Post on 26-Dec-2015
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,
Colombia
Photo: 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 Participant
Participant 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 I
Patient Is
MRSA +
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 II
Enter 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 III
Truth 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