Perioperative Infection Prevention: Using Positive Deviance in the Pursuit of Excellence


Healthcare-associated infections (HAI) are preventable. Yet despite ongoing surveillance, rigorous protocols and well-researched policies, HAI’s still occur in one in twenty patients, according to the Centers for Disease Control and Prevention (CDC). The CDC notes that surgical site infections remain the most common HAI, affecting 1 in 50 patients. 

By Victoria Steelman, PhD, RN, CNOR, FAAN
Healthcare-associated infections (HAI) are preventable. Yet despite ongoing surveillance, rigorous protocols and well-researched policies, HAIs still occur in 1 in 20 patients, according to the Centers for Disease Control and Prevention (CDC). The CDC notes that surgical site infections remain the most common HAI, affecting 1 in 50 patients. 

Clearly, perioperative nurses and infection preventionists need to work closely together to identify best practices that prevent SSIs. But how?

As incoming AORN president, I believe that infection preventionists can fuel the powerful quality improvements that lead to excellence when they tap the wisdom of front-line hospital staff.

I’m not alone. Many change management consultants now see that some of the best insights come from the very people who are immersed in the day-to-day realities of patient care.

Positive deviance (PD) rests on the premise that in every hospital, some individuals or groups engage in uncommon behaviors that help them better solve problems than their peers. Positive deviants are not rule-breakers; rather, they are front line staff who pioneer innovate ways to reduce infections, despite conflicting priorities.

When infection preventionists use a PD methodology to identify and spread these effective, innovative strategies, all operating staff become more engaged and patient outcomes improve.

Positive Deviance in Action
Consider how the Veterans Affairs Pittsburgh Healthcare System in 2005 used PD to reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA) infections.

As described on the Agency for Health Quality and Research (AHRQ)’s Health Care Innovations Exchange, VAPHS chief of staff Dr. Rajiv Jain first called a meeting of 125 individuals, including physicians, nurses, nurses’ aides and custodians. He asked for an all-hands-on-deck approach to stopping the spread of MRSA.

Over multiple subsequent meetings, individuals shared dozens of ideas for infection control. For instance, to improve physician and nurse hand hygiene, participants suggested antibacterial foam dispensers be placed where staff and patients handle commonly used items; inside and outside patient rooms; and throughout rooms used for occupational and physical therapy.

To prevent the transmission of MRSA pre- and post-operatively, MRSA-positive patients were taken straight from isolation rooms to the surgery suite. The hospital also converted a storage room into separate post-operative recovery room for MRSA-positive patients.

But most surprising were the contributions of non-clinical staff. Edward Yates, a housekeeper, identified a potential cause of infection transmissions in how step-down unit rooms were cleaned. Non-isolation rooms were typically given a lighter cleaning while isolation rooms received a more thorough cleaning. Because of the two-day time period required to identify MRSA through nasal swabs, a non-diagnosed MRSA-positive patient could recover in a non-isolation room and leave the bacteria behind for the next patient.

Not only did Yates’ insight lead the team to give all rooms a thorough cleaning, but it also spurred the creation of a standardized “best practice” for room cleaning. Further, in realizing that many housekeeping staff could not read the English-language cleaning instructions, Yates created a text-free diagram to explain the protocol.

These approaches and many others, taken together, resulted in a 50 percent decline in MRSA infections in one year, generating an estimated $1.1 million in cost savings.

The PD Approach
According to the Positive Deviance Initiative, PD is a “problem-solving, asset-based approach.” But unlike other asset-based approaches, the PD methodology involves all stakeholders and is based on the principle that the community owns the process and the solution.
The PD method is summarized in four D’s and an M: define, determine, discover, design and monitor.
• Define the problem or opportunity and define the outcome you want
• Determine if there are individuals in your organization who are already exhibiting the desired behavior or producing the desired results
• Discover uncommon practices and behaviors that enable the smaller set of healthcare workers to outperform others in their organization
• Design interventions that let others in the organization access the new behaviors
• Monitor results 

How To Get Started
I can think of many places where we need to find innovative ways to improve our practices. The challenge might be preventing surgical site infections; improving environmental cleaning in the OR; or boosting hand hygiene and compliance with double-gloving.
Just look around. Select one of these problems or opportunities. In your facility, today, you are likely to discover operating room nurses who are exemplary in producing the desired behavior or results.

Ask yourself, how do they do it?  What are they doing differently?  Can I generalize what they are doing to other nurses? Can I engage these positive deviants to become evangelists for the new practice? Or should I ask for outside consulting help to begin a formal PD process?
Regardless of which approach you take, I’m confident that infection preventionists have much to learn from operating nurses, and that this collaboration is key to positive patient outcomes. In the coming year, I look forward to hearing from you about how you discovered excellent practices within your organization. As Socrates wrote, “There is nothing so well learned as that which is discovered.”

Incoming AORN president Victoria Steelman, PhD, RN, CNOR, FAAN, is an assistant professor at the University of Iowa College of Nursing. 

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