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Service Delivery Innovation Profile

Comprehensive Program Focused on Culture Change, Education and Training, and Solicitation of Employee Ideas Significantly Reduces Incidence of Common Hospital-Acquired Infection

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The Billings Clinic, a not-for-profit organization in Billings, MT, addressed its rising rate of methicillin-resistant Staphylococcus aureus infections by making infection control a top institutional priority and by creating a comprehensive package that combines adoption and monitoring of strict infection control protocols, active surveillance, training and education, and the solicitation and implementation of employee ideas through an approach known as “positive deviance.” According to information provided in June 2009, after the implementation of the program, the incidence of health care–associated methicillin-resistant Staphylococcus aureus infections decreased by 81 percent from the end of 2005 through the end of 2008. A reduction in health care-associated methicillin-resistant Staphylococcus aureus infections continues to be realized with a 76-percent decrease from 2005 through December 2013.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospital–acquired Staphylococcus aureus infections and other key metrics, including adherence to surveillance and isolation protocols.
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Developing Organizations

Billings Clinic
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Date First Implemented


Problem Addressed

Methicillin-resistant Staphylococcus aureus (MRSA) infections are an increasingly common, serious, expensive problem that can often be prevented if evidence-based infection control procedures are followed.
  • An increasingly common problem with serious human and financial costs: In 2005, an estimated 94,360 individuals developed serious MRSA infections in U.S. hospitals, and roughly 18,650 hospitalized patients died of causes related to serious MRSA infections. In 2004, MRSA accounted for 63 percent of staph infections, up from 2 percent in 1974 and 22 percent in 1995.1 The average hospital MRSA infection costs $20,000 to treat.2 A Billings Clinic analysis also found that the typical MRSA infection added $20,000 in costs, except for patients getting joint infections, where costs were twice that amount ($40,000). Despite using an evidence-based approach for preventing MRSA transmission, Billings Clinic has experienced a steady rise in MRSA rates in recent years; between 2000 and 2005, the number of hospital-associated MRSA infections per 1,000 patient days rose in incidence from 0.15 to 0.81.3
  • Easily transmitted, but also preventable: The main method by which the infection is transmitted is through human hands, especially health care workers’ hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized patients.1 Established MRSA infection control protocols have been shown to be effective in preventing MRSA transmission, but hospital staff members often fail to follow these protocols.

What They Did

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Description of the Innovative Activity

The Billings Clinic has transformed its organizational culture to one in which MRSA prevention behaviors are a top priority. This transformation has been accomplished through use of established infection control protocols, active surveillance, training and education/feedback, and the solicitation and implementation of ideas from frontline employees through an approach known as “positive deviance.” Key elements of the program include the following:
  • Creating a culture where MRSA control is a top priority, with a focus on supporting employee-generated ideas: Billings leaders have adopted and promoted the positive deviance approach to create social and behavioral change, as positive deviance emphasizes the role of frontline employees in generating solutions to problems. (See the Context of the Innovation section of this profile for more background on positive deviance.) These leaders also realize that, to encourage employees to come forward with solutions, they need to create a culture in which employees are motivated to do so. In communications to employees, Billings leaders emphasize the significance of the MRSA issue and the need for employees to think of infection control as their problem rather than something handled only by infection control specialists. To that end, they encourage employees to share their ideas on infection control and to point out and correct—in a collaborative, collegial manner—any errors they may witness in the infection control behaviors of coworkers.
  • Hand hygiene and disinfection procedures: Staff members are required to wash hands before and after every patient contact and to disinfect all items that come in contact with MRSA-positive patients. A number of employee-generated ideas have increased adherence to this protocol:
    • Disinfection of all items: Staff began disinfecting previously overlooked items that can spread MRSA, such as keys to drug storage compartments and dinner trays.
    • Larger garbage cans: To accommodate the increased use of disposable gowns, gloves, and other items that help prevent transmission, Billings Clinic purchased larger garbage cans that help reduce the time spent emptying trash.
    • Isolation carts: Isolation carts were purchased so that isolation precaution supplies were organized and readily available for staff outside patient rooms.
    • End-of-day rounding on MRSA patients: Physicians decided to begin rounding on MRSA patients at the end of the day, when they had more time to take precautions. In addition, some male physicians stopped wearing ties because of their potential to transmit MRSA.
  • Active surveillance and quicker test results: As of August 2011 all patients admitted to the hospital receive a nasal swab test for MRSA on admission, transfer, or discharge. Patients who stay longer than 1 week are swabbed every 7 days. Patients who are found to be positive for MRSA are placed in contact precautions. Billings Clinic continues to use a specialized culture media which allows for quicker, more accurate results, allowing staff to begin taking contact precautions with MRSA-positive patients more quickly. Rapid PCR testing is also offered for surgical patients when their MRSA status is needed to adjust prophylactic antibiotic and treatment with topical mupirocin to reduce their risk of a surgical site infection.
  • Patient flagging system: Billings Clinic created an alert system that flags all patients who have a history of MRSA and electronically sends a notice to the units with an order to begin isolation precautions. The purpose of the flagging system is to begin isolation more quickly, therefore reducing the potential for MRSA transmission.
  • Isolation of MRSA positive patients: Patients infected or colonized with MRSA are placed on contact isolation protocols based on the Centers for Disease Control and Prevention (CDC) 2006 Multi-Drug Organism Resistant Guidelines.
  • Monitoring and feedback: Staff members in all inpatient units where active surveillance testing is conducted, receive prevalence, incidence (transmission), and swabbing rate compliance information each week.
  • Education and training: Billings has put in place a variety of educational and training programs focused on reducing MRSA transmission.
    • Monthly unit educational meetings: Each unit holds a monthly meeting in which they discuss MRSA prevention practices. The group’s coordinators use a range of educational methods during these sessions, including imitation, where an experienced worker demonstrates a tactic (e.g., the proper technique for nasal swabbing or disinfecting a room) and then participants practice the tactic with each other. Program coordinators also use unusual teaching methods, such as having employees dunk their gloved hands in chocolate pudding and wipe it on their isolation gowns to illustrate contamination with MRSA bacteria. This helps make the invisible germs visible to staff so they can discover for themselves the need to practice more carefully so as to not contaminate their surroundings or themselves while providing care to patients.
    • Improvisational theater for training: In response to frontline worker requests for more training, program coordinators converted an unused space into a simulated patient room. Known as the “the theater in the round,” this space serves as host to a mandatory 1.5-hour training session in which 12 to 15 individuals participate in one of four improvisational sketches. After each MRSA-related scenario is acted out, the audience provides feedback about what the staff did well and where they can improve. This scenario-playing emphasizes a key positive deviance principle—that participants find it easier to act their way into a new way of thinking than to think their way into a new way of acting. According to information provided in May 2014, improvisational theater–style learning sessions continue to be a part of the nursing fundamentals course for newly hired nursing personnel and remain an ongoing and effective method for infection prevention and control education and training for direct care nursing and support staff. Requests continue and sessions are provided regularly to requesting clinical areas.
    • Patient education: Staff developed a patient-friendly brochure and use Washington State Health Department's Living with MRSA publication to share information with patients to prevent MRSA transmission. Information provided in July 2010 indicates that another patient education brochure entitled MRSA & Athletics: What's YOUR Game Plan? was developed to provide information to help prevent the spread of MRSA in athletic settings. This brochure was co-created with Billings Clinic, the local health department, and another local hospital. It is provided to all patients who receive sports physicals at all Billings Clinic locations.
  • Active solicitation and support for implementation of employee ideas: A group of 20 to 40 MRSA champions, known as the Positive Deviance-MRSA Partnership and representing all hospital units and ancillary departments, meets monthly to solicit ideas for preventing MRSA and to identify staff who are already using positive infection practices. During these “discovery-and-action dialogues,” staff members identify barriers to successful MRSA prevention, which the Positive Deviance-MRSA partnership team then works to eliminate. With the partnership’s encouragement and support, employees implement many of the ideas that emerge from these dialogues. When needed, program coordinators provide direct assistance, such as help in securing funding or other resources.

Context of the Innovation

Billings Clinic is a not-for-profit organization that consists of primary and specialty care clinics, a 285-bed hospital, and a long-term care facility. Billings Clinic offers 35 specialties, including cardiovascular services, orthopedics, neurosciences, oncology, and women’s and children’s services. Billings Clinic was chosen as a pilot test site for a CDC-sponsored research study on MRSA prevention using the positive deviance approach in the ICU. Although positive deviance was initially used to fight childhood malnutrition in Vietnam, the concept can be used in the hospital setting to focus on the importance of identifying and spreading the word about effective, innovative strategies that are being used by individual workers at all levels of the organization. (The name “positive deviance” refers to the focus on uncommon strategies that lead to positive changes and results.)

Did It Work?

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Pre- and post-implementation comparisons suggest that this comprehensive program has significantly reduced the incidence of hospital-acquired MRSA infections, due primarily to better adherence to infection control procedures such as regular surveillance.
  • Major decline in health care–associated MRSA infections: The incidence of health care–associated MRSA infections at the facility decreased in incidence by more than 61 percent from 2005 until the end of 2007, from 0.81 to 0.30 health care–associated MRSA infections per 1,000 patient days. According to information provided in June 2009, incidence decreased by 81 percent (down to 0.13 infections per 1,000 patient days) by the end of 2008. Information received in May 2014 indicates the incidence is 0.20 infections per 1,000 patient days and reveals a sustained reduction since 2005.
  • Near-universal surveillance: From January to December 2007, the percentage of intensive care unit (ICU) patients who were swabbed at admission for MRSA rose from 91 to 98 percent, whereas the percentage swabbed at discharge increased from 65 to 84 percent. According to information provided in June 2009, these percentages rose to 99 percent and 92 percent, respectively, by the end of 2008. Furthermore, the inpatient medical unit has improved swabbing rates since beginning active surveillance in November of 2008 (e.g., from 91 to 98 percent for admission swabs, and from 80 to 88 percent for discharge swabs). The inpatient cancer care unit has maintained admission swab rates of 100 percent since beginning active surveillance in February 2009; the discharge swabbing rates have been at 90 percent since February 2009. Information provided in May 2014 indicates that active surveillance testing has expanded to all inpatient units with swabbing rates consistently above 90 percent and often 100 percent.
  • Increased adherence to isolation protocols: The number of gowns used each month increased from 2,000 in March 2006 to 16,000 by December 2007 and to 17,000 by May 2009. According to information provided in July 2011, gown use has increased to more than 25,000 gowns per month. Additionally, adherence to hand hygiene has improved from 2005 to May 2011 with compliance before patient care at 95 percent, after patient care at 97 percent, and after glove removal at 97 percent. Random, unannounced observations of hand hygiene have also increased from 2,255 observations in 2005 to 32,580 observations in 2009, 20,916 observations in 2010 to 57,135 observations in 2011, 47,252 observations in 2012, and 33,153 observations in 2013 with hand hygiene performance reaching 95 percent compliance before patient care, 96 percent compliance after patient care, and 96 percent compliance after glove removal. (Updated May 2014.)
  • Lower costs: Information provided in May 2014 indicates that since beginning this cultural change initiative in January 2005, Billings Clinic has sustained 76 percent fewer health care–associated MRSA infections which directly corresponds to reduced MRSA costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospital–acquired Staphylococcus aureus infections and other key metrics, including adherence to surveillance and isolation protocols.

How They Did It

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Planning and Development Process

Key steps involved in planning and developing the program included the following:
  • Kickoff meeting: Senior hospital officials organized a community forum open to all interested employees.
    • Sharing patient stories: Rather than use a traditional PowerPoint presentation, leadership decided to convey the importance of preventing MRSA transmission by sharing real patient stories. Four former Billings patients were invited to recount their experience with MRSA infections that developed during their hospital stays.
    • Recruiting volunteers: At the end of the community forum, 10 attendees volunteered to serve as coordinators for the new MRSA prevention program.
  • Committee formation: The 10 volunteer coordinators formed a committee known as the Positive Deviance-MRSA Prevention Partnership, which directed the overall program. The team decided to implement the program on four units (the ICU, an inpatient medical unit, an inpatient surgical unit, and the anesthesia treatment unit) and in five departments (respiratory therapy, rehabilitation, housekeeping, engineering, and radiology).

Resources Used and Skills Needed

  • Staffing: Billings Clinic did not add any new personnel for the program, which is coordinated by the hospital’s infection control team and the MRSA champions who serve on the Positive Deviance-MRSA Prevention Partnership as a part of their regular job responsibilities. However, staff members are paid for their participation in MRSA education and training sessions. In addition, Billings Clinic had access to positive deviance coaches to aid in the implementation of positive deviance techniques and group facilitation methods that lead to the behavioral and cultural changes that emerged as a part of their participation in a grant program.
  • Costs: Major expenditures include new isolation carts, larger trash cans, and infection control supplies (e.g., gowns, gloves, alcohol-based antiseptic dispensers).
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Funding Sources

Centers for Disease Control and Prevention; Billings Clinic; Delmarva Foundation; Plexxus Institute; Robert Wood Johnson Foundation's Pioneer Portfolio
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Tools and Other Resources

For more information on positive deviance visit

Adoption Considerations

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Getting Started with This Innovation

  • Get financial and other support from top-level administration: The program requires a significant financial commitment, including MRSA inservice training sessions. Without adequate financial resources, employee ideas that require new supplies or equipment cannot be implemented, causing the program to lose momentum. As infection control behavior increases, costs increase, including the costs of supplies such as gowns, gloves, and alcohol-based antiseptic gel.
  • Quickly implement employee ideas: Move quickly to implement promising employee ideas, or workers may believe that their contributions are not being taken seriously.

Sustaining This Innovation

  • Enlist program coordinators with varying work backgrounds: Having all different types of staff represented—including nonclinical workers—helps ensure that information will be conveyed in meaningful ways to all staff.
  • Trust staff, including “unlikely” contributors: The positive deviance approach often results in surprises as to which employees come forward and become major contributors (and those who were expected to come forward sometimes do not). Do not dismiss volunteers who may not fit the traditional image of hospital leaders.
  • Share results: Promote transparency by openly sharing performance results with staff on a regular basis.
  • Make sure that each employee understands the importance of his or her role in reducing MRSA: Employees will not change behaviors unless they understand how those behaviors can both lead to and prevent MRSA infections.
  • Hold rehearsals: Have employees actively rehearse new procedures, as this increases the likelihood they will incorporate them into their everyday work routines. Written policies alone are often ignored.
  • Share stories: Have workers share stories of MRSA infections from their own experiences (as both patients and employees). Storytelling is an effective way of communicating the real-world impact of MRSA infections.

Additional Considerations

Changing employee behaviors and hospital culture is a difficult problem that requires administrators to employ a different approach. Positive deviance offers such an approach, providing a new set of tools that can augment evidence-based medicine in addressing complex issues such as reducing the transmission of MRSA.

More Information

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Contact the Innovator

Nancy Iversen, RN, CIC
Director of Patient Safety and Infection Control
Billings Clinic
2800 10th Avenue North
Billings, MT 59107
Phone: (406) 657-4823

Innovator Disclosures

Ms. Iversen has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Information on positive deviance is available at:

To read more about the Billings Clinic Innovation:


1 Centers for Disease Control and Prevention. Methicillin Resistant Staphylococcus aureus. March 3, 2010. Available at:
2 Institute for Healthcare Improvement. Reducing MRSA infections: staying one step ahead. Available at:
3 PowerPoint slide provided by Nancy Iverson, RN.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 13, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.