From Invisible to Visible - Positive Deviance Initiative

igorous hand-washing and scrubbing procedure
in the doctor’s ward, most notably with chlorideof-lime
solutions, a powerful antiseptic.
Infections dropped precipitously—from 17 percent
of all patients to one percent.
Despite this scientific knowledge, compliance
with hand hygiene protocols among most healthcare
workers remains less than 50 percent.
Gowns, gloves, and consistent hand hygiene are
often viewed as a time consuming nuisance. The
insight that knowledge does not change behavior
was the reason why Billings Clinic was paying
more and more attention to addressing the “how”
of behavior change. The “how” was Positive
Deviance.
Nick Wolter sent Nancy Iversen, the director of
patient safety, to a workshop on Positive
Deviance, conducted by Jerry and Monique
Sternin, in Boston in July 2005. Ms. Iversen,
inspired by how people at Waterbury Hospital in
Connecticut had achieved early success with
using PD for medication reconciliation, was eager
to start PD at Billings Clinic.
The next year, Billings Clinic became one of the
six beta site healthcare systems that took part in a
Plexus Institute-led MRSA Prevention
Partnership xix . These beta sites agreed to tackle
MRSA as a behavioral and social problem using
Positive Deviance as the driving approach. In late
summer 2006, a Billings Clinic team led by Ms.
Iversen, visited the Veterans Health
Administration Pittsburgh Healthcare System
(VAPHS), a sister beta site that had implemented
PD some months previously, and had some lessons
to share xx .
In spring 2006, the Plexus team that included
Jerry and Monique Sternin and Keith McCandless
had come to Billings Clinic for the PD MRSA
kick-off event. The Sternins’ visit generated both
enthusiasm and skepticism. However, with CEO
Nick Wolter’s backing, and Billings Clinic’s commitment
to be a beta site partner on the Plexus
Institute-led MRSA Prevention Partnership, the
PD process began to roll.
Keith McCandless and Joelle Everett, two highly
accomplished organizational change consultants,
and Monique Sternin, were coaches for the
Billings PD MRSA initiative. Just the after the
kickoff event staff who were interested in working
on stopping MRSA infections met to begin.
As 2006 was coming to a close, Billings Clinic had
initiated a concerted MRSA prevention program
consisting of active surveillance, culturing of
patients admitted to the Intensive Care Unit
(ICU), contact precautions for any patient in the
hospital known to be colonized or infected with
MRSA, hand hygiene, and hospital-wide implementation
of the Positive Deviance approach to
improve adherence to infection control practices.
The first step at Billings Clinic was a rigorous
effort to get a baseline on MRSA prevalence. A
prevalence study on all hospital patients and 300
volunteer healthcare workers was conducted in
the fall of 2006. The MRSA prevalence rates for
patients at Billings Clinic were in line with
national averages: just under eight percent for
Coaches Joelle Everett (left) and Keith McCandless
(center) Carlos Arce, director, organizational and
leadership development at Billings Clinic
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