Author: Rajiv Jain, MD. FACP, Healthcare Consultant
Background
Rajiv Jain, MD. speaks on the MRSA Prevention Initiation and Positive Deviance at VA Pittsburgh Healthcare System
What attracted us to use PD?
Staff own the solutions and the data as opposed to top down solution
Relatively quicker implementation
Less cost (consultants stay in the background)
Sustains itself, can be used as a large scale solution
PD Phase I (2005-2007)
Expanded the MRSA Prevention Program from 1 to 13 units including Nursing Home at VA Pittsburgh Healthcare System (VAPHS)
Duplicated results: 65% reduction in MRSA infections
PD Phase II- (2007-2010)
2007-2010:
Expanded the Prevention Program initially to 8 beta sites and then nationally to 152 Acute Care Medical Centers and Nursing Homes
65 % reduction in infections. (NEJM: 364:15, April 2011)
2010-present:
Maintenance phase
Recent results show 80% reduction in MRSA infection rates (8 years experience, Publication AJIC)
How did we spread beyond VAPHS?
Invited leadership and Staff to come to the alpha site
Warm kick offs with patient and staff stories
Training provided in PD principles and MRSA Prevention approach (Defined “what”)
Staff developed implementation plans for their own facility (developed “How”)
Staff supported by local and National consultants; regular calls; sharing of data; training materials
Staff recognition and strong communications strategy
What gave us confidence to use PD for scale up?
During the beta sites implementation at 8 sites, 4 facilities used PD facilitators over and above the training and support provided by the National MRSA office while remaining 4 facilities were just trained and supported by the Program office in the MRSA bundle which included a component of cultural transformation very heavily influence by PD based approaches at VAPHS. Only difference in the 2 groups was the facilitators. Training visits to alpha site and kickoffs were the same
We observed that the results were quite similar in both groups which implies that learnings from PD based experience at VAPHS got internalized in the system and created a social change that no longer required further facilitation at the local level. It also points out that PD based practices are quite versatile.
Additional reflections
Use of the Patient stories of their personal experience with MRSA infection deepened staff’s understanding of the toll taken by these infections
Each discipline (Nurses, Physicians, House keepers etc.) involvement in development of procedures for prevention of infection and then training their colleagues contributed to social acceptance and change.
Ramp up was made easier as we facilitated the dissemination of this information thru conference calls, e mails , seminars, and sharing of data.
Understanding by staff of their individual role in spread and prevention of infections and greater team work contribute to better compliance with hand hygiene, gowning gloving, cleaning etc. Having a Directive signed by the Secretary also provided affirmation of support at the highest level.
After seeing the excitement in staff, I was convinced that using PD approach was the right way to proceed for scaling things up
CDC MMWR: March 8, 2019 / 68(9);214-219
PD Scales Up…
Vertically
VAPHS (Alpha Site)
RWJF Beta Sites
Horizontally
VHA- 153 facilities
Pittsburgh- From PD/MRSA Prevention to:
Education- Truancy, school drop out
Mental Health- Social isolation, shortened life span
Mood Disorders- Epidemic in U.S. colleges
When to Use PD
Seemingly “intractable problem
The problem is measurable
The problem requires behavioral change
Positive deviants are present in the community
Leadership commitment
Enabling a Patient Safety Culture
Develop an epistemology of approaches to eliminating patient harm that include defect and asset based strategies.
Understand that problems can have simple and complicated technical aspects as well as complex dimensions that require behavior change.
Educate and train staff to be able to define a problem in all of its dimensions, draw from the rich repertoire of improvement strategies and apply the appropriate solutions.
Acknowledgments
Frontline staff and patients of participating hospitals
Bob Muder, MD, MS, VA Pittsburgh Healthcare System
Cheryl Squier, RN, ICP, VA Pittsburgh Healthcare System
Rajiv Jain, MD, VA Pittsburgh Healthcare System
Candace Cunningham, RN VA Pittsburgh Healthcare System
Cheryl Creen, RN, MSN, VA Pittsburgh Healthcare System
John A. Jernigan, MD, MS, CDC
Jerry and Monique Sternin, Positive Deviance Institute
Curt Lindberg, Plexus Institute
Margaret Toth, MD, CQO, Delmarva Foundation
Robert Wood Johnson Foundation
Agency for Health Research and Quality
Beta Site Coordinators and Staff