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Lessons from the Field. How to successfully coach a Positive Deviance Initiative ODN Conference Tuesday, 10/21/08 Session T18 3:00PM – 4:15PM Cathi Balboa Carlos Arce Sharon Benjamin. POSITIVE DEVIANCE: Different Process = Better Results.

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Lessons from the Field

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Lessons from the field

Lessons from the Field

How to successfully coach a

Positive Deviance Initiative

ODN Conference

Tuesday, 10/21/08

Session T18

3:00PM – 4:15PM

Cathi Balboa

Carlos Arce

Sharon Benjamin

Lessons from the field

POSITIVE DEVIANCE: Different Process = Better Results

We care about what works: we’re grounded in theory but responsible for SUCCESSSolutions to wicked problems CAN be found and success sustainedPositive Deviance provides an important and different means of facilitating changeUsing Positive Deviance the emphasis shifts from finding the right answers to asking better questionsPeople can change and success should be shared!

Positive deviance helps us see solutions before our very eyes

Positive Deviance helps us see solutions before our very eyes

In every community or organization there are certain individuals or groups whose uncommon practices/behaviors enable them to find better solutions to intractable problems than their neighbors or colleagues who have access to the same resources

Positive deviance pd approach

Positive Deviance (PD) Approach

Engages the very people “whose behavior needs to change to solve the problem” to identify existing solutions from within

Staff move from “Yeah, but….”


“I make the difference”

Lessons from the field

If we start by looking for existing solutions – and include everyone – especially unusual suspects – the solutions we discover vastly exceed

our wildest notions in their elegance, simplicity, scope and speed of implementation.


Lessons from the field

PD Enables us to Act TODAY

The presence of Positive Deviants demonstrates that it is possible to find successful solutions TODAY before all the underlying causes are addressed

Lessons from the field

Successful Applications of PD in All Walks of Life

When to use positive deviance

When to use Positive Deviance

Wicked, Important Problem

Behavior needs to change NOT knowledge


Progress is measurable

Skilled facilitation is available

Focus on practice rather than knowledge

Focus onPracticeRather than Knowledge

It’s easier to ACT your way into a new way of THINKING, than to THINK your way into a new way of ACTING

Discovery action

Discovery & Action

PD findings are passed through a lens of “accessibility”

Can everyone potentially adopt a behavior? Only behaviors/strategies accessible to all within a cohort or location are kept

The rest are TBU…..

……True but Useless!!!

Pd exercise scenario

PD Exercise - Scenario

You are a group of internal and external OD Consultants that work with an organization where the culture is known for its rampant “scope creep”.

The facts that you know are:

  • 70%+ of their projects are labeled “Failures”

  • 80%+ are over budget and late

  • 50%+ are abandoned because resources are pulled.

    In small groups, designate a facilitator, scribe & participants

    Use the 6 PD questions to “discover” some


Pd s six key questions

PD’s Six Key Questions

What would you like to know about this problem?

What do youdo about it?

What are the barriers that prevent you from doing the right thing 100% of the time?

Who do you know who is doing the right thing or who has overcome these barriers? (the positive deviants)

Who else needs to be in this conversation that isn’t here? (i.e. “Don’t decide about me without me”)

How do we invite those people to be part of the action?

What other ideas do you have?

Case study why 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. You are more likely to die from MRSA than AIDS.

  • 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.

  • There is evidence which suggests that when everyone gets involved the spread of MRSA can be stopped. Precautions are relatively simple but involve nearly everyone changing “autopilot” behaviors.

  • A fitting, creative challenge for complexity-inspired approaches, Plexus, and Positive Deviance.

Big questions facing hospitals

Big questions facing hospitals

  • Is PD going to work for us?

  • How can we responsibly let go of control?

  • Is it safe to unleash wildly productive self-discovery?

  • Will it be effective to encourage local discovery & action?

  • Isn’t it our job to have the answers?

Big results

Big Results

Clinical results: 35% average drop in MRSA infection rates (preliminary CDC results)

The Billings Clinic incidence rate declined by 88%

Albert Einstein Medical Center infections dropped 35% so,

57 people went back to their families, homes and lives.

Expected organizational results

Hand hygiene and gowns & gloves use improved at all sites

Self-report data on performance & employee satisfaction improved

Unexpected benefits

  • Improved nursing recruitment into tough units

  • Improved process for on-call scheduling

Coaching a pd initiative

Coaching a PD initiative

Carlos was on the inside and learned how an internal OD person can leverage PD

Sharon was on the outside and learned how PD makes a big difference and leveraged existing OD initiatives

Cathi mapped differences between PD

and traditional change approaches

We ALL saw it working!

What you might have heard

What you might have heard...

  • Nothing will make a difference!

  • We’re doing everything we can do!

  • You’ll never get them to change!

  • Just tell us what to do!

  • Don’t tell me what to do!

  • We’ll always have transmissions!

Lessons from the field

Healthcare-associated MRSA Infections

Housewide Incidence Rates

January 1999 – June 2008

Incidence Rate =

# cases / patient days X 1,000

Case is defined as healthcare-associated infection.

Lessons from the field

Healthcare-associated MRSA Infections

ICU Incidence Rates

January 2004 – June 2008

Incidence Rate =

# cases / patient days X 1,000

Case is defined as healthcare-associated infection.

New way to act

New Way to Act

  • Changed how we interact/how we solve problems

  • New Approaches: Confusing and Powerful

  • Reduced Transmissions

  • Increased Hand Hygiene compliance

  • Uncovered new leaders

  • Invited and recognized innovation

And speaking of acting

And, speaking of acting….

Harnessing self discovery

Harnessing Self-Discovery

  • We learn best when we discover things for ourselves

  • Unlocks the secrets of how innovative practices and behaviors enable some individuals to find successful solutions to common problems

  • With access to no special resources and within the same set of constraints; innovators are revealed right before our eyes!

Complex lessons

Complex Lessons

It takes


and faith!

  • This is truly social science

  • Simple actions generate grand results

  • Data and need for certainty

    can be distracting…

    • “It’s weak”, “It’s a hoax”, “You don’t know for sure”

    • Shouldn’t keep us from improving

  • Movement created with limited formal leaders

    (Imagine what could be accomplished with more)

  • “Easier to act our way into a new way of thinking than to think our way into a new way of acting.”

How is pd different as a process

How is PD different as a process?

Focus on pd behavior

Focus on PD Behavior

We can’t (yet) clone people

Lessons from the field

Jasper Palmer discovered a better way to remove gowns and gloves





But we canadopttheirsuccessful

behaviors & strategies


How does my role as an od practitioner change

HOW does my role as an OD practitioner change?

Paradigm shift - we move from expert to facilitator

Requires comfort with uncertainty, power sharing & lack of control

Mastering a subtle, elusive process with unusual metrics

Learn to hug clouds

Who’s doing what shifts & it’s labor intensive

It’s a profoundly circular process – it’s not linear!

Scaling up strategies change radically

Uncovers & creates new problems…… and that’s the good news

Inability to forecast all outcomes & consequences

We move off stage

Our answers are not relevant – our questions are

Selected bibliography sources

Selected Bibliography & Sources

Cosgrove, S.E., (2006). The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin. Infect. Dis. 42: S82-9.

Elixhauser, A.,& Steiner, C., (2007). Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005. AHRQ Healthcare Cost and Utilization Project, Statistical Brief #35, July.

Klevens, R.M., Morrison, M.A., Nadle, J, Petit, S., Gershman, K., Ray, S., Harrison, L.H., Lynfield, R., Dumyati, G., Townes, J.M., Craig, A.S., Zell, E.R., Fosheim, G.E., McDougal, L.K., Carey, R.B., Fridkin, S.K., (2007). Active Bacterial Core Surveillance (ABCs) MRSA Investigators. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. Oct 17;298(15):1763-71. PMID: 17940231

Muto, C.A., Jernigan, J.A., Ostrowsky, B.E., Richet, H.M., Jarvis, W.R., Boyce, J.M., and Farr, B.M., (2003). SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infection Control and Hospital Epidemiology 24, no. 5:362-386.

Tanner, R., Sternin, J. (2005). Your Company's Secret Change Agents. Harvard Business Review. May.

Plsek, P.E., (2001). Appendix B: Redesigning Health Care with Insights. Science of Complex Adaptive Systems in Crossing the Quality Chasm. Institute of Medicine.

Krebs, V., & Holley, J., (2006). "Building Network Weaving Through Smart Communities," http://www.orgnet.com/BuildingNetworks.pdf

Photo credits: Keith McCandless, slides 2, 21, 25, 26

Positive Deviance Initiative/Jerry Sternin, slides 6, 7, 9

Lessons from the field

For More Information

Carlos Arce


Sharon Benjamin, PhD


Cathi Balboa cbalboa@earthlink.net

Jerry & Monique Sternin


Jon Lloyd, MD


Margaret M. Toth, MD


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