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

1. 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

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

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

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

6. Funding from AHRQ and CDC

7. Testing Spread and Implementation of Novel MRSA-Reducing Practices HHSA290200600013 (Current)

9. Learning community of practice (7 hospitals)

10. Electronically and culturally interconnected

11. International consortium

12. Effectiveness -- Reduced rates 60-85%

13. Pittsburgh VA

14. RWJ Sites

16. Panarchy or Ecocycle Model of Change Maturity Renewal Creative Destruction Birth For more information on the ecocyle go to http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html

17. 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 Network or group level A change in conversation A change in routine A change in resource commitment or influence 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

19. Patient barriers/facilitators

20. Organizational buy-in

21. Leadership support

22. Training

24. Functionality/scope

25. Computer/IT support

26. Flexibility in IT tools

27. Iterative design

29. Workload

30. Financial factors

31. Unintended external consequencesWestbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007

32. Strategy

33. Tranformative Change: 7 Effective Strategies Fostering Change Communication & Collaboratives Local, Focused Implementation Frontline Staff Engagement Organizational Learning Support, Resources & Accountability Feedback & Reinforcement Qualitative Thematic Analysis, Healthcare Associated Infections (HAI) Initiative Assessment Program , AHRQ ACTION, HHSA290200600013I , 2010

34. “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

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

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

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

39. 20 infection control providers (ICPs) spanning 16 hospitals Kho, Lemmon, Dexter, Doebbeling AMIA 2008

40. % of Coded Segments in the Technical Sub-Section by Themes & Sites 12 Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131

41. 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

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

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

46. Creative Kickoffs Multiple kickoff meetings to maximize participation Very serious and very fun

47. Staff Engagement

48. Partnership Meetings Monthly meetings with volunteers D&A’s Brainstorm solutions Discuss ideas

50. C00

51. ID MD

52. System office grant manager (ACT project)

54. Discovery & Action Dialogues Seven facilitators trained in the first month Jumped in the deep water with 20 minutes of training

55. 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.

56. Sharing Results Community briefing Making sense of maps on the units Clinical leaders Admin leaders Where am I? Is our network smarter than MRSA?

57. Social Network Mapping + Culture Survey Dreaming up & researching questions Social networking software Creating a “family of measures”

58. 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

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

60. 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

61. 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

62. 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 AureusBacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges, Cosgrove, et al, February 2003

64. Less effort on Surveillance

65. Maximize return on surveillance efforts

66. More effort on active Intervention

67. Results Oriented

68. Actionable Information & Value-added services

69. Standardized, Accurate Measurement

71. • “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

72. Thank You! Questions? Contact Brad Doebbeling bdoebbel@iupui.edu bdoebbeling@gmail.com