This document describes an improvisation learning simulation used at Billings Clinic and other hospitals to address the spread of MRSA. The simulation involves staging improv scenes acted out by staff to demonstrate safe behaviors for isolation precautions. Early results show a 22-70% drop in MRSA transmissions at some sites. The simulation provides structure but allows for creative adaptation. Scenes explore challenging situations and positive behaviors through roles like nurses and patients. Feedback helps refine the scenes to better fit each unit. The goal is to notice, amplify and develop safe behaviors through this powerful learning experience.

1. Acting Our Way Into New ThinkingPrototyping Safe Behaviors With Improv Learning Simulations Billings Clinic Players Executive Producers Joelle Everett & Keith McCandless

2. Scenes from the Isolation Precautions Room Making the Invisible Visible The Billings Clinic is one of seven hospitals in a RWJF funded initiative focused on eliminating transmissions of MRSA. The Plexus Institute is coordinating a bold unit-based, self-organizing approach called Positive Deviance. Early results are impressive.

3. WHY MRSA? Why Create A Learning Simulation for MRSA? MRSA (Methicillin Resistant staphylococcus aureus) is a common bacterium that has quickly adapted to resist nearly all antibiotics. MRSA is a growing global crisis that causes unnecessary suffering, death and staggering expense. It has spread across many barriers in part because of the iceberg effect – millions of people are colonized with only a small fraction showing visible symptoms. Most importantly, evidence is being generated which suggests that when everyone gets involved the spread of MRSA can be stopped [1]. Precautions are relatively simple but involve changing everyday “autopilot” behaviors for providers, patients, and families. A fitting, creative challenge for a learning simulation.

4. Beta Site Hospitals Albert Einstein Medical Center, Philadelphia, PA Billings Clinic, Billings, MT Franklin Square Hospital Center, Baltimore, MD The Johns Hopkins Hospital, Baltimore, MD University of Louisville Hospital, Louisville, KY VA Pittsburgh Healthcare System, Pittsburgh, PA Al Tunal Hospital, Bogota, Colombia Photo: David F. Gasser

5. WHY Positive Deviance?Acting Our Way Into New Thinking In every community there are certain individuals whose uncommon practices & behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources. The focus in on social proof -- within the unit -- embodied in tacit and latent behaviors.

6. Setting the Stagewith the MRSA Design Team Ensemble, rapid-cycle script writing by the infection control staff, OD leader & infectious disease MD chief. Min specs for 4 scenes in 90 minutes flat! “What’s my line?” Improv Photos by Keith McCandless

7. Casting CallsCalling All Units! A flurry of casting calls, Want to be an improv player? Everyone says, Yes!

8. Theatre In the Round A diverse audience, from many units across the clinic, assembles in the conference room… now an inpatient medical room. For the next 60 minutes, no one knows what to expect.

9. Artistic director Carlos at work, starting and stopping the improv on a whim. “Action… Cut!”

10. Audience As Active Participant Participant feedback forms at-the-ready. What helps? What else? Who wants to join in the ongoing design work?

12. Working Without a Script Players getting into character. Hey, is that our MRSA clinical leader playing a patient!?

13. Scene I Patient Is MRSA + Is The Room Safe & Ready? Min Specs needed to start the action.

14. Rrrring, Rrrring, … the Scene Opens in Empty Space The patient is out of the room with a rehab therapist. “Rrrring, Rrrring, Rrrring,” a Lab Tech is calling the Inpatient Medical unit clerk with swabbing results.

15. The long-awaited, much anticipated PERFECT YELLOW SUPPLY CART is wheeled into the room in preparation from Mr. Graham’s return from rehab. Nurse Christi comments, “Wow, this cart has everything! Check out the coat rack and super sized garbage can!” :-)

16. Clerk and nurse check and re-check the supplies. “Hey, let’s put up the new-and-improved Isolation Precautions sign from the MRSA Prevention Partnership!

17. Scene II Enter Patient How is the patient notified?

18. Mr. Graham is wheeled to the room by a rehab therapist. David’s wife Edith greets them at the room.

19. Edith & David notice something is very different. Why are you putting on all that stuff? Why can’t you help me into bed right now!?

20. You have a drug resistant infection. Where did I get it? We don’t want to spread it to others.

21. Mr. Graham and the therapist maintain their sense of humor… in the face of hard news.

22. With empathy, more detailed information is shared by the nurse and therapist.

23. Scene III Truth To Power How to have effective, difficult conversations?

24. Surgeon rushes into the room and greets patient. Oooppps! Misadventure- in-progress…

25. Leg wound examined. MRSA tie soup!

26. Nurse suggests gloves & gown. Nice glove color.

27. I did not notice that you washed your hands. Did you know this patient was MRSA positive?

28. No worries, we will take care of that infection in surgery. Hmmmm?

29. Scene IV Safe Travel What do I wear?

30. Ahhh, ensemble hand hygiene!

31. Elegant gowning and gloving simplified.

32. Linens akimbo, then safely handled.

33. Confident technique: Wiping down, up and all around.

34. Ready to roll, calm, cool and well dressed. Let’s go, We are ready for surgery.

35. The CEO joins in the action. This is hard and very important work locally and nationally. I appreciate all your efforts to eliminate MRSA transmissions!

36. To date, thirty-five improvs have been staged covering 75% of clinic staff. Also, the approach is spreading across beta-site hospitals.

37. Results So Far… Early Signals -- 2007 versus 2006 22% to 70% drop in transmissions and other infections in three sites Clear shifts toward collectively mindful safe behaviors Vigorous engagement across departmental silos “Spillover” into other change initiatives Collaboration outside the hospital with clinics, LTC, & community settings

38. Min Specs for Four Scenes

39. Audience/Participant Feedback Form

40. Setting Up and FacilitatingImprov Learning SimulationsMinimum structure that unleashes creative adaptability! Setting the Stage Pick situations/scenes together that are challenging… in which exploring positively deviant “how to” solutions may be helpful Specify the minimum details of the local context in a simple storyboard: Location and props needed (e.g., ICU, clinic, bed, hallway, phone, cart, sign) Key roles (e.g., nurse, doctor, patient, family member) Handful of clinical details (e.g., 62 year old male with diabetes, leg wound) Title, including a simple question to be explored, for the scene (e.g., “Safe Travel: What Do I Wear?”) The event that starts the scene (e.g., phone call from the lab to the unit) Rules for the Facilitator Clarify the purpose of this activity (e.g., to provide a powerful learning experience, helping everyone notice, amplify, and develop behaviors that fulfill your aim) Create a response form so ALL participants can suggest specifically how each scene can be more full of learning and better fit their local context or unit Convene fast-feedback exchanges immediately after each scene (2 minutes in pairs or threesomes… then full group conversations work well) Try to document everything with video, photos, words (helps with prototyping) Thank everyone for “acting their way into new thinking!” Rules for the Creative Director Recruit players with interest in and enthusiasm for resolving the challenges at hand (acting experience not required) Start and stop the action using your intuition Offer side-coaching as needed at any time (keep it fun and light) Create opportunities for post-performance feedback to the players Specify the minimum to get the action started (see “Setting the Stage”) Rules for the Players Trust and accept all offers (“Yes, and…”) Make action-filled choices, giving and taking Engage in one conversation at a time Listen, watch, concentrate (Look, don’t think!) Work to the top of your intelligence Now that ALL the rules are clear, GO WILD. More details available @ www.socialinvention.net