Acting Our Way Into New ThinkingPrototyping Safe Behaviors With

Improv Learning Simulations

Billings Clinic PlayersExecutive Producers

Joelle Everett & Keith McCandless

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.

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.

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,

ColombiaPhoto: David F. Gasser

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.

Setting the Stage with 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

Casting CallsCalling All Units!

A flurry of casting calls, Want to be an improv player?

Everyone says, Yes!

Theatre In the RoundA 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.

Artistic director

Carlos at work, starting and stopping

the improv on a whim.

“Action… Cut!”

Audience As Active ParticipantParticipant feedback

forms at-the-ready.

What helps?

What else? Who wants to join

in the ongoing

design work?

Patient InformationMeet the lively Mr. David Graham, a 62 year old

male with diabetes and a leg wound… and feisty wife

Edith.

Working Without a Script

Players getting into character.

Hey, is that our MRSA clinical leader playing a patient!?

Scene IPatient IsMRSA +

Is The Room Safe & Ready?

Min Specs needed to start the action.

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.

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!” :-)

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!

Scene IIEnter Patient

How is the patient notified?

Mr. Graham is wheeled to the room by a rehab therapist.

David’s wife Edith greets them at the room.

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!?

You have a drug resistant infection.

Where did I get it?

We don’t want to spread it to others.

Mr. Graham and the therapist maintain their sense of humor…

in the face of hard news.

With empathy, more detailed

information is shared by the

nurse and therapist.

Scene IIITruth To Power

How to have effective,

difficult conversations?

Surgeon rushes into the room

and greets patient.

Oooppps!

Misadventure-in-progress…

Leg wound examined.

MRSA tie soup!

Nurse suggests gloves &

gown.

Nice glove color.

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

No worries, we will take care of that infection in

surgery.

Hmmmm?

Scene IV

Safe Travel

What do I wear?

Ahhh,

ensemble hand hygiene!

Elegant gowning and gloving simplified.

Linens akimbo,

then safely

handled.

Confident technique:

Wiping down, up and all around.

Ready to roll, calm, cool and

well dressed.

Let’s go, We are ready

for surgery.

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!

To date, thirty-five improvs have been

staged covering 75% of

clinic staff. Also, the approach is

spreading across beta-site hospitals.

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

Min Specs for Four ScenesScene 1 Scene 2 Scene 3 Scene 4

MRSA + Enter Patient Truth to Power Safe Travel

Question to Answer Question to Answer Question to Answer Question to Answer

Is the Room Safe & Ready? How is thePatient Notified?

How Do I Have Effective, Difficult Conversations?

What Do I Wear?

Location Location Location Location

Inpatient Medical Hallway/Patient Room Patient Room Patient Room &Hallway

Scene Initiation Scene Initiation Scene Initiation Scene Initiation

Call from Lab with + MRSA results

Patient coming back in wheelchair from

Rehab

Doctor Enters / Exits w/out obvious hand hygiene

OR Transporter arrives (wheel out bed /

gurney)

Cast/Roles Cast/Roles Cast/Roles Cast/Roles

Lab TechUnit Clerk

NurseICP (phone)MD (phone)EVS (phone)

PatientNurse

Transporter (chart)Relative

Patient Relative

Doctor (in/out)Nurse (in/out)

PatientOR Transporter

NurseCNA

Key Quote Key Quote Key Quote Key Quote

How do we get the room ready?

What are we going to do?

What happened?What do I have?

…not just 5 minutes ago. Time for surgery …ready to roll.

Audience/Participant Feedback Form

Scenes What Was Helpful? What Else… What would improve this scene

for use in your unit?

MRSA +Is the Room Ready and Safe?

Enter PatientHow Is the Patient Informed?

Speaking Truth to PowerHow Do I Have Effective, Difficult

Conversations?

Safe TravelWhat Do I Wear?

Setting Up and Facilitating Improv 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