Using Cultural Change to
Control Superbugs
Michael Gardam
Physician Director, CHICA Canada
Medical Director, Infection Control
University Health Network
1
Outline
•Different problems require different
approaches
•Introduction to a New Approach to Controlling
Superbugs
•What we’ve learned
Why a new approach?
• Education, checklists, guidance documents are
necessary but not sufficient
• Tired to nagging
• Tired of owning this problem
• Traditional strategies don’t work well enough
3
“Insanity: doing the same things
over and over again and
expecting different results.”
-Albert Einstein
4
The Hand Hygiene Hurdles
5
Current healthcare culture does not
put a high value on infection
prevention and control
6
What type of problem
are you facing?
Controlling superbugs is a
complex problem
7
High
Simple
Complicated
Complex
Low
Low
Agreement
Adapted from Brenda Zimmerman, 2010
High
Simple or complicated problems
•
•
•
•
•
Search for solutions i.e. “fix it”
Problem solve
Checklists
Algorithms
Best practices
5
Complex problems
• “Social immune response”
– highly sensitive to local culture and conditions
•
•
•
•
•
No one size fits all
Local solutions, multiple actions
Allows for paradoxes
Importance of relationships, intuition
“minimum specifications”
10
The “minimum specifications” of
infection control
•
•
•
•
•
Hand hygiene
Environmental cleaning
Surveillance (clinical, laboratory)
Routine practices, additional precautions
Appropriate antibiotic use
If we do these well, our problems should largely
go away…
11
Strategies
• Simple/complicated problems may respond
better to “top down” approaches
• Complex problems may respond better to
“bottom up” approaches
• Infinite variations of both approaches
12
“Up, down and out”
The NACS approach
• Tackle behaviour and culture head on
• Specific engagement of front line staff
– Unusual suspects
• Shifting of ownership from infection
prevention and control to the front line
• Use a variety of techniques referred to as
“liberating structures” to achieve this
– Positive Deviance is one liberating structure
In any group…
Increasing performance
Some examples
•
•
•
•
•
Smoking cessation
Medication reconciliation
Malnutrition
Gang violence and inner city youth
Controlling healthcare associated infections
16
Key points
•
•
•
•
Ideas come from those who are ”touching”
the problem
The group acts on ideas from “someone
just like me”
The groups succeeds and fails
What works for one group may not work
for another despite a similar challenge
Reinventing the wheel
• The role of
infection control is
to define the what
the wheel needs to
do…not how, or
how fast, to build
it
Fewer infections
Team 3
Team 1
Team 2
Superbug Tools
• Sharing Stories
• TRIZ
• Improvisation
• Discovery and Action Dialogues
• Social Network Analysis
• Wise crowds
• 25 gets you 10
• 15% solution
These tools allow you to
• Clarify the problem
• Improve participation
• Unleash the ideas of those touching the
problem
• Notice patterns, common themes
• Spread ideas
• Sustain change
TRIZ
• Design a system whereby you can ensure that
100% of patients will be infected with a
superbug within 2 days of admission to your
facility
21
Discovery and Action Dialogues
• 15-20 minute facilitated discussions with
front line staff in their work setting
• Different people will be at different sessions
• Allow ideas to float to the surface
22
Who do you talk to about the prevention of superbugs?
Legend
RN
External
Clinical
Educator
Allied Health
Director
ICP
Admin
Housekeeping
MD
Executive
Volunteer
Resources
Ward Clerk
Patient
Education
Manager
23
Who do you want to work with in the future?
Legend
RN
External
Clinical
Educator
Allied Health
Director
ICP
Admin
Housekeeping
MD
Executive
Volunteer
Resources
Ward Clerk
Patient
Education
Manager
24
“It’s a lot easier for an organization
to adopt new words than it is to
actually change anything.
Real change is uncomfortable. If it’s
not feeling that way, you’ve
probably just adopted new words.”
-Seth Godin
25
Local innovations
• Empty hand rub
indicators
• Disinfectant wipe
brackets
• New isolation carts
• Videos
• Antimicrobial
stewardship
•
•
•
•
•
Point of care hand rub
“green is clean”
New signage
Food tray shelves
Staff and patient
clothing hooks
• Changes to bedside
education
• …
26
60.00
1.40
50.00
1.20
1.00
40.00
0.80
30.00
0.60
20.00
0.40
10.00
0.20
0.00
Soap used (L) per 1,000
patient days
Alcohol gel used (L) per
1,000 patient days
Incidence density of
HAIs per 1,000 patient
days
0.00
1
2
3
4
6000.00
0.40
0.35
5000.00
0.30
4000.00
0.25
3000.00
0.20
Number of boxes of
gloves used per 1000
patient days
Number of gowns used
per 1000 patient days
0.15
2000.00
0.10
1000.00
0.05
0.00
Incidence density of
HAIs per 1000 patient
days
0.00
1
2
3
4
2
7
120.00
0.40
0.35
100.00
0.30
Soap used (L) per 1,000 patient
days
80.00
0.25
60.00
0.20
Alcohol gel used (L) per 1,000
patient days
0.15
40.00
0.10
Incidence density of HAIs per
1,000 patient days
20.00
0.05
0.00
0.00
1
2
3
4
2
8
What we’ve learned
•
•
•
•
•
•
•
There is an appetite for a new approach
Long term strategy/approach
“failure to launch”
Teams need more prodding
Teams need to commit
There are limits to virtual programs
Coaching is crucial
29
“Culture Eats
Strategy
For Breakfast.”
-Attributed to Henry Ford
Will deviate for change
•
michael.gardam@uhn.on.ca
•
leah.gitterman@uhn.on.ca
•
positivedeviance.ca
•
stopsuperbugs.com
•
Twitter:
@DrMichaelGardam