Editor, Judith Riess visited Billings Clinic and discussed with Dr. Mark Rumans the hospital’s approach to reducing MRSA.

Experimental learning makes the invisible become visible. Here, chocolate pudding is used to show how germs spread. (Photo: Julie Burton/ Billings Clinic)
Experimental learning makes the invisible become visible. Here, chocolate pudding is used to show how germs spread. Image Credit: Julie Burton/ Billings Clinic

Millions of people are suffering from hospital acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) is an especially common and deadly bacteria that is resistant to penicillin related antibiotics and had been on the rise worldwide for the past three decades. In 2010, encouraging results from a CDC study published in the Journal of the American Medical Association showed that invasive (life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 28% from 2005 through 2008. Decreases in infection rates were even bigger for patients with bloodstream infections. In addition, the study showed a 17% drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.

The main way the infection is transmitted is through human hands. Hands may be contaminated by contact with infected patients. Healthcare provider-to-patient transfer is common, especially when healthcare providers move from patient to patient without performing necessary hand-washing techniques between patients. It is estimated that in the US as many as 100,000 people develop MRSA infections each year. The average hospital cost for treating a MRSA patient is $20,000 to $27,000. Therefore, reducing infection rates helps save patient lives and helps reduce the rising cost of healthcare.

These declines in MRSA rates can be directly attributed to the education and training that has taken place over the past five years in hospitals and clinics.

In partnership with the Veterans Administration Pittsburg Healthcare System (VAPHS) the Plexus Institute and the Delmarva Foundation, the PDI promoted the use of the Positive Deviance approach to eradicate MRSA infection transmission in a network of 40 hospitals nationwide.

The PD approach enabled the hospital staff to improve their adherence to evidence based precautions, “the MRSA Bundle”, which included hand hygiene, active surveillance, environmental cleaning and contact isolation precautions. This resulted in a 50% reduction in MRSA rates which resulted in n expansion of the program in which Billings Clinic took part.

The potential of the Positive Deviance approach and the idea that small changes can have significant impact, motivated Nick Wolter, Billings Clinic’s CEO, and Nancy Iversen, Billings’ Director of Patient Safety and Infection Control, to actively seek participation as one of the beta sites in the Plexus Institute collaboration with Positive Deviance funded by Robert Woods Johnson Foundation to reduce MRSA. This was based on the success of the Veterans Administration, Pittsburgh’s MRSA Reduction program using Positive Deviance.

Innovative Activity Description

The Billings Clinic made MRSA prevention a top priority and in the process transformed its organizational culture. By creating a comprehensive package that combines adoption and monitoring of strict infection control protocols, active surveillance, training and education, and the solicitation and implementation of employee ideas through “positive deviance”, Billings Clinic’s 272 bed hospital reduced health care associated MRSA infections by 84% over a 2.5 year period earning for itself a ranking of #1 Patient Safety Hospital by US News and World Report, Consumer Report and the Lucien Leap Foundation.

The following are key elements of the program:

  • Creating a culture where MRSA control is a top priority, with focus on supporting employee-generated ideas: Leaders adopted and promoted the positive deviance approach to create social and behavioral change, as positive deviance emphasizes the role of frontline employees in generating solutions to problems. Leaders encouraged employees to come forward with solutions, and strove to create a culture which motivated employees to do so. In communications to employees, Billings’ leaders emphasize the significance of the MRSA issue and the need for employees to think of infection control as their problem rather than something handled only by infection control specialists. To that end, they encourage employees to share their ideas on infection control and to point out and correct—in a collaborative, collegial manner—any errors they may witness in the infection control behaviors of coworkers.
  • Hand hygiene and disinfection procedures: Staff members are required to wash hands before and after every patient contact and to disinfect all items that come in contact with MRSA-positive patients. A number of employee-generated ideas have increased adherence to this protocol:
    • Disinfection of all items: Staff began disinfecting previously overlooked items that can spread MRSA, such as keys to drug storage compartments and dinner trays.
    • Larger garbage cans: To accommodate the increased use of disposable gowns, gloves, and other items that help prevent transmission, Billings Clinic purchased larger garbage cans that help reduce the time spent emptying trash.
    • Isolation carts: Isolation carts were purchased so that isolation precaution supplies were organized and readily available for staff outside patient rooms.
    • End-of-day rounding on MRSA patients: Physicians decided to begin rounding on MRSA patients at the end of the day, when they had more time to take precautions. In addition, some male physicians stopped wearing ties and lab coats because of their potential to transmit MRSA.
    • Active surveillance and quicker test results: Beginning August 2011 all patients admitted to the hospital receive a nasal swab test for MRSA on admission, transfer, or discharge. Patients who stay longer than one week are swabbed every seven days. Patients who are found to be positive for MRSA, are placed in contact precautions. Billings Clinic continues to use a specialized culture media which allows for quicker, more accurate results, allowing staff to begin taking contact precautions with MRSA-positive patients more quickly. Rapid PCR testing is also offered for surgical patients when their MRSA status is needed to adjust prophylactic antibiotic and treatment with topical mupirocin to reduce their risk of a surgical site infection.
  • Patient flagging system: Billings Clinic created an alert system that flags all patients who have a history of MRSA and electronically sends a notice to the units with an order to begin isolation precautions. The purpose of the flagging system is to begin isolation more quickly, therefore reducing the potential for MRSA transmission.
  • Isolation of MRSA positive patients: Patients infected or colonized with MRSA are placed on contact isolation protocols based on the Centers for Disease Control and Prevention (CDC) 2006 Multi-Drug Organism Resistant Guidelines.
  • Monitoring and feedback: Staff members in all inpatient units where active surveillance testing is conducted, receive prevalence, incidence (transmission), and swabbing rate compliance information each week.
  • Education and training: Billings put in place a variety of educational and training programs focused on reducing MRSA transmission.
    • Monthly unit educational meetings: Each unit holds a monthly meeting to discuss MRSA prevention practices. The group’s coordinators use a range of educational methods during these sessions, including imitation, where an experienced worker demonstrates a tactic (e.g., the proper technique for nasal swabbing or disinfecting a room) and then participants practice the tactic with each other. Program coordinators also use unusual teaching methods, such as having employees dunk their gloved hands in chocolate pudding and wipe it on their isolation gowns to illustrate contamination with MRSA bacteria. This helps make the invisible germs visible to staff so they can discover for themselves the need to practice more carefully so as to not contaminate their surroundings or themselves while providing care to patients.
    • Improvisational theater for training: In response to frontline worker requests for more training, program coordinators converted an unused space into a simulated patient room. Known as the “the theater in the round,” this space serves as host to a mandatory 1.5-hour training session in which 12 to 15 individuals participate in one of four improvisational sketches.

      ICU decline in MRSA Infections. (Photo: Julie Burton/ Billings Clinic)
      ICU decline in MRSA Infections. Image Credit: Julie Burton/ Billings Clinic

      After each MRSA-related scenario is acted out, the audience provides feedback about what the staff did well and where they can improve. Scenario-playing emphasizes a key positive deviance principle—that participants find it easier to act their way into a new way of thinking than to think their way into a new way of acting. Information provided improvisational theater–style learning sessions continue to be a part of the nursing fundamentals course for newly hired nursing personnel and remain an ongoing and effective method for infection prevention.

    • Patient education: Billings staff developed a patient-friendly brochure and use Washington State Health Department's Living with MRSA publication to share information with patients to prevent MRSA transmission. In July 2010 another patient education brochure entitled MRSA & Athletics: What's YOUR Game Plan? was developed to provide information to help prevent the spread of MRSA in athletic settings. This brochure was co-created with Billings Clinic, the local health department, and another local hospital. It is provided to all patients who receive sports physicals at all Billings Clinic locations.
  • Active solicitation and support for implementation of employee ideas: A group of 20 to 40 MRSA champions, known as the Positive Deviance-MRSA Partnership and representing all hospital units and ancillary departments, meets monthly to solicit ideas for preventing MRSA and to identify staff who are already using positive infection practices. During these “discovery-and-action dialogues,” staff members identify barriers to successful MRSA prevention, which the Positive Deviance-MRSA partnership team then works to eliminate. With the partnership’s encouragement and support, employees implement many of the ideas that emerge from these dialogues. When needed, program coordinators provide direct assistance, such as help in securing funding or other resources.
The Clinic’s approach to MRSA prevention focused on what worked, believing that among its pool of employees—doctors, nursing staff, housekeepers, therapists, patient transporters, technicians, pastors, social workers, and support staff—there are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance, in doing his hospital rounds, a physician purposely sees his MRSA patients last—a simple practice that greatly reduces the risk of transmitting MRSA. A Billings Clinic patient transporter uses his gait belt to strap a MRSA patient’s oxygen cylinder to an IV pole, so it won’t brush against other surfaces during transport.

These individuals are “positive deviants” PD goes hand- in- hand with Improvisation Learning which was used throughout staff training. Fifty” Improv” sessions were conducted and Nancy Iversen, said it was not always easy and at first there was a great deal of resistance. However, the Improv sessions helped staff learn for themselves to solve problems and find solutions. The Improv scenarios explored practical problems, how to deal with a rehab patient, how to transport a patient, how to provide food trays without spreading infection, how to discuss problems with those in power positions and how to dispose of contaminated gear. In one Improv session, a physician, while examining a patient’s leg wound that was oozing brown goo, paused to shake hands with the patient’s family, back-patted a nurse, touched some objects, and resumed the examination. Within seconds, the patient’s body, the bedding, the hands and clothes of the doctor, the nurse, and the patient’s family showed brown stains. The brown goo, chocolate pudding, substituted for MRSA, making visible how the invisible, bacteria spreads. Improv participants, front-line workers from multiple units, emphasized that the Improvs were a fun and refreshing way of learning. It was not another lecture, or a briefing. The scenes provided continuous “aha” moments.

The PD processes at Billings Clinic were guided by a constant stream of data gathering, analysis and action. When the MRSA initiative was launched a baseline on MRSA prevalence was carried out. Piloting units in the study made a commitment to support and draw more resources and people into the MRSA prevention initiative and tap more sources of support and influence. Network mapping helped identify “suspects” whose influence could then be tapped. In studying the maps with her team, Nancy Iverson found “unlikely suspects” who were highly connected with others and served as resources but had not previously been recognized as leaders.

Plexus has found Billings Clinic’s results so impressive that their story has been included in the book, “Inviting Everyone: Healing Healthcare through Positive Deviance.”

The entire staff feel privileged to have created an environment that is safer for patients. Billings Clinic has personal service expectations for each member of its staff that comes in contact with patients, guest, superiors and colleagues. Their vision is “to be recognized as the healthcare organization providing the best clinical quality, patient safety and service experience in the nation” and the organization has been recognized as #1 for their patient safety initiative.