Positive Deviance Wisdom Series, Number 3, pp. 1-8. Boston, Tufts University: Positive Deviance Initiative.
A tragedy of such appalling magnitude unfolds itself daily in U.S. hospitals. On average, hospital acquired infections (HAIs) kill about 275 patients in U.S. hospitals a day. This is largely because their doctors, nurses, therapists, ambulance drivers, and other health care workers did not follow hand hygiene protocols, were too busy to properly gown and glove, or were, simply, in a hurry.
A leading bacterial source of HAIs is Methicillin Resistant Staphylococcus Aureus (MRSA), a deadly pathogen resistant to most commonly-used antibiotics, that can live up to six weeks on environmental surfaces and transmits easily through contact. MRSA infections have increased 32-fold in the U.S. in the past three decades. Amidst this alarming reality, a handful of U.S. hospitals have shown sharp declines in MRSA infections. At Billings Clinic, a multi-specialty physician practice in Billings, Montana, healthcare-associated MRSA infections have dropped by a whopping 84% in the past 2.5 half years.
What is Billings Clinic doing differently? As opposed to the traditional approach of focusing on what does not work, and rewarding or punishing employees to practice safety, Billings Clinic’s approach to MRSA prevention focuses on what works, believing that among its vast pool of employees, doctors, nursing staff, housekeepers, therapists, technicians, pastors, and social workers, there are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance: A physician purposely sees his MRSA patients last during rounds, a simple practice that greatly reduces the risk of transmitting MRSA. An ICU nurse disinfects a patient’s side rails several times during her shift to keep MRSA from being picked up and spread. A nurse places a clean sheet between herself and a MRSA patient to avoid direct microbial transfer.
A physician stops wearing his tie, his white coat, and long sleeves, all vectors for the spread of MRSA infections. Many others adopt his practice.
These individuals, and dozens of others like them, at Billings Clinic are Positive Deviants. They are “Deviants” because their behaviors are not the norm and “Positive” as they model the desirable MRSA-prevention behaviors. As more people discover how to practice safety, the norm across the institution begins to shift.
TRACKING INTRACTABLE BEHAVIORAL PROBLEMS In the summer of 2004, Billings Clinic CEO Nick Wolter, MD attended a workshop in Durham, NH, where Jerry Sternin, co-founder of the Positive Deviance Initiative at Tufts University, made an impromptu 15 minute presentation on the topic. Sternin emphasized that the Positive Deviance (PD) approach was especially suited to address intractable social and behavioral problems.
Following basic hand hygiene protocols, Wolter knew, was an intractable behavioral problem in U.S. hospitals, including his own. Adherence to hand hygiene protocols for every patient encounter in U.S. hospitals ranged from 29 to 48 percent. This meant that, more than likely, the interaction between a health care worker and a patient carried the risk of infection transfer. This figure was highly problematic as patients expect hospitals to be safe environments, not transmission vectors of deadly pathogens. As a physician, Wolter knew that if he washed his hands before examining a patient, it would be cumbersome to wash them again just because he answered his pager during the process. When one’s hands feel clean, the behavioral tendency is to resume interrupted work, not fully grasping the implications for infection transfer…
