Reflections
These reflections were written by MD’s about their experiences using the Positive Deviance (PD) approach in the field of healthcare in the U.S. The reflections below deal mostly with the issue of the hospital acquired infection methicillin-resistant Staphylococcus aureus (MRSA) but also offer general insight into the challenges and rewards of using the PD approach to solve difficult problems.
Reflections of Jon Lloyd, MD
In this Reflection, Jon begins by explaining that the techniques that bacteria use to survive (by using the 4 C's: communicating, collaborating, connecting, and coordinating) are the very techniques that many healthcare professionals fail to employ – leading to a fragmented and vulnerable healthcare system where hundreds of thousands of patients die annually from healthcare acquired infections (HAI's). Jon goes on to explain how the use of the PD approach in six hospitals in the US has lead to statistically significant and sustained reductions in MRSA and other HAI's. Jon explains that providing the freedom and opportunity for the people who directly interact with the patients to share their successful practices and to take ownership of solutions has lead to both a social system and bio-system change from within.
Reflections of Margaret Toth, MD
This Reflection explores the tendency to use "best practices" rather than the PD approach to promote change, which often causes a "social immune response" in the people who are forced to implement the "best practices" as defined by people external to their community. However, when the PD approach is used to find high quality ideas from within, people are able to take ownership of the idea and of the process of implementing the idea, making the changes long-lasting.
In this Reflection, Margaret explores the idea of "Best Practices" and the fact that looking externally for ideas and solutions is natural and acceptable as long as it is done by the people whose behavior need to change, at a point at which they have already had a chance to explore their own ideas.
In this Reflection Margaret discusses the difficulty she has as a facilitator of the PD process to be a strong listener and consequently trying to figure out "how to turn the work back over to the staff generating the ideas and solutions." Friend and fellow PD advocate, Dr. Jon Lloyd, inspired Margaret to realize that the facilitator role does not carry ideas back to the staff, but simply LEAVES THEM WITH THEM.
In this Reflection Margaret explains a response she wrote when asked a question about the risks involved with physicians not washing their hands. Margaret's response, which she recognizes as being a much different response from one she would have previously given, recognized that hand washing does not just apply to physicians and should not be the only consideration when discussing MRSA prevention. MRSA prevention, Margaret emphasizes, involves every person who comes in contact with the care environment and involves the entire community.
Margaret presents the challenge the challenge of teaching positive deviance during a very brief one hour presentation. Rather than attempting to teach PD in under one hour, Margaret gave the audience a set of questions to help them begin exploring ways to make their environment safer and to help the audience experience what it feels like to use PD. Margaret also explores the way in which PD spread on its own after being used in Viet Nam by Jerry and Monique Sternin.
Margaret shares stories that lie at the heart of Positive Deviance, including a story about a new physician from New Mexico who was surprised and horrified to discover that she was unknowingly carrying MRSA on her stethoscope. Margaret also shares a story that Jerry Sternin often told about Nasrudin and the donkeys.
Margaret discusses "unusual suspects"- in this case patients, and shares excerpts from the blog of a man with scleroderma, which details his eye-opening interactions with hospital staff.
In this Reflection Margaret discusses a team in the hospital who thought about ways in which data might stimulate engagement - staff would want to know if a patient had acquired an MRSA infection and would begin trying to discover where the lapse had occurred to allow the infection to spread.
Margaret discusses the surprising similarities between many of the solutions that are discovered amongst hospitals. In this case, one of the US beta-site hospitals had a similar solution to one which was used at Hospital El Tunal in Columbia - both hospitals decided to use security guards as a first line of defense in advising hospital visitors and staff about hand hygiene compliance. Because security guards are generally at the entrance of the building and can sometimes appear threatening (especially in Columbia where they carry guns), the hospitals viewed the security guards as perfect agents of advising hand hygiene.
Margaret discusses her experience being the patient rather than the physician, and her horrified observation of all of the times that nurses, residents, physicians, and other staff failed to properly wash their hands – or picked up equipment/supplies that had dropped to the floor and simply picked it up and used it. Margaret was terrified by the experience and encourages people to participate in a Discovery and Action group.
In this Reflection Margaret explores the various techniques used by different hospitals to "make the invisible, visible." In Columbia, photos of cultures taken from the hands of hospital staff were displayed with signs such as, "this is the hand of a surgeon," and, "this is the hand of a nurse." At Billings Clinic in Montana the staff began to do improvisational reenactments of common scenarios so that they could identify gaps that could lead to infection, etc.
In this Reflection Margaret discusses the importance of allowing people to describe Positive Deviance in their own words, rather than trying to explain it to them. Examples of people’s explanations are included.
In this Reflection Margaret explores the vast changes that have occurred in Patient Safety and Quality Improvement departments at hospitals over the years. Quality departments went from being small, expendable departments which did not track core measurements or superbugs, to being extremely important departments that are mandated to obtain certain measures and data, and follow best practices and other guidelines. Margaret wonders about the unintended consequences of this change.
In this Reflection Margaret discusses her interaction with a positive deviant named Glenna, who Margaret observes as having a special hand washing technique. Margaret asked Glenna about her technique and asked her questions about how she learned it, etc. Margaret emphasizes the importance of tactile learning - of having people "act out" how they do things, because there are often important, slight variances that not even the person doing the action is aware of.
Margaret discusses the "Palmer Method," a method created by Jasper Palmer of the Environmental Services (EVS) department at the Albert Einstein Medical Center, for safely removing and disposing of an isolation gown. A video of Jasper demonstrating his technique is available here. Margaret encourages readers to reach out to and involve EVS staff in Positive Deviance.
Margaret explores the consequences of hospital staff being pressed for time and trying so hard to turn over rooms for new patients that major oversights occur. Margaret asks how others have made accommodations for the scarcity of time.
In this Reflection Margaret discusses the data that staff would like to have access to, and efforts to acquire access to that data. Margaret also discusses the hidden variation in data, and the variation in the way that staff members perform a nares culture.
In this Reflection Margaret discusses the “invisible network” of people becoming connected through the use of PD in hospitals and the enthusiasm of people who are new to the network.
Resource Spotlight:
Letting Go, Gaining Control: Positive Deviance and MRSA Prevention
This article, recently featured in Clinical Leader, discusses healthcare-associated infections and outlines the specific steps of the PD process that some pioneering hospitals are taking to reduce transmission.