroes. The purpose of these conversations is to uncover PDs and barriers to good practice, create innovative new solutions, and build a network of people concerned with the issue.
- A belief that the expertise to tackle tough problems is in the room.
- An acknowledgement that for solutions to last they need to fit the unique history and dynamics of an organization.
- Managers, quality improvement staff and, in the case of MRSA, infection control practitioners, who see their role as not primarily as providing answers and plans to “roll out” but supporting participation and action at the “local level”.

I would really like to know what strikes you about PD and the MRSA story.

I am also wondering if there are tough quality problems you are facing you believe might benefit from a PD approach (as PD is really new in healthcare in the US, the only two issues which have been addressed so far are MRSA and medication reconciliation).

Curt

And speaking of the VA Pittsburgh hospital, it was cited in lead of the July 27, 2007 New York Times front page article on how hospitals are addressing MRSA.

See.. I'm Kind of a Big Deal

As you can see under "about me" I'm the project coordinator, so I...coordinate... things:

There are a couple of cohorts piloting PD for MRSA prevention: the RWJF funded cohort with 6 main sites [what we are calling beta sites] implementing PD and receiving coaching support and about 20 sites [what we are calling partner sites] in the learning phase and doing ad hoc PD, the Veterans Health Administration cohort with 5 VA hospitals, and the Merck Latin America Division cohort in Colombia with 2 main sites. There is also a Maryland cohort [that I do not coordinate but is in partnership with us] with multiple beta sites and partner sites sponsored by the Maryland Patient Safety Center (a collaboration between Delmarva Foundation and The Maryland Hospital Association).
And supporting PD in all the sites are the PD coaches.

And throughout the rest of the blog, you will hear from most of these voices, who are doing the work on the ground level, sharing exciting stories and news, challenges and lessons learned and ultimately how they're changing health care in the US.

Ok so now that is out of the way... here are some pictures of the network


Well here is the fabulous bunch of PD coaches who are providing support to the sites using PD, you can't see them all too well here and we're also missing Kevin and Henri, but good enough for this purpose. If you see them out and about please give them a high-five or a hug, they are working [and often donating alot of their own time] hard alongside the hospital teams to work on MRSA prevention.



This is the group picture of the PD coaches and the teams from the RWJF cohort beta sites, plus CDC epidemiologists, and two physicians from the PD hospital in Bogota, Colombia. Again, if you see or know any of these people, give them a high-five and or a hug, they are working hard and really long hours to prevent MRSA transmission and improve patient care.




So this is my boss, Curt Lindberg
he oversees well pretty much everything and facilitates learning conversations that happen weekly with the PD coaches and every-other-weekly calls with the PD sites. He also reaches out to other organizations, groups, and collaboratives to engage them in our PD/MRSA work. And this is only one of the million of other things he does, like running Plexus.

Meet the Cast

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The pictures [compliments of awesome graphic facilitator and PD coach Keith McCandless] are from a recent meeting we had in Pittsburgh. These are [some] the faces of the people involved in the PD/MRSA work: they include environmental services staff, nurses, doctors, epidemiologists, hospital support services, organizational development consultants, patient quality personnel, people from quality improvement organizations, and PD coaches. All across the country, from New Jersey to California and even from Colombia [!], people came together to learn and share lessons, stories, and strategies in MRSA prevention.

What is PD/MRSA?

In 2005 Plexus Institute received a grant from The Robert Wood Johnson Foundation to launch a pioneering initiative employing positive deviance(PD) to prevent the transmission of MRSA infections in healthcare facilities. This initiative involves a partnership between Plexus, the federal CDC, the Positive Deviance Initiative at Tufts University, the Maryland Patient Safety Center and a nationwide network of 40 hospitals committed to preventing hospital-acquired infections.

What is unique (and congruent with complexity thinking) about Positive Deviance is that it engages all members of a hospital community in the process of discovering successful practices that are already in use by some of its members or in the process of developing new practices. This distributed ownership stands in stark contrast with the conventional top-down protocol driven approach to infection control.

Plexus has recently begun to play an important role in a collaborative initiative at the VA hospital in Pittsburgh (which was the first to start implementation) that has produced very encouraging results. In 2006, for the first time in the history of the hospital MRSA transmission rates for surgical patients have dropped to almost zero.

Impressed by the results at the Pittsburgh VA hospital, the Department of Veterans Affairs engaged Plexus Institute in August 2006 to support five of its hospitals for the first phase of a national effort to tackle MRSA in all 160 VA hospitals in the country. The VA national initiative, called “Getting to Zero” aims to eradicate MRSA throughout its system.

In addition, with sponsorship from the Latin American division of Merck, Plexus has begun to work with a network of hospitals in Colombia to help them apply Positive Deviance in their efforts to combat MRSA.

Interested? Click here to get more background information. And join us on this awesome journey- check our blog often and please feel free to leave comments, ideas, suggestions.