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Acting Our Way Into New Thinking Prototyping Safe Behaviors With Improv Learning Simulations. Billings Clinic Players Executive Producers Joelle Everett & Keith McCandless. Scenes from the Isolation Precautions Room Making the Invisible Visible

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acting our way into new thinking prototyping safe behaviors with improv learning simulations

Acting Our Way Into New ThinkingPrototyping Safe Behaviors With Improv Learning Simulations

Billings Clinic Players

Executive 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
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
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
Setting the Stagewith 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 calls calling all units
Casting CallsCalling All Units!

A flurry of casting calls, Want to be an

improv player?

Everyone says, Yes!

theatre in the round
Theatre In the Round

A 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.

audience as active participant
Audience As Active Participant

Participant feedback

forms at-the-ready.

What helps?

What else?

Who wants to join in

the ongoing design work?

working without a script
Working Without a Script

Players getting into character.

Hey, is that our MRSA clinical leader playing a patient!?

scene i
Scene I

Patient Is


Is The Room

Safe & Ready?

Min Specs needed to start the action.

rrrring rrrring the scene opens in empty space
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


Isolation Precautions

sign from the

MRSA Prevention


scene ii
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


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


is shared by the

nurse and


scene iii
Scene III

Truth To Power

How to have





Surgeon rushes

into the room

and greets









MRSA tie





gloves &


Nice glove



I did not

notice that you

washed your


Did you know

this patient was

MRSA positive?


No worries,

we will take

care of that

infection in



scene iv
Scene IV

Safe Travel

What do

I wear?




hand hygiene!













Confident technique:


down, up

and all around.


Ready to roll,

calm, cool and

well dressed.

Let’s go,

We are ready

for surgery.


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
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
Setting Up and FacilitatingImprov 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 @