New Approach to Controlling Superbugs Virtual Learning Session 1 Discovering Positive Deviance Michael Gardam Leah Gitterman
The Premise Of Positive Deviance <ul><li>No matter how seemingly intractable a problem, in every community there are indiv...
Why focus on a behaviour change approach? <ul><li>Current “top down” approaches have had limited success </li></ul><ul><li...
Sharing best practices <ul><li>Solutions imported from external sources results in “social immune response” in the same wa...
PD and MRSA <ul><li>US pilot project </li></ul><ul><li>Implementation of PD followed by 20 month follow up period </li></u...
Examples from Healthcare <ul><li>Hook story </li></ul><ul><li>Transportation cards </li></ul><ul><li>Isolation signage </l...
The power of storytelling <ul><li>One death is a tragedy; one million is a statistic.  </li></ul><ul><li>Stories can captu...
This is about… <ul><li>Creating sustainable change </li></ul><ul><li>Helping culture to shift </li></ul><ul><li>Indentifyi...
Who have the knowledge? ≈
100% 4% 9% 74% Problems known to top managers Problems known to middle managers Problems known to supervisors Problems kno...
100% 74% 9% 4%
TAKE  <ul><li>Talk amongst yourselves </li></ul><ul><li>Think about someone you know who you suspect might be a positive d...
Tell us your stories
Positive  D eviance D etermine D iscover D esign D efine D iscern D isseminate
D efine <ul><li>Define the  problem , its perceived causes and related current practices (situation analysis) </li></ul><u...
D etermine <ul><li>Determine if there are any individuals/entities in community who ALREADY exhibit desired behavior or st...
<ul><li>Discover uncommon practices/behaviors enabling the PDs to outperform/find better solutions to the problem than oth...
<ul><li>Design and implement activities enabling others in “community” to access and PRACTICE new behaviors (focus on “doi...
D iscern <ul><li>Discerns the effectiveness of activities or project through ongoing monitoring and evaluation </li></ul>
D isseminate <ul><li>Disseminate successful process to appropriate “other” (scaling up) </li></ul>
How does it work? <ul><li>Invite those who are interested </li></ul><ul><li>Front-line staff must be there (the “Gurus”) <...
Who is included? <ul><ul><li>Everybody who touches the problem </li></ul></ul><ul><ul><li>Get the right people around the ...
Getting Started <ul><li>You have to decide how to “kick off” this process in your facility </li></ul><ul><li>Examples: </l...
Take 15  Talk amongst yourselves <ul><li>What would this look like in your organization? </li></ul><ul><li>How would you l...
Tell us your stories
Min Specs What We Must Do What We   Must Not Do What Will Emerge in Unique Forms <ul><li>Actively seek involvement, reach ...
Min Specs What We Must Do What We   Must Not Do What Will Emerge in Unique Forms <ul><li>Adapt and build as units develop ...
Min Specs <ul><li>Each organization will decide what to measure based on their needs </li></ul><ul><li>Give answers before...
Min Specs <ul><li>Processes and conditions that allow new & latent strategies to be put into practice </li></ul><ul><li>In...
Min Specs <ul><li>Answers and successful strategies that emerge will differ by organization </li></ul><ul><li>Ignore littl...
Min Specs <ul><li>Strategies for  how  this will happen will vary between organizations </li></ul><ul><li>Be silent or wis...
Min Specs <ul><li>Supporting infrastructure will vary among sites </li></ul><ul><li>Dampen friendly competition among unit...
Min Specs <ul><li>Enthusiasm that spill over into other challenges </li></ul><ul><li>Treat as a discrete project </li></ul...
Min Specs <ul><li>How this is done will vary by site </li></ul><ul><li>Assume there will be no backsliding </li></ul><ul><...
Min Specs <ul><li>Be ready to be surprised </li></ul><ul><li>Manipulate “buy in” </li></ul><ul><li>Cultivate “ownership” <...
PD Tools <ul><li>Kick offs  </li></ul><ul><li>Improvisation </li></ul><ul><li>Sharing Stories </li></ul><ul><li>Discovery ...
Resources <ul><li>SHN! Community of Practice </li></ul><ul><li>Faculty office hours: every Monday from 1-2pm </li></ul><ul...
Learn from the people Plan with the people Begin with what they have Build on what they know. Of the best leaders When the...
 
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Wave 1: Learning Session 1

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  • Solutions before our eyes What enables people to find these solutions? Findings are accessible to all
  • Work well in settings where problems are completely knowable – simple.
  • Stories can hold the tensions and paradoxes we have to navigate daily. They are a way of sharing ideas and insights but also a way of helping people own and share their own exepriences.
  • Leaders guide the process, remove barriers Allocation of scarce resources Facilitate/allow the discovery to take place
  • LR: Reference collections of small behaviours often collectively make a difference – may not be one or more people but what they do
  • Vast Majority of the work happens at the frontline or with community residents – you may need to set up ways to meet and make sense of what is happening. Experts are the people themselves.
  • Six D’s – See Handbook
  • Similar to viral marketing Let group come up with solution on their own Define: The problem, its perceived causes and related current practices; what a successful outcomes look like Determine: if there are individuals or entities in the community who ALREADY exhibit desired behaviour Discover: Uncommon practices/behaviours enable the “deviants” to outperform the community Design: Design and implement intervention enabling others to access and PRACTICE new behaviours
  • Don’t answer questions nobody has asked yet-work only on those that people have asked and want to find solutions for.
  • Wave 1: Learning Session 1

    1. 1. New Approach to Controlling Superbugs Virtual Learning Session 1 Discovering Positive Deviance Michael Gardam Leah Gitterman
    2. 2. The Premise Of Positive Deviance <ul><li>No matter how seemingly intractable a problem, in every community there are individuals whose uncommon practices/behaviours enable them to find better solutions to problems than their neighbours who have access to the same resources. </li></ul>
    3. 3. Why focus on a behaviour change approach? <ul><li>Current “top down” approaches have had limited success </li></ul><ul><li>Traditional “best practice” approach has been disappointing </li></ul><ul><li>We need to acknowledge that we are human! </li></ul>
    4. 4. Sharing best practices <ul><li>Solutions imported from external sources results in “social immune response” in the same way that our body triggers an immune defense response </li></ul>NEW IDEA
    5. 5. PD and MRSA <ul><li>US pilot project </li></ul><ul><li>Implementation of PD followed by 20 month follow up period </li></ul><ul><li>No attempt to decolonize patients </li></ul><ul><li>26-62% reduction in MRSA clinical infections </li></ul><ul><li>1 site had an 80% drop in MRSA infections </li></ul>SHEA 2009
    6. 6. Examples from Healthcare <ul><li>Hook story </li></ul><ul><li>Transportation cards </li></ul><ul><li>Isolation signage </li></ul><ul><li>Nursing student Hand Hygiene video </li></ul><ul><li>Vancouver General: HH rates </li></ul><ul><li>Toronto East: cleaning equipment, antibiotic stewardship, passport </li></ul>
    7. 7. The power of storytelling <ul><li>One death is a tragedy; one million is a statistic. </li></ul><ul><li>Stories can capture the complexity of the situation. </li></ul>
    8. 8. This is about… <ul><li>Creating sustainable change </li></ul><ul><li>Helping culture to shift </li></ul><ul><li>Indentifying existing and/or uncommon practices </li></ul><ul><li>Developing new behaviours to overcome barriers </li></ul><ul><li>Acting your way into a new way of thinking </li></ul>
    9. 9. Who have the knowledge? ≈
    10. 10. 100% 4% 9% 74% Problems known to top managers Problems known to middle managers Problems known to supervisors Problems known to front line managers The “Awareness” Iceberg This internationally acclaimed study conducted by Sidney Yoshida, was initially presented at the International Quality Symposium, Mexico city, 1989. It indicated how management's failure to understand its processes and practices from the perspective of its customers, suppressed the company's profits by as much as 40%. 
    11. 11. 100% 74% 9% 4%
    12. 12. TAKE <ul><li>Talk amongst yourselves </li></ul><ul><li>Think about someone you know who you suspect might be a positive deviant… </li></ul><ul><li>What are they doing? What makes you recognize their behaviour as unusual or different? </li></ul>
    13. 13. Tell us your stories
    14. 14. Positive D eviance D etermine D iscover D esign D efine D iscern D isseminate
    15. 15. D efine <ul><li>Define the problem , its perceived causes and related current practices (situation analysis) </li></ul><ul><li>Define what a successful solution/outcome would look like (described as a behavioral or status outcome) </li></ul>Stakeholders community
    16. 16. D etermine <ul><li>Determine if there are any individuals/entities in community who ALREADY exhibit desired behavior or status (PD identification) </li></ul>
    17. 17. <ul><li>Discover uncommon practices/behaviors enabling the PDs to outperform/find better solutions to the problem than others in their “community” </li></ul>D iscover
    18. 18. <ul><li>Design and implement activities enabling others in “community” to access and PRACTICE new behaviors (focus on “doing” rather than transfer of knowledge) </li></ul>D esign
    19. 19. D iscern <ul><li>Discerns the effectiveness of activities or project through ongoing monitoring and evaluation </li></ul>
    20. 20. D isseminate <ul><li>Disseminate successful process to appropriate “other” (scaling up) </li></ul>
    21. 21. How does it work? <ul><li>Invite those who are interested </li></ul><ul><li>Front-line staff must be there (the “Gurus”) </li></ul><ul><li>Create conditions for people to discover and adopt their own solutions </li></ul><ul><li>Identify and analyze the positive deviants </li></ul><ul><li>Create ways to spread peer to peer </li></ul><ul><li>Track and publish results </li></ul>
    22. 22. Who is included? <ul><ul><li>Everybody who touches the problem </li></ul></ul><ul><ul><li>Get the right people around the table </li></ul></ul><ul><ul><li>Who isn’t here? </li></ul></ul><ul><ul><li>“ nothing about me without me” </li></ul></ul>
    23. 23. Getting Started <ul><li>You have to decide how to “kick off” this process in your facility </li></ul><ul><li>Examples: </li></ul><ul><ul><li>UHN </li></ul></ul><ul><ul><li>US experience </li></ul></ul><ul><ul><li>CPSI study sites </li></ul></ul>
    24. 24. Take 15 Talk amongst yourselves <ul><li>What would this look like in your organization? </li></ul><ul><li>How would you launch it? </li></ul><ul><li>Anybody you know who might be interested? </li></ul><ul><ul><li>Front line, middle management, senior management? </li></ul></ul>
    25. 25. Tell us your stories
    26. 26. Min Specs What We Must Do What We Must Not Do What Will Emerge in Unique Forms <ul><li>Actively seek involvement, reach out beyond the usual suspects and allow participants to self-select </li></ul><ul><li>With the exception of infection control leaders, appoint or designate participants </li></ul><ul><li>That what the core team looks like at each facility will vary </li></ul>
    27. 27. Min Specs What We Must Do What We Must Not Do What Will Emerge in Unique Forms <ul><li>Adapt and build as units develop momentum </li></ul><ul><li>Start cross-unit activities too soon </li></ul><ul><li>Unit leaders & network weavers will appear at different times </li></ul>
    28. 28. Min Specs <ul><li>Each organization will decide what to measure based on their needs </li></ul><ul><li>Give answers before the question is asked </li></ul><ul><li>Track progress and feed back to community… generating new questions </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    29. 29. Min Specs <ul><li>Processes and conditions that allow new & latent strategies to be put into practice </li></ul><ul><li>Interfere with adoption of new practices if no harm is anticipated </li></ul><ul><li>Follow existing science and evidence based practices to prevent transmission </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    30. 30. Min Specs <ul><li>Answers and successful strategies that emerge will differ by organization </li></ul><ul><li>Ignore little changes, suggestions, and adaptations that emerge from discovery dialogues </li></ul><ul><li>Use inquiry based process Discovery and Action Dialogues </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    31. 31. Min Specs <ul><li>Strategies for how this will happen will vary between organizations </li></ul><ul><li>Be silent or wishy-washy on suggested actions </li></ul><ul><li>Feed back to others and rapidly act on suggestions or communicate why they cannot be acted upon </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    32. 32. Min Specs <ul><li>Supporting infrastructure will vary among sites </li></ul><ul><li>Dampen friendly competition among units </li></ul><ul><li>Create conditions and opportunities to enable others to share practices </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    33. 33. Min Specs <ul><li>Enthusiasm that spill over into other challenges </li></ul><ul><li>Treat as a discrete project </li></ul><ul><li>Recognize that process is continuous & a new way of managing-leading-thinking </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    34. 34. Min Specs <ul><li>How this is done will vary by site </li></ul><ul><li>Assume there will be no backsliding </li></ul><ul><li>Allow for a periodic “booster” shot </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    35. 35. Min Specs <ul><li>Be ready to be surprised </li></ul><ul><li>Manipulate “buy in” </li></ul><ul><li>Cultivate “ownership” </li></ul>What Will Emerge in Unique Forms What We Must Not Do What We Must Do
    36. 36. PD Tools <ul><li>Kick offs </li></ul><ul><li>Improvisation </li></ul><ul><li>Sharing Stories </li></ul><ul><li>Discovery and Action Dialogues </li></ul><ul><li>Social Network Analysis </li></ul><ul><li>Ethnographic mapping </li></ul>
    37. 37. Resources <ul><li>SHN! Community of Practice </li></ul><ul><li>Faculty office hours: every Monday from 1-2pm </li></ul><ul><li>www.positivedeviance.ca </li></ul><ul><li>www.positivedeviance.org </li></ul>
    38. 38. Learn from the people Plan with the people Begin with what they have Build on what they know. Of the best leaders When the task is accomplished The people all remark We have done it ourselves Lao-Tzu’s Tao Te Ching (6 th Century BCE)

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