Positive deviance and common sense

When I first heard about “positive deviance” (and learned that research funding was being distributed to study it), I assumed it was a new, high-level approach to quality improvement that I needed to master. But every time I read about it, or asked someone to explain it to me, it seemed very much like common sense…..empower people to change things for the better, then recognize and learn from those who succeed.

So I enjoyed this article about positive deviance from the Boston Globe, loaded with examples (several from healthcare settings). The first sentence of the last paragraph sums it up for me:

“At bottom, positive deviance amounts to simple common sense”

Many of the controversial infection control approaches we discuss in this blog are best understood as the opposites of positive deviance. I’m thinking of legislative mandates and other dogmatic, punitive approaches to infection control (e.g. legislation requiring hospitals to adopt a single approach to MRSA control, mandating an annual vaccine under threat of dismissal, etc.).

Any of you out there who consider yourselves black-belt positive deviants, feel free to enlighten me about its many complexities.

A low-cost but effective hand hygiene observation program

The December issue of Academic Medicine has a paper that describes UCLA Medical Center's hand hygiene program, which uses pre-health career college students as volunteer observers. The students are trained to use standardized tools and the program yields about 9,000 observations per year. The authors of the paper note that the advantages of the program are that it gives the students experience in the healthcare setting and its low cost ($5,000/year). Disadvantages are the lack of nighttime observations and gaps in observations when the university is not in session. Hand hygiene across the institution has increased from 50% to over 90%. Click here to view the program's website.

At VCU Medical Center we are currently in the third year of our observer program, which also relies on students (undergraduate and graduate). Our observers are paid an hourly wage, which allows us to obtain nighttime observations as well as year-round coverage. Although our program is four times more costly (still a bargain), it yields four times as many observations, and the results in improvement in hand hygiene compliance are very similar to those at UCLA.

New Jersey hospital bans neckties

Jersey City Medical Center will now prohibit healthcare providers from wearing neckties. Bowties are still allowed. From the infection control standpoint, I think banning white coats would have a bigger impact, but it's a good start to push healthcare workers to become more cognizant of the role of clothing in infection control.

More freaky feedback, please

In a post today on his “Freakonomics” NY Times blog, Stephen Dubner continues the hand hygiene discussion Mike blogged about recently. He highlights a reader comment about “closing the loop” by providing real time reminders to doctors that their hands are contaminated. I agree that providing frequent and timely reminders is a critical part of improving hand hygiene, but I don’t think it is necessary that such reminders focus solely on the presence of microbes….I (unlike some of my colleagues) believe that most physicians have accepted the germ theory of disease, and most also realize that their hands can (and do) carry pathogens that pose risks to patients.

So I think several varieties of feedback will do: adherence rates, infection rates, bedside reminders from patients, families or healthcare workers, the intermittent presence of a discreet observer, any of these will help. It is essential, though, that such feedback be provided as close to the point of care as possible (we all know how effective feedback is when given in a large auditorium or conference room!). And as for the common refrain that we’ll never achieve sustained adherence rates over 60-70%? Wrong. We have plenty of experience now that higher rates can be both achieved and sustained.

Looking for a flu shot?

If you're wanting to get a flu shot, Google has a great tool--FluShot Finder. Click here, enter your zip code, and you'll get a listing of where the seasonal and H1N1 vaccines are available near you, along with a map. Pretty cool!

Impact of bare below the elbows on hand hygiene

A new study in the Journal of Hospital Infection evaluated the quality of hand hygiene in physicians and medical students using an alcohol based product that contained a fluorescent marker, which allowed for a highly quantitative measure of surface area that was decontaminated. (I'll post a link to the PubMed citation as soon as it's available). Hand hygiene effectiveness was compared between study subjects who were bare below the elbow and those who were not. As might be predicted, there was no difference in decontamination of hands between the two groups; however, decontamination of wrists was significantly better in the bare-below-the-elbows group.

Tamiflu-resistant H1N1

Two clusters of patients with tamiflu-resistant H1N1 infections have been reported today. One cluster is in Wales, and the other is a cluster of 4 immunocompomised patients at Duke University. The Duke cases were nosocomial in origin. Very worrisome....