TAKING TRANSFORMATIONAL CHANGE TO SCALE:

REDUCING MRSA AND OTHER INFECTIONS

5th National Pay for Performance Summit:

Mini Summit IV: Tools and Strategies to Support Transformational Change

San Francisco, CA, March 8-10, 2010

Brad Doebbeling, MD, MSc

Professor of Medicine, Epidemiology, & Biomedical Engineering, Indiana University School of Medicine

Senior Scientist, IU Center for Health Services Research, Indianapolis VA COE, Regenstrief Institute,

Indianapolis

Award Number: HHSA290200600013I, Task Order No. 4

Acknowledgements Funding from AHRQ

Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria HHSA2902006000131 (Completed)

Healthcare Associated Infections (HAI) Initiative Assessment Program HHSA290200600013I (Current)

Implementing and Improving the Integration of Decision Support into Outpatient Clinical WorkflowHSA2902006000131(Current)

Funding from AHRQ and CDCTesting Spread and Implementation of Novel MRSA-

Reducing Practices HHSA290200600013 (Current)Thanks to our collaborators, partners, providers, patients!

Capacity for Impact High priority project to avert illness, suffering,

and death

Unique International Collaborative Learning community of practice (7 hospitals) Electronically and culturally interconnected International consortium

Effectiveness -- Reduced rates 60-85% Pittsburgh VA RWJ Sites Phase 1 Indy

Framework

Birth

Maturity

Creative Destruction

Renewal

For more information on the ecocyle go to http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html

Panarchy or Ecocycle Model of Change

Network or group level

A change in conversation A change in routine A change in resource commitment or influence

Institutional level

A change in culture A change in laws A change in resource distribution/availability

Organizational level

A change in strategiesA change in procedures A change in resource distribution/availability

Individual level

A change of heart A change of habits A change of ambition

“Getting To Maybe: How the World is Changed”Frances Westley, Brenda Zimmerman, Michael Patton, 1996, Random House Canada

Social Subsystem• Key stakeholder views • Patient barriers/facilitators• Organizational buy-in• Leadership support• Training• Unintended social

consequences

Technical Subsystem• Usability• Functionality/scope• Computer/IT support• Flexibility in IT tools• Iterative design• Unintended technical

consequences

Joint Optimization• Integration of CDS -

for CRC screening - into clinical workflow

External Subsystem (Context)• PERFORMANCE MEASUREMENT• Workload• Financial factors• Unintended external

consequences

Socio-technical Systems Framework

Westbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007

Strategy

1. Fostering Change

2. Communication & Collaboratives

3. Local, Focused Implementation

4. Frontline Staff Engagement

5. Organizational Learning

6. Support, Resources & Accountability

7. Feedback & Reinforcement

Tranformative Change: 7 Effective Strategies

Qualitative Thematic Analysis, Healthcare Associated Infections (HAI) Initiative Assessment Program , AHRQ ACTION, HHSA290200600013I , 2010

“Collaboration” – What does it mean? “Coming together is a beginning. Keeping

together is progress. Working together is success.” – Henry Ford.

“Teamwork divides the task and multiplies the success.” - Unknown

“Teamwork is the ability to work together toward a common vision; the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” – Andrew Carnegie

Infection control a regional problem, requiring coordinated effort

Created citywide electronic notification system to prospectively track all known patients with MRSA

Track over 17,000 patients with a h/o MRSA infection or colonization across Indianapolis.

Delivered 2698 admission alerts on patients with a history of MRSA, 19% from another institution.

20 infection control providers (ICPs) spanning 16 hospitals

Kho, Lemmon, Dexter, Doebbeling AMIA 2008

Alerts

0

50

100

150

200

250

300

350

400

Alerts

An Operational Citywide Electronic Infection Control Network

% of Coded Segments in the Technical Sub-Section by Themes & Sites

Site 1 Site 2 Site 3 Site 40.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

CoordinationUsabilityPaper-electronic blendRigidityFunctionality

12

Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131

Unique Strategy for Sustained Organizational Change Combining Lean and Positive Deviance

Lean from manufacturing○ Major QI Approach in Healthcare

Positive Deviance (PD)○ Experts within organization

Opportunity to learn & innovate- ○ Challenges and synergies

MRSA Phase Two What is Positive Deviance?

Technique to engage front line staff in owning & improving processes and sustaining change

Based on identification of practices of used by ‘positively deviant’ staff/departments

Critical for staff involvement/buy-in

Integrated Lean/PD approach

DevelopFuture State

Process

Process ControlStrategy

Baseline Current

Processes

Identify Operational

Barriers

Define the Problem

Discovery

Action

Creative Kickoffs Multiple

kickoff meetings to maximize participation

Very serious and very fun

Staff Engagement

Partnership Meetings Monthly meetings

with volunteers D&A’s Brainstorm solutions Discuss ideas

Resource Group (RG)Rolling boulders out of the way,

quickly responding to requests from CG

Core Group (CG)Convenes Cross-Unit meetings,

grant coordination

Other Units supported

with D & A Dialogue

ICU/MICU supported w/ Active Surveillance + D & A

Dialogue

Special Groupssupported

with D & A Dialogue

Solutions that MUST have Resource Group support

Vast majority of the action

happens on this end of the

iceberg

Fastresponse

One Is Too Many Partnership

One Is Too Many

Diverse Core & Resource Groups

ICP manager Director of Quality Nurse educators from two

intervention units Lean expert OD expert Nurse project coordinator

• VP Nursing • C00• ID MD• System office grant manager (ACT

project)• Two coaches from Plexus

Goal to ‘discover’ the issues and potential solutions, then take ‘action’ ASAP.

Informal meetings with front line staff to discuss current status of the process.

Incorporate as many front line staff as possible.

It is easier to “act your way into a new way of thinking” than to “think your way into a new way to acting”

Discovery and Action Dialogues

Discovery & Action Dialogues Seven facilitators trained

in the first month

Jumped in the deep water with 20 minutes of training

Transmission Disaster Response Teams Transmission Disaster

Response Teams D&ADs dialogues and

leader rounds linked with specific transmission cases to build collective mindfulness within and across units.

Sharing Results Community

briefing Making sense

of maps on the units

Clinical leaders

Admin leaders

Where am I? Is our network smarter than MRSA?

Social Network Mapping + Culture Survey Dreaming up

& researching questions

Social networking software

Creating a “family of measures”

Social Network Analysis Reveals communicative

patterns of complex groups and teams

Identifies the strength and frequency of connections

(e.g., with whom and how often do you communicate about reducing MRSA)

Describes current network in general & MRSA Bundle implementation in particular

Whom would you like to include or see involved in future MRSA prevention work?

Organizational Benefits of Change Staff developed skills and

processes

Documented, standardized processes

Isolation signs and chart stickers

Documented protocols for Active Surveillance & Prevention

Patient, family and staff education materials and methods

Partnering in Data Collection, Analysis,

Reporting Document impact in standardized language

Characterize efforts and strategies that work and disseminate nationally

Engagement of teams & coaches planning and conducting

Dissemination strategies- capturing stories, social networks, engagement, outcomes

Document ROI Impact

Reduction in MRSA isolates in an ICU

Literature Cost Savings (per Infection):

$ 6,916 - $35,000

Active Surveillance & Precautions Cost: Max $ 610 per infected patient (10%)

Methods challenging

Working with teams (& CFOs) to capture these data in meaningful way

Source: The Impact of Methicillin Resistance in Staphylococcus Aureus Bacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges, Cosgrove, et al, February 2003

Vision for Data Services – R&D Needed

Increased use of Electronic Data

Less effort on SurveillanceMaximize return on surveillance efforts

More effort on active InterventionResults Oriented

Actionable Information &Value-added services

Standardized, Accurate Measurement

Optimized Outcomes- Clinical & Financial

Conclusions Start small, build on success. Organizational change & sustainability

strategies needed. Change initiatives need both top-down

support and bottom-up engagement. Collaboratives foster teamwork! Resource and data intensive. Enthusiasm builds from within

because redesign teams own it! Informatics tools helpful –needs

R&D

“Collaboration” – What does it mean? “Alone we can do so little; together we can do so

much.” – Helen Keller “Strength is derived from unity. The range of our

collective vision is far greater when individual insights become one.” – Andrew Carnegie

“Collaboration equals innovation.” - Michael Dell

Thank You!

Questions? 

Contact Brad Doebbeling bdoebbel@iupui.edu bdoebbeling@gmail.com