Trillium Health Centre implemented Positive Deviance methodology to reduce antibiotic resistant organisms acquired in the hospital. Key aspects of implementation included engaging frontline staff through improvisation activities to shift culture and encourage open communication. The "Nurse Jackson" concept was created to non-threateningly address infection control issues and led to staff becoming more aware of practices and collaborative in improving them. Surveys found high rates of staff knowing and using the term with positive ratings of its impact on practices. Successes are being shared more broadly and sustainability measures include ongoing audits and reporting.

1. Trillium Health Centre and The Canadian Positive Deviance Project Trillium Health Centre’s Positively Deviant Story Presented by: Louise Koyanagi, RN, BScN Monday December 6, 2010 New Approach to Containing Superbugs Webex Teleconference

2. Interdisciplinary Team Members Pilot Site Lead: Louise Koyanagi Lead RN, The Betty Wallace Women’s Health Centre Positive Deviance Core Team Registered Nurses (6) IPAC practitioner (1) Hospitality Associate (1) PD Coach (1) - external Trillium Pilot Units West Toronto-Complex Continuing Care Unit Mississauga-Neurosurgery 2B

3. Aim: Positive Deviance at Trillium To implement Positive Deviance (PD) methodology to all staff, creating positive social and behavioural change in infection control practices for at least the duration of the project (September 2009 –May 2011). To reduce and maintain Antibiotic Resistant Organisms (ARO) acquired in hospital (AIH) to zero by utilizing Positive Deviance methodology through the organization.

4. PD as an Enabler Support of Janet Davidson O.C., President and CEO, senior management and Infection Prevention and Control Alignment with Trillium’s Philosophy of Care and Strategic Themes On-going support from external “PD Coaches” Monthly all-sites teleconferences, facilitated by project leaders Enthusiastic core team of staff to initiate the project locally Generates discussion and involves “front-line” staff

5. Path to Implementation of PD News blasts through internal news medium; i CARE and Trillium News and Events HIROC/Axiom news article (January 29, 2010) about Trillium’s involvement with the PD Project Meetings with Senior Management team Lunch and Learn sessions for all staff at Mississauga and West Toronto “ Buzz Meetings” with eight individual units Discovery and Action Dialogues (DADs) Social network mapping survey (April 2010)

6. Lessons Learned Although a “front-line” approach, support from Managers imperative Greater participation when individual units/groups approached Present PD information at scheduled staff meetings Informal meetings with part-time and allied health staff most effective Incentives (i.e. coffee shop gift cards)

7. More Lessons Learned Hospitality and portering staff appreciative to have a forum for their voices to be heard Share responsibilities within the Core Team “ Meeting requests” via e-mail Regular updates to senior management team TRIZ vs. DADs for time constraints

8. Barriers to Overcome Unit demands (patient acuity, staffing) Time spent on Discovery and Action Dialogues (DADs) Cultural shift to front-line staff (skepticism) Time constraints core team staff availability of meeting space Language Computer access Two site hospital model

9. Pilot Units Chosen May 2010 Neurosurgery 2B (acute care) Complex Continuing Care (long term care) Data collection specific to these two units In addition, generalized data collection for hospital will be shared Support from unit Managers to facilitate staff participation

10. Pilot Units Complex Continuing Care and Rehabilitation , Trillium – West Toronto (60 beds) Staff Compliment (78): 18 Full-time RNs (including 1 Clinical Educator) 14 Part-time/casual RNs 20 Full-time RPNs 14 Part-time/casual RPNs 12 Allied Health staff (Physiotherapist, Occupational Therapists, Pharmacist, Dietician, Social Worker, Unit Clerks & Hospitality Associates) Neurosurgery 2B , Trillium – Mississauga (29 beds) Staff compliment (64): 31 Full-time RNs (including 1 ACNP & 1 Clinical Educator) 12 Part-time/casual RNs 4 Full-time RPNs 2 Part-time/casual RPNs 15 Allied Health staff (Physiotherapist, Occupational Therapists, Pharmacist, Dietician, Social Worker, Unit Clerks & Hospitality Associates)

11. PD in Action ‘Beat It!’ Improvisation The “Nurse Jackson” concept created through a performance by front line staff and family on Complex Continuing Care (West Toronto) “Nurse Jackson” revisited with 75 colleagues participating at M-site Exaggerated poor infection control practices by a health care providers. The performers used humor to highlight the seriousness of infection transmission in hospital. This resulted in the implementation of code word “Nurse Jackson”, now used on a regular basis by staff on Q-CCC, to address their colleagues (at all levels) in a non-threatening manner. (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

12. Changes Implemented Culture Shift/Open Communication Daily DADs between ALL staff creating a ‘no-blame’ culture. The ‘voice’ of the Hospitality Associate (HA) now stronger and valued. Improved collaboration between all staff on the unit regarding Infection Prevention and Control measures (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

13. Complex Continuing Care (CCC) (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

14. “Nurse Jackson” Showed Us… Non-blaming, fun ways address serious unit concerns and show proven long term benefits, out-weighing short term struggles Staff engagement is the key to making sustainable changes Acknowledging the expertise of our front line colleagues shifts the focus for change from a ‘top down’ approach to a grass roots model (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

15. “Nurse Jackson” Awareness and Satisfaction Survey Results 96% of all staff knew the meaning of code word “Nurse Jackson” Survey include Nursing, Allied health, Unit Coordination Associates (UCA), HAs and student nurses. 45% indicated they have comfortably used the term “Nurse Jackson” to address IPAC matters. 31% indicated that they have been called “Nurse Jackson”, heightening their awareness and immediate improvement of personal IPAC practices. 93% of staff rated the Nurse Jackson concept as: “ outstanding” highly functional relevant to their practice and have witnessed a notable improvement in IPAC practices on the unit.

16. Evidence of Sustainability Surveillance: Hand hygiene audits; DADs, Staff/patient surveys Quarterly reporting of Acquired in Hospital (AIH) Antibiotic Resistant Organisms (ARO) will be displayed for review and discussion of the findings Quarterly usage reporting will be shared. This will include such items as soap, purell and personal protective equipment (PPE) Staff requesting to view Improvisation Video. 96% (CCC) staff surveyed indicated interest in future IPAC initiatives. (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

17. Next Steps “ Nurse Jackson” presented to Trillium President and Vice President weekly meeting in August 2010 for organization wide awareness and support. “ Nurse Jackson” presented with positive response to: Halton and Neighboring Districts Infection Control Group Peel Community and Long-term Care Regional Infection Control Network. Nurse Jackson unleashed during Improv Event during Infection Control week with approximately 75 people in attendance. Nurse Jackson concept to be adopted as a learning/teaching tool to new hires and student orientation of CCC services Future Nursing Journal Article (Adapted from presentation to Quality Storyboard submission by Jackie Nugent, Trish Hutton and PD Team, 2010)

18. Trillium PD Core Team Louise Koyanagi, RN, Pilot Site Lead, The Canadian Deviance Project Lead Nurse, The Betty Wallace Women’s Health Centre Tricia Hutton, RN, Infection Prevention and Control Diane Wienwurm, Infection Control Practitioner Gillian Dennis, RN, Oncology Clinic Doug Hogan, RN, Clinical Leader, 6J Oncology/Medicine Jackie Nugent, RN, Clinical Leader, Complex Continuing Care Joe Pasia, RN, Manager, Neurosurgery 2B Serena Johnson, Hospitality Associate, Complex Continuing Care Erika Bailey, PD Coach, Erika Lee Bailey and Associates

19. Contact Information For further information about Trillium’s PD journey… Louise Koyanagi, RN, BScN Pilot Site Lead, The Canadian PD Project Trillium Health Centre-West Toronto 150 Sherway Drive Toronto, ON M9C 1A5 E-mail: lkoyanagi@thc.on.ca Tel: 416-259-7580 ext. 5776 Fax: 416-521-4036