Form follows Function, or Function follows Form

[try saying that 10x straight]
I've been a little busy lately and have not had the time to write anything or follow up with my solicitations for guest bloggers. Hopefully I will have lots of stories written by the people directly involved, soon! I promise.

But- just a quick story I wanted to share.
Curt and I had the chance to visit a pilot site this Monday and heard about some pretty awesome stuff happening there. They have a new PD unit up and running for about 3 or so months now and the unit has been making tremendous progress. So when we got to visit the unit, Curt and I were especially excited since we don't really get to "hang out" with the hospital staff, we only hear stories about them and what they're doing. The unit manager, Gene, shared with us some really great stories and the one of how the unit became involved was especially interesting.

Gene has been involved in the project since day one[ 9 or 10months ago] but only as a sideline participant. But once she began hearing stories from the other units she was slowly getting excited about getting her unit on board as well. Although she has been sharing what she had heard and learned with her unit, it is a huge unit and she was worried about the workload and the reaction of her staff. So one day, during one of her regular staff meetings, she talked about bringing the unit on board and how best to start and her concerns and how they can go about getting ready to start. Then one of the staff, a LPN, casually mentioned "What's wrong with now?" And that was it; they started that day.

I know, I know, my narrative is not giving the story due justice. I might be ruining it but this story totally makes me jump out of my seat so I thought I share it here.
Why I think it is so cool? In my experience, whenever I am embarking on something new, I'm usually worrying too much about getting myself prepared to start. Like- getting ready so that I can be ready to start something. Essentially, its fussing over form and function; so really "what's wrong with now?"

I am trying to get the nurse manager to write something for the blog, but if you are familiar with healthcare at all, she has a million and one things still left unchecked on her to-do list.

Meeting the pioneers of Positive Deviance.....

Jerry and Monique Sternin, pioneers of the PD approach and also leading Plexus PD/MRSA Initiative will be keynote speakers at the annual Organization Development Network Conference at the Baltimore Inner Harbor October 21-24th. Here you can learn more about the PD approach and how it can be applicable for problem solving in your organization- PD has been applied to solve intractable issues such as child malnutrition, genital mutilation, medication reconciliation, child trafficking...

Intrigued? Registration information can be found here and today[ Sept 14th] is the last day for early bird rates so do it soon!

----------------------------------
Anyhow, I am working on getting guest pieces from the frontline so hold tight, more great stories to come!

SAVE THE DATE!

When: January 8-9, 2008
Where: Albert Einstein Medical Center
5501 Old York Road
Philadelphia, PA 19141

Positive Deviance: Busting the MRSA Myth

Healthcare associated infections are one of the top ten leading causes of death in the United States. These infections afflict two million patients every year and a growing number of infections are resistant to standard antibiotic treatment. The antibiotic resistant infection most frequently identified in US hospitals is Methicillin Resistant Staphylococcus Aureus (MRSA). The prevalence of MRSA increased 32-fold between 1976 and 2004. For every 1,000 persons in the US there are 46 people who are either infected or colonized with MRSA.

Despite its nationwide increase, MRSA is preventable. Plexus Institute, under a grant from The Robert Wood Johnson Foundation, is spearheading a prevention initiative that involves a partnership among Plexus, the Positive Deviance Initiative at Tufts University, the federal Centers for Disease Control and Prevention, the Southwest Pennsylvania MRSA Prevention Collaborative, the Delmarva Foundation, the Maryland Patient Safety Center, and a nationwide network of 40 hospitals. Six “beta site” hospitals are using Positive Deviance, an innovative social change process, in their MRSA prevention work.

Fighting MRSA is not just a responsibility for epidemiologists and infection control professionals. It requires the attention and energy of every person in the healthcare environment, from van drivers, housekeepers, administrators, and doctor sand nurses to patients, families and visitors. Positive Deviance is one way to create that engagement. We began this project a year ago, and early results in declining MRSA rates are very encouraging. In addition, hospital staffs are reporting improved relationships with patients and among people who work traditionally together as well as those who have not previously collaborated. We’ve known for decade how to prevent infection. The hard part is making sure that all those things are done, all the time. New cooperation and new relationships allow people to find creative ways to make sure all the necessary steps are followed, and to remove the unexpected barriers that prevent them from being followed consistently.

Join us as experienced practitioners present their experiences with PD and the results they have achieved in preventing MRSA transmissions. Learn with team members and PD support coaches who will share their insights on a successful approach to stopping the spread of MRSA. All are welcome!

Stay tuned for more details..............

Thinking about the words we use: a look at buy-in vs ownership

There is a great article in Indianapolis Star yesterday, highlighting a pilot project in Indianapolis in which all hospital systems are screening for MRSA in their ICUs and work with staff to improve hand hygiene and compliance to isolation precautions. Heading this 18-month project is Dr.Brad Doebbeling researcher from the Indiana University School of Medicine and whom we are also working with in our work against MRSA.

One of the really neat things about this particular initiative is the focus on staff involvement in the implementation. When asked about the declining infection rates at a participating site, St.Francis Hospital and Health Centers, the manager of infection control mentioned that getting staff input in the process of planning and implementation of the measures is a major component of its success. But what makes me feel uncomfortable was when she used the words "staff buy-in" to describe this engagement. Am I too picky about this? Maybe, but is it buy-in? or is it something else a little bit more....? So here is the origin of this confusion. I found a great piece written by Henri Lipmanowicz, Plexus board chairman and a PD coach, about this exact thing: And then to see why he is quite an authority in this area, click here.

I think it is very, very important to make a clear distinction between buy-in and ownership and not present them as if they were the same or interchangeable. It is important because buy-in is what everybody talks about and it more often than not doesn’t work precisely because it is the opposite of ownership.

Ownership is when you own or share the ownership of an idea, a decision, an action plan, a choice; it means that you have participated in its development, that it is your choice freely made.

Buy-in is the opposite: someone else or some group of people has done the development, the thinking, the cooking and now they have to convince you to come along and implement their idea without you having been invited at the table upfront before the goose was cooked. They decided without you but now they need your buy-in because without you their great ideas and plans can’t get implemented and so are worth nothing. But since you were not part of the process this great idea is a strange one; you cannot fully understand its history or genesis. Since you were not part of the process you cannot be aware of all the other options that were considered and rejected, and of the thinking that went into these choices. You feel ignored, imposed upon, pushed around, unappreciated and your immune system naturally kicks in to reject this foreign idea. You will look like you agree eventually to this new idea because you have no choice and your masters will cheer believing that you have bought in and that you are now as convinced as they are. Your implementation will inevitably be a pale imitation of what it could have been had you been an owner instead of a “buyer-in” and be truly convinced.

What is wrong with buy-in is the notion that it is perfectly ok for a few to make the decisions and then to impose them on all the others and still expect that they will be willing and able to implement them perfectly as if they had made the decisions themselves. That is a total illusion. It is an illusion that exists because in most organizations there is no evidence showing the difference between what people can accomplish when they implement ideas they developed together versus what happens when they implement ideas that were imposed on them.

Most organizations have no clue about the value of true enthusiasm and true commitment because they have never seen it. And the reason they have never seen it is because they have never created conditions for people to implement ideas they own without reservations. When experts are working very hard at making plans for others (those they consider non-experts) to execute, it is impossible for them to consider, and least of all admit, that enthusiasm and deep understanding by those others (inferior non-experts) could double or triple the impact of their expert ideas. That obviously would defeat their value as experts!!!

Deep understanding can only be achieved by making oneself the journey of discovery and invention. Someone else’s story of the journey will always be a pale imitation of the experience.

If leaders involved UPFRONT all the people that will be involved later on in the implementation there would be no need for buy-in for the simple reason that there would be ownership.

Of course the immediate reaction to such a proposition is that it is ludicrous because it is obviously impossible to involve everybody upfront. Wrong!!! Since it is possible to involve all the people afterwards, it has to be possible to involve them all upfront. And therefore the proper question is not whether but how. There are ways and processes from which to choose depending on the circumstances.

Hence my message is: ANYTIME YOU OR SOMEONE AROUND YOU THINKS OR TALKS ABOUT BUY-IN BEWARE! It is a danger signal telling you that your development and implementation process is missing the essential ingredient of involving all who should be. Reconsider your process before you waste a lot of time and energy or achieve mediocre results. One key is to not separate the development of ideas from the implementation of ideas: the same people should be involved in both and it should be one single integrated process.

To conclude, trying to achieve buy-in is most often an attempt to compensate for a problem that should not have been created in the first place, namely the exclusion of all the people whose buy-in is now being sought from the development process. It is a little bit like the need to motivate people; more often than not it is a sign that the real problem is to avoid de-motivating them in the first place.

I have of course oversimplified and exaggerated in order to make my point sharper. Some disagreement and debate around situations when what I wrote doesn’t apply should help in making the whole distinction between buy-in and ownership clearer.

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.