Skip Navigation
Events & Podcasts >
January 2009
Engaging Stakeholders: How to Obtain and Retain Buy-In for Your Innovations
Moderator: Judi Consalvo, Program Analyst, AHRQ Center for Outcomes and Evidence Innovators: Georgia Oliver, RN, MS; Patria Johnson, MSSW; Paul Melinkovich, MD; Nancy Iversen, RN, CIC View Slides Listen to Audio file Read Transcript
Panel Slides

Jump to Slides:

Moderator: Judi Consalvo, Program Analyst, AHRQ Center for Outcomes and Evidence
1 2 3 4 5 6 7 8 9 10 11

Innovators:

Georgia Oliver, RN, MS, Patria Johnson, MSSW
12 13 14 15 16 17 18 19 20 21 22

Paul Melinkovich, M.D.
23 24 25 26 27 28 29 30 31 32 33 34 35

Nancy Iversen, RN, CIC
36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

Slide 1

Text Description Follows

Engaging Stakeholders: How to Obtain and Retain Buy-in for Your Innovations

A Public Webcast
January 27, 2009
2:00 – 3:30 PM (EST)

Back to top

Slide 2

Text Description Follows

What Is the Health Care Innovations Exchange?

Searchable database of service innovations

  • Includes successes and attempts
  • Wide variety of sources ? including unpublished materials
  • Vetted for effectiveness and applicability to patient care delivery
  • Categorized for ease of use: extensive browse and search functions
  • Innovators’ stories and lessons learned
  • Expert commentaries

Learning opportunities

  • Learning Networks: A chance to work with others to address shared concerns
  • Educational content
  • Web Events featuring innovators, experts, and adopters

Back to top

Slide 3

Text Description Follows

Plans for a Webinar Series

  • One aspect of opportunities to learn and interact
  • Possible topics:
    • Collecting evidence to improve your innovation
    • Transferability of innovations
    • Adaptation/customization/refinement of innovation during adoption
    • Attempted innovations
  • We’d like your input: What would be most useful to you?

Back to top

Slide 4

Text Description Follows

Today’s Topic: Engaging Stakeholders

  • How do you communicate the benefits of a new approach to different stakeholders?
  • How do you build strong partnerships?
  • How do you ensure that all pertinent voices are represented?
  • How do you cultivate champions who will help you move forward?

Back to top

Slide 5

Text Description Follows

What Is a Stakeholder?

  • Anyone who has a stake in the process or outcome of the innovation:
    • Patients
    • Physicians, nurses, and other health care providers
    • Executive management
    • Board
    • Community organizations
    • Volunteers

Back to top

Slide 6

Text Description Follows

Our Speakers

  • Georgia Oliver, Project Director, Memphis Healthy Churches
  • Patria Johnson, Program Manager, Memphis Healthy Churches
  • Paul Melinkovich, MD, Director, Community Health Services at Denver Health
  • Nancy Iverson, RN, CIC, Director of Patient Safety and Infection Control at Billings Clinic in Montana

Back to top

Slide 7

Text Description Follows

Diverse Settings, Common Themes

  • Gaining buy-in at the start
  • Maintaining buy-in throughout
  • Garnering support from new stakeholders midway through
  • Similarities and differences in engaging internal partners and external partners
  • Changes in collaborations/partnerships across time
  • Points for possible tension/conflict
  • Methods for mediation and resolution
  • Small wins versus large victories

Back to top

Slide 8

Text Description Follows

Submitting Questions

  • When: After the presentations
  • How:
    • Dial *1 to contact the operator, who will open your line.
    • Send a written question through the “Q&A Center.”

Back to top

Slide 9

Text Description Follows

Need Help?

  • From your computer:
    • Click “help” button
    • Email support@vcall.com
    • Send a note to the Q&A feature
  • From your telephone:
    • 1-866-490-5412 for technical assistance
    • Dial *0 (star-zero)
  • To join by telephone rather than by webinar
    • 1-877-705-6008

Back to top

Slide 10

Text Description Follows

Submitting Questions

  • Dial *1 to contact the operator, who will open your line.
  • Send a written question through the “Q&A Center.”

Back to top

Slide 11

Text Description Follows

Questions or Comments
Follow-up Discussion

  • If you are interested in participating in the follow-up discussion, please email us at info@innovations.ahrq.gov by Monday February 2nd.
  • Subscribe to receive e-mail updates: http://innovations.ahrq.gov/contact_us.aspx

Back to top

Slide 12

Text Description Follows

Memphis Healthy Churches: Innovations Exchange Webinar

Georgia Oliver, RN, MS
Patria Johnson, MSSW
January 27, 2009

Back to top

Slide 13

Text Description Follows

What is Memphis Healthy Churches?

  • An outreach program of Christ Community Health Services targeting African American Churches with health and wellness programs

Back to top

Slide 14

Text Description Follows

Our History

  • Began in 1998 as a partnership with Baptist Health Care System and CCHS, Inc. as the ACCESS (A Community-based Cancer Education and Support Service) Program
  • In the first year, over 20 churches participated in the program

Back to top

Slide 15

Text Description Follows

Our History(continued)

  • Due to success, we seized the opportunity to include other major diseases that effect African Americans, such as diabetes, heart disease, HIV/AIDS and obesity
  • In 1999, name changed to “Memphis Healthy Churches”
  • Today, 100 churches and over 150 health representatives participate in the program

Back to top

Slide 16

Text Description Follows

Program Statement

Memphis Healthy Churches is positioned on the front line in the fight against preventable diseases in the African American community including cancer, cardiovascular disease, obesity, diabetes and HIV/AIDS.

Currently, we provide disease prevention education in 100 African American churches. Trained health representatives work actively with their pastors to promote lifestyle changes and healthy behaviors in their congregations.

Back to top

Slide 17

Text Description Follows

Gaining Buy In at the Start

  • Identify the target population to be served
  • Make cultivation and education of stakeholders a top priority.
  • Seek external sources of funding to serve as a catalyst for individual churches to initially participate.
  • Cultivate relationships and partnerships with other health and community organizations to secure resources, in-kind support, and technical assistance.
  • Dedicate paid staff to the project, focusing their work on supporting the volunteers.
  • Identify a sponsor with the resources and infrastructure to provide support to the program, such as trainers for clinical topics.

Back to top

Slide 18

Text Description Follows

Maintaining Buy-In Throughout

  • Partnership
  • Training
  • Technical Assistance
  • Incentives
  • Recognition

Back to top

Slide 19

Text Description Follows

Garnering Support from New Stakeholders

  • Define goal(s)
  • Assess available resources to meet goals
  • Determine who has resources and develop partners accordingly

Back to top

Slide 20

Text Description Follows

Sharing Similarities and Differences Internally and Externally

  • State mission and vision clearly
  • Branding program distinctions is key
  • Celebrate like interventions and strategies with stakeholder (Do not reinvent the wheel)

Back to top

Slide 21

Text Description Follows

Coping with Change in Collaborations/Partnership Over Time

  • Expect change
  • Promote autonomy
  • Redefine goals and anticipated outcomes

Back to top

Slide 22

Text Description Follows

General Advice

  • Start where the people are
  • Communicate, communicate
  • Acknowledge and celebrate success

Back to top

Slide 23

Text Description Follows

IUse of Toyota “LEAN” Production Model to Increase Efficiency & Productivity at Community Health Centers

Paul Melinkovich, MD, FAAP
Director, Denver Community Health Services
AHRQ Innovations Exchange Webinar
January 27, 2009

Back to top

Slide 24

Text Description Follows

Problems Addressed

  • Inefficient processes for clinical work
  • Low provider productivity
  • Prolonged patient waiting time
  • Variable patient cycle times
  • Staff and patient dissatisfaction

Back to top

Slide 25

Text Description Follows

Interventions

  • Toyota “Lean” Production System at corporate level ? Eliminate waste and standardize processes
  • Value Stream Mapping resulting in
    • Projects
    • Just Do Its (JDIs)
    • 3P/2P Events
    • Rapid Improvement Events (RIE)
  • Events used to develop and implement interventions at clinic level

Back to top

Slide 26

Text Description Follows

Streamlined Appointment Scheduling

  • Open access scheduling system
  • Standard schedule – Every 20 minutes
  • One appointment type
  • Stricter policy for early and late arrivals
  • Policy for “no shows”

Back to top

Slide 27

Text Description Follows

Provider Dyads to Improve Cycle Time

  • Standardized roles for
    • MDs
    • Allied Health Providers (AHPs)
    • RNs
    • Medical Assistants (MAs)
  • Designated provider/MA dyad
  • Tandem work when possible

Back to top

Slide 28

Text Description Follows

Desktop Management

Developed standard processes for

  • Medication refills
  • Non-appointment requests
  • Laboratory follow-up
  • Forms completion
  • Other similar requests

Back to top

Slide 29

Text Description Follows

Results

  • Productivity increased from 8.0 to 9.9 visits/session
  • Patient cycle time reduced from 88 to 58 minutes
  • No-show rate reduced from 21% to 15%
  • Revenue enhanced more than $3.0 million

Back to top

Slide 30

Text Description Follows

Challenges

  • Inertia – “Things will always be the same around here”
  • Staff resistance to change
  • Middle management resistance
  • Difficulty spreading “best practices”
  • Decentralized clinic system
  • Sustaining change

Back to top

Slide 31

Text Description Follows

What Worked to Overcome Challenges

  • Having a systematic method for process improvement
  • Having a clear set of metrics to measure improvement
  • Experimenting and refining interventions
  • Cohesive managers at executive level
  • Ongoing communication with middle managers and teams

Back to top

Slide 32

Text Description Follows

Gaining Support at Start

  • Good definition of problem -- “What do we need to fix?”
  • Clear map of where to go -- “How are we going to get there?”
  • Much communication -- “What have we achieved?”
  • Early innovators involved at beginning
  • Leadership support

Back to top

Slide 33

Text Description Follows

Maintaining Support

  • Communication of success
  • Refining interventions
  • Leadership presentations to middle managers
  • Recognition to successful teams at leadership meetings
  • Cross-fertilization of teams when conducting events

Back to top

Slide 34

Text Description Follows

Sustaining Interventions

  • Communication
  • Production reports comparing teams
  • Acknowledging challenges
  • Changing the culture to “Eliminate Waste”
  • Celebrating success

Back to top

Slide 35

Text Description Follows

QUESTIONS?

Back to top

Slide 36

Text Description Follows

Harnessing Positive Deviance to Reduce MRSA Infections at the Billings Clinic

Nancy Iversen, RN, CIC
Director, Patient Safety & Infection Control
Billings Clinic
Innovations Exchange Webinar, January 27, 2009

Back to top

Slide 37

Text Description Follows

  • Not-for-profit, community owned and governed
  • Integrated Delivery System
  • 3400 employees
  • 230+ employed physicians representing 35 specialty departments
  • 272-bed hospital, 90-bed nursing home
  • 7 regional branch clinic locations
  • Multi-state management affiliations and support services

Back to top

Slide 38

Text Description Follows

POSITIVE DEVIANCE
A Different PROCESS
Better RESULTS

Back to top

Slide 39

Text Description Follows

Positive Deviance (PD) Key Principles

  • Community Ownership
  • Self-Discovery
  • The people are “the experts”
  • Immediacy of action
  • Emphasis on practice
  • On-going measurement reinforcing change

Back to top

Slide 40

Text Description Follows

MRSA Overview

Number of MRSA Infections Reported In US Hospitals
1993----------2,000
2005----------368,000

Back to top

Slide 41

Text Description Follows

PD/MRSA Prevention Partnership Structure

PD/MRSA Prevention Partnership
Purpose: Sharing & Connection

Back to top

Slide 42

Text Description Follows

Our Experience: MRSA Incidence Rates

Pictorial view of MRSA Incidence Rates

Back to top

Slide 43

Text Description Follows

Healthcare-associated MRSA Infections

Pictorial view of ICU Incidence Rates, January 2004 – November 2008

Back to top

Slide 44

Text Description Follows

Key Interventions ~ The “Science” Bundle

  • Hand hygiene
  • Decontamination of the environment and equipment
  • Contact precautions for infected and colonized patients
  • Active surveillance cultures (ASCs)

Back to top

Slide 45

Text Description Follows

Measurements

  • Prevalence Survey
  • Active Surveillance – nares culture on admission, discharge, transfer or death
    • Measuring MRSA Transmission (colonization)
  • MRSA Infections (tissue invasion of MRSA w/ signs/symptoms)
  • Compliance with hand hygiene and contact isolation

Back to top

Slide 46

Text Description Follows

How is the reservoir for MRSA identified?

Clinical microbiology cultures capture “the tip of the iceberg”

  • 75-85% of the MRSA reservoir goes unidentified by clinical cultures alone1
  • Colonized patients, not just infected patients, lead to transmission of MRSA2

Back to top

Slide 47

Text Description Follows

The “Cultural” Bundle

  • Make the invisible, visible
    ~ chocolate pudding to simulate contamination ~
  • Reinforce with Feedback
  • Solutions that are co-created and owned
    ~ ownership vs. buy-in
    ~ discovery & action dialogues ~
  • Act your way to a new way of thinking ~ create experiences that allow self-discovery ~

Back to top

Slide 48

Text Description Follows

Hand Hygiene / Contact Precaution Intensive Care Unit

January 2007 – November 2008

Back to top

Slide 49

Text Description Follows

Theatre In the Round

A diverse audience, from many units across the clinic, assembles in the conference room… now an inpatient medical room.

Back to top

Slide 50

Text Description Follows

Gown Use

June 2003 – December 2008

Back to top

Slide 51

Text Description Follows

The Power of “Improv”

  • Experiential
  • Allows self-discovery
  • Creating sustainable behavior change
  • Enjoyable and highly effective learning experience

Back to top

Slide 52

Text Description Follows

Our Experience

pictorial view of MRSA Incidence Rates

Back to top

Slide 53

Text Description Follows

The “Awareness” Iceberg

  • 4% - Problems known to top managers
  • 9% - Problems known to middle managers
  • 74% - Problems known to supervisors
  • 100% - Problems known to front-line managers

Back to top

Slide 54

Text Description Follows

Business as usual

  • Leadership: powerful, few. Make decisions about how work is done
  • Middle managers: implement decisions
  • Front line workers- experts at the work they do: carry out decisions, rarely engaged in deciding HOW work is done

Back to top

Slide 55

Text Description Follows

Business as usual

  • Front line workers: experts at the work they do, decide HOW to do work, & foster self-discovery among peers
  • Leadership and middle managers support and filter ideas, and remove barriers for implementation of practices from frontline workers

Back to top

Slide 56

Text Description Follows

Rules for Leaders ~ PD

  • Go and ask the experts
  • Seek all the “touchers”
  • Know the solutions are in plain sight
  • Honor “nothing about them without them”
  • Leave the solutions with their owners

Back to top

Engaging Stakeholders audio file (mp3 11.8 MB; duration: 1:23:00)
Transcript

Operator

Greetings, ladies and gentlemen and welcome to the Engaging Stakeholders: How to Obtain and Retain Buy-In for Your Innovations. At this time, all participants are on a listen-only mode. A brief question and answer session will follow the formal presentation. If anyone should require operator assistance during the conference, please press *0 on your telephone keypad. As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Ms. Judi Consalvo. Thank you, Ms. Consalvo, you may begin.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you. Good afternoon, everyone. On behalf of the Agency for Healthcare Research and Quality, I’d like to welcome you to our webinar on Engaging Stakeholders: How to Obtain and Retain Buy-In for Your Innovations. As he said, my name is Judi Consalvo and I’m the program analyst for AHRQ Health Care Innovations Exchange.

 

We are thrilled to have so many people participating in today’s event. We had approximately 600 people register and based on the information you provided when you registered for the webinar about half of you consider yourself to be innovators. So, we hope you’ll take away from this event some useful and inspiring ideas. If, after the webinar, you are interested in continuing this discussion during a more informal followup conference call, please email us at info@innovations.ahrq.gov.

 

So, what is the Innovations Exchange? The Innovations Exchange is a comprehensive program intended to accelerate the development and adoption of innovations in health care delivery. The program supports the agency’s mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans with a particular emphasis on reducing disparities in health care and health among racial, ethnic, and socioeconomic groups.

 

Launched in the spring of 2008, the Innovations Exchange has the following components:

 

Searchable descriptions of a wide range of innovations, the descriptions of successful and attempted innovations, provide information on the innovative activity, its impact, how the innovator developed and implemented it, and other information that you can use when deciding whether to adopt the innovation. In some cases, there is a story behind the story or expert commentary or highlight in innovation’s nuisances, importance, and applicability.

 

Learning Network. Through the learning network, you can connect with innovators and other adopter organizations to learn new approaches to delivering care, develop effective strategy, and share information.

 

And we have educational resources. This site offers you a variety of resources designed to help you learn about the process of innovation, the process of adoption, and the step you can take to make your organization more receptive to innovative approaches to care. These resources include written materials and opportunities to participate in webcast and discussion group.

 

The Innovations Exchange is constantly expanding with new topics and new ideas. We put out a publication every two weeks which focuses on a particular topic area and include new innovations, attempts, and tools.

 

We are exploring ways to support the development and adoption of innovations in health care delivery by offering you opportunities to interact with each other and industry experts. This webinar is part of that effort. We welcome your thoughts on topics for future webinars. At the end of today’s event, your computer will automatically take you to a brief evaluation form. Please be sure to complete the form as your comments will help us to plan future events that meet your needs. You can also email your comments and ideas to us at info@innovations.ahrq.gov.

 

Today’s topic is Engaging Stakeholders. We’re here today to talk about a challenge that nearly every innovator must face, getting key stakeholders to approve and support new ideas and practices. How do you communicate the benefits of a new approach to different stakeholders? How do you build a strong partnership? How do you ensure that all pertinent voices are represented? How do you cultivate champions who will help you move forward?

 

What is a stakeholder? We’re defining stakeholders loosely as anyone who has a stake in the process or outcome of the innovation. One challenge for innovators is to identify all of those stakeholders because some are not as obvious as others. And I think you will see that point in some of our presentations today.

 

Our speakers today are Patria Johnson, who is the Program Manager from Memphis Healthy Churches; Georgia Oliver, the Project Director of Memphis Healthy Churches; Paul Melinkovich, the Director of Community Health Services at Denver Health; and Nancy Iversen, Director of Patient Safety and Infection Control at Billings Clinic in Montana.

 

As you can see, they represent a variety of health care settings and will each provide a unique perspective. They will be sharing their experiences working with physicians, nurses, patients, volunteer health care workers, community leaders, and other health care providers.

 

You will notice there are some common themes in today’s presentation, gaining buy-in at the start; maintaining buy-in throughout; garnering support from new stakeholders midway through; similarities and differences in engaging internal partners and external partners; changes in collaborations, partnerships across time, points for possible tension, conflict, method for mediation, and resolution; small wins versus large victories; and identifying key stakeholders. As I said, these are diverse settings but these are common themes that all of us will face and look at.

 

So let me do a polling question right now. We’d like to know which of these issues have been challenges for you. Please answer the following question now on your screen. What has been your biggest challenge so far with stakeholders? And I won’t go through all of them but you can select as many as you need starting off with gaining buy-in at the start.

 

As we gather your responses, let me clarify how we’re going to handle some of the questions. We would very much like to hear from you and we’ll open the phones after the presentations are over so that you can ask questions of any of our speakers. You may want to jot down your questions for the speakers since we won’t open the phones until all four of the speakers have completed their presentations. To ask a question over the telephone, press *1 on your telephone keypad. You’re also welcome to send us your questions by using the Q&A feature on the website. Just type in your question and click on send. If we have enough time, we’ll answer questions that come to us in this manner, but we’re really hoping to hear from you over the phone. So, we encourage you to please participate, call in, and give us your question.

 

Now, once again, if you need help, if you have any trouble with the slides or your connection to the webinar, you can click on the help button or send a note using the Q&A feature and someone will get back to you. If you are listening by phone, you can also press *0 on your phone for assistance or call 1-866-490-5412. If you experience any difficulty with the audio stream through your computer, you can always join us by telephone. The telephone number is 1-877-705-6008. The number is always available on the right hand side of the screen.

 

Finally, we are recording this event so that anyone who couldn’t make it today or needs to leave the webinar early can listen to the recording or read the transcript. You’ll be able to find links through a downloadable recording, the slide, and a transcript on AHRQ Health Care Innovations website in the next couple of weeks. So, let’s see before we move any further if we can look at your responses to our questions.

 

I’m seeing it come up. So, as you are listening to the following presentations, think about how each presenter address the common themes and about how the same things could apply to your setting.

 

So, I’m looking at the results, gaining buy-in at the start 76, maintaining buyout throughout 93. And as we go down the line there’s pretty much an equal amount of you garnering support from your stakeholders 27, similarities and differences 22, and okay changes in collaborations and partnerships across time 44. So, I think one of the first thing here is maintain buy-in throughout. That seems to be what most of you have indicated and the next again is gaining buy-in at the start. So, thank you. Thank you so much for that and we’re going to move on and turn to our presenters.

 

Our first presenters are Georgia Oliver and Patria Johnson. They run the Memphis Healthy Churches Program to the Christ Community Health Services in Memphis, Tennessee.

 

Georgia Oliver is a registered nurse with over 30 years of experience in health care. She also holds an MS in Health Service Administration and is the Director of Outreach Services at Christ Community Health Services.

 

Patria Johnson obtained a master’s degree in Social Work from the University of Tennessee, College of Social Work. Currently, she is employed by Christ Community Health Services as the program manager from Memphis Healthy Churches. As a result of seeing the adverse effects of diabetes and cardiovascular disease in her family, Patria is committed to encouraging all people to live healthy, whole, and abundant lives.

 

Memphis Healthy Churches is a faith-based health promotion program dedicated to reducing five key health disparities - cancer, cardiovascular disease, diabetes, HIV/AIDS, and obesity. This program is mobilized in area congregations throughout Memphis.

 

Georgia and Patria, we are so happy that you are with us and thank you for being here today.

 

Georgia Oliver – Memphis Healthy Churches – Project Director

Thank you. And this is Georgia, I would like to just give you a brief overview and history of Memphis Healthy Churches and then Patria will you give the program format and explain how we gained buy-in and have been able to sustain our program.

 

Memphis Healthy Churches as you heard is a program of Christ Community Health Services targeting African American churches. Christ Community Health Services is a comprehensive health service with clinics located throughout the Memphis area. Most of our clinics are in areas that have limited access to health care. So, in Memphis, the majority of our patients are African American or minority. We also have a mobile medical van that serves the homeless. And in 1998, a partnership was started between Baptist Memorial Health Care System and Christ Community Health Services to start a community-based cancer education and support service. This was done because most of the African Americans were not being treated for cancer and certainly were not going for early detection preventive type programs.

 

We celebrated our 10-year anniversary last Friday, so we have been in business for quite a while. By the end of the first year of the program, we had over 20 churches participating in this program and that was phenomenal for us because we had a goal of 10 churches by the end of the first year.

 

Due to the success of our program, about the second year, we had a request from the churches participating in the program to include other disease entities other than cancer. So, we decided to look at diabetes, heart disease, HIV/AIDS, and obesity and include that in our program for the African American churches.

 

In 1999, we decided to change the name of our program to Memphis Healthy Churches because there was a managed care organization in Memphis called Access MedPlus and many of the participants in the program were confused and we found that we needed to change our name. That was important for us to go back to the drawing board and look at why do we need to change our name, and we allowed our participants to help us come up with the name, Memphis Healthy Churches.

 

Today, we have 100 churches and over 150 trained health representatives participating in this program.

 

Now, I’d like to allow Patria who is truly the Memphis Healthy Churches program manager. She lives, sleeps, does everything for this program, and we are very proud to have her as our staff member. She will give you information about the program, how we gained buy-in, and how we’ve been able to sustain this program.

 

Thank you.

 

Patria Johnson – Memphis Healthy Churches – Program Manager

Good afternoon. Again, Memphis Healthy Churches is a community-based program in conjunction with Christ Community Health Services, a provider of health resources for underserved persons. With Memphis Healthy Churches, we really consider ourselves to be on the battlefield against preventable diseases that affect our community. We focus largely on cancer, cardiovascular disease, obesity, diabetes, and HIV/AIDS. And as you heard earlier, we have over 100 churches that have joined forces with us, if you will, to combat these diseases and their despaired effects on our community. So, the million dollar question for this webinar, how do you maintain buy-in throughout?

 

Memphis Healthy Churches has a 10-year history and the reason why I feel that we have been able to maintain buy-in is because of the partnerships that we had in the community. We’ve developed great relationships with our local communities where we provide health services. We have partnerships with the churches. Our pastors are our key champions and they join forces with us to make sure that our program is successful. We have partnered with many volunteer health organizations and hospitals within the Memphis area. Baptist Memorial Health Care has been our key founding partner from the very beginning, but other voluntary health organizations have been paramount in helping us to maintain buy-in throughout and those include partnerships with the American Diabetes Association, the American Heart Association, the American Cancer Society, and many, many more.

 

Our training is very important. If you’re going to fight a battle, you need to be equipped with tools to help you. Having a comprehensive training program for our volunteer health representatives has been very much a great support for them so that they are able to take lessons learned from their congregation into their communities on how to not only prevent but also maintain the health status of their parishioners to ensure that they are not experiencing detrimental effects of the diseases that affects them.

 

Technical assistance is a lot of what we do. The churches develop their programs. The programs are tailored to their congregation and what their congregation needs, but we provide ongoing assistance to help them.

 

The real reason why people really are bought in to what we do is because we provide great incentives throughout the program. Ms. Oliver mentioned that we celebrated our 10-year anniversary. We have an awards banquet annually to let our volunteers know how much we support them so I can’t say enough about recognition.

 

Garnering support from new stakeholders. What’s really important in the beginning is to design your goal. You have to be on the same page. You have to know what is it that you want to accomplish. When you know what you want to accomplish, you’re better able to assess the available resources to meet those goals. And once you determine who has those resources, you can move forward with your partners accordingly.

 

Sharing similarities and differences internally and externally. It’s important for an organization to clearly state what their mission is internally and what their vision is internally before you can communicate that message externally. So branding program distinction is key. There are a number of organizations that do similar work here in Memphis with regard to help disparity work in partnerships with churches, but we have to state exactly what our brand is and our brand is that we are unashamedly faith-based and we target the African American community. That’s our target because that is where the disparities lie. So we had to make that distinction early on. But we also celebrate similar interventions. We believe that we can play well and play fair with others and there is no point in reinventing the wheel if other stakeholders have products and services that we can replicate in our program.

 

Coping with change and collaborations in partnerships over time. It’s important to expect change because no two people, no two organizations will think alike and stay the same forever. Change is inevitable. But it is important to promote autonomy among all partners and collaborative entities within the relationships. Again, there may be times that you need to redefine goals and the anticipated outcomes that are needed.

 

Some general advice that we’ve learned is to start where the people are. We do surveys in our congregations - that’s one of the first things that we do. We set up a meeting with the pastors, the congregations to assess their needs, so that we can begin where the people are. We get the buy-in on the front end from the pastor. Once the pastor endorses the program, that’s all the buy-in that we need because within the African American community in particular, the pastor or the faith leader is revered much and they will do the things that their pastor deems important.

 

Throughout this program, we have seen the detrimental health effects that have happened to many of the faith leaders. Many of them as a result of our program, they been diagnosed with diabetes or heart disease or they’ve had stroke or had to deal with prostate cancer. So, it’s become important to them that they know their health status and they’re teaching their congregation to adopt healthier lifestyles.

 

Communicate, communicate. I can’t say that word too much because that’s what’s so important in having a successful partnership and a relationship wherever you are is to communicate.

 

And we need to acknowledge and celebrate success. Whether the victory is big or small, we must celebrate success. There will at times be conflict and it will be necessary to convince people along the way. There may be times that we have to sit down and talk about the things that we disagree upon, but I believe having both parties weigh in among differences is important. And when you can’t find a simple resolution, mediation is always good.

 

So, that’s some general advice about how we have maintained the support of our volunteers throughout Memphis Healthy Churches.

 

Thank you.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you, Patria. And thank you for sharing your approaches and what works in your program and in your particular community and especially for touching on gaining buy-in, maintaining buy-in, and gaining support from your stakeholders.

 

So, we would like to now move on to our next speaker, Paul Melinkovich. Dr. Melinkovich is the Director of Denver Community Health Services, a community-oriented primary care program with a network of 8 community health centers and 12 school-based health centers serving the low-income residents of Denver. A board certified pediatrician, he has served as the President of the Colorado Chapter of the American Academy of Pediatrics and the Chair of the Committee on Community Health of the National AAP. He is President of the Board of Directors of the National Assembly on School-Based Health Care. Dr. Melinkovich received his undergraduate degree from the University of Wyoming and his medical degree from the University of Washington. He completed his residency in pediatrics and a community pediatric fellowship at the University of Colorado Health Sciences Center. He has been practicing community pediatrics and child advocacy for 31 years. He was a founding member of the Colorado Children’s Campaign, the child advocacy organization for Colorado and served as their second board president. He is a professor of pediatrics and preventative medicine at the University of Colorado Health Sciences Center. His areas of interest include school and community health, equity in child health, immunization delivery, and quality improvement in ambulatory care settings.

 

Thank you, Dr. Melinkovich, for being here with us today.

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

Thank you. I couldn’t find the unmute button so I apologize. I have a bit of a cold so I hope I keep my voice throughout this whole thing.

 

What I wanted to talk about is how we have used the Toyota “Lean” production model to increase efficiency and productivity at our community health centers. And I think it deals with issues around engagement of stakeholders, keeping people engaged throughout the process, and some of the themes that have been mentioned as needing to be addressed or were hoping to be addressed with this webinar.

 

Just a little background, Community Health Services is a network of federally qualified health centers that are located in Denver, Colorado. We have 8 community health centers, 12 school-based health centers, and a couple of urgent care centers. The intervention I’m going to talk about takes place in our community health centers and what we’re trying to do is we’re trying to, as the opening slide says, to improve efficiency and productivity. The problems that we’re trying to address with this intervention I think are common to many primary care delivery sites where we have really very inefficient processes for some of our clinical work. We have challenges with provider productivity; often the waiting time in the waiting room prior to an appointment is longer than patients desire. The time that it takes patients to cycle through the system is variable and sometimes longer than desirable and often both the staff and the patients are dissatisfied with their experience. The intervention that we use to address these problems is adapting what is called the Toyota “Lean” production system. It was pioneered at Toyota and is how they make cars. It has been adapted to the healthcare delivery setting in a number of sites and at a corporate level. We have chosen “Lean” as a way to improve processes not just in patient flow in the ambulatory care settings but in some of the other areas of problems like emergency department divert, hospital flow, and discharge in the hospital.

 

A little background on “Lean.” “Lean” uses a value stream mapping as a way to identify for your area of concern, different things that you can do in the “Lean” lexicon. You can do projects, there are things called “just do it” where you say, “This is something that needs… we just do it.” There are things that we call 3P or 2P events which are really planning events as to how you use space and personnel. 3P is a place, personnel, and processes, 2Ps are just you have already the place design so you’re looking at processes and personnel. And then we do a lot of what’s called rapid improvement events where you take a week and for four days, you take a small group of people to look very critically at a very narrow process to try to improve a process, for instance like cycle time in the clinic. You use these events to develop interventions at the clinic level.

 

The core of message with “Lean” is that we’re trying to eliminate waste. Some of things we accomplish through “Lean” is we streamlined our appointment scheduling system, we develop an open-access scheduling system where people can call the same day for the bulk of their appointments. We standardize the schedule so that we don’t have multiple appointment types. We just had one appointment type every 20 minutes. We had a stricter policy for early and late arrivals and we have a policy for no show patients.

 

The other thing we did is we developed what we called provider dyads to improve cycle time. In doing that, we really looked at the dyad being a provider, either a nurse practitioner, a physician, or a physician assistant and a medical assistant and that dyad worked together to provide care. We standardized the roles for our physicians, for our allied health providers, for our nurses and our medical assistance. And when possible, we move from sequential work to tandem work so when we could actually have the medical assistant and the provider in the room at the same time so that it would shorten the time of patient cycle, we would do that.

 

The other thing we looked at is doing things that usually we call desktop management where things that would need to be done to help patients but don’t require a face-to-face visit. When you say desktop, it’s things that are done basically at the desk, medication refills, appointment requests like request for forms completion, durable medical equipment forms, work excuses, laboratory followup, and other similar requests. We try to develop a standard process for handling all of these requests from patients that didn’t require an appointment.

 

The results of the processes that we put in place where to improve productivity of our providers from 8 visits per 4-hour sessions to almost 10 visits per 4-hour sessions. The patient cycle time, the time that it took patients to get through to clinic went from 88 minutes to 58 minutes. Our no show rate or missed appointment rate went down to almost 15 and in some places 10%.

 

In over a couple of year period of time, we enhanced revenue by more than $3 million which, of course, the organization always like to see in addition to having happier patients.

 

So really the bulk of the questions are what are the challenges that we had to doing this? The first challenge, I would say, is that there is always an inertia in any organization. You hear comments like things will always be the same no matter what we do. There’s a fair amount of resistance to change; I’m sure you all experienced that in any innovations. There’s often change at the middle management level. Even when we identified practices that we call best practices at one site, there was sometimes a difficulty spreading it to other sites because everybody wanted to do it their own way so it really didn’t become a standard practice which is a core concept of “Lean.” It becomes again a different practice at every site.

 

We have a very decentralized clinic system. With a decentralized structure, being able to get some commonality in how we practice from site to site was a challenge. And then of course sustaining the change. Sometimes we’re very challenged. We had implemented a change at the site and then you go back a few months later and it was back to the old way of processing.

 

What worked to overcome challenges? One thing I think that was key in being able to address some of these challenges was to have a systematic method of process improvement like “Lean” and training people in how to use that process.

 

The second thing was to have a very clear set of metrics so that we can measure and see whether or not we are achieving success. Experimenting and refining the intervention as we went through the process, we’ve been doing this now for three years, helps because I think sometimes we learn again that there’s better ways again and again. Having us at the executive level, we have a core set of managers at the central level. There are eight of us. Having real cohesiveness of that group and so really a good leadership support was important and then having ongoing communication with our middle managers and our team members.

 

Gaining support at the start I think really was most successful when we could really be clear about what the problem was. As I said earlier on, there’s a fair amount of staff dissatisfaction as well as patient dissatisfaction with the processes we had in place. So we needed to be clear about what we wanted to fix and be clear about how we’re going to do it. Having a change process in place, a lot of communication particularly as we went to the process of saying this is what we hope we would achieve. We identified what we would call early innovators at the beginning; people who we knew were really interested in doing innovations at their site.

 

Early innovators are involved at the beginning so that we could actually get people involved who were open to change and have good leadership support. Maintaining support I think is a lot of the same principles. Communication was clearly important to keep the innovation moving throughout, continually refining our interventions. We used our middle manager meetings as a way to do leadership presentations of every time a team did an event and showed some improvement, they would be recognized for their success at the leadership meetings and then when we did events at different sites, we would often take the staff on one site and move them to another site to be involved in the teams so that you can spread interventions across sites.

 

In terms of sustaining interventions, communication continued to be a main method. I think ongoing communication, having a communication strategy for innovation, is extremely important. We did a lot of production reports which displayed how well teams were doing with their interventions. So again having the metrics and being able to compare teams provided a little bit of healthy competition. Honestly, acknowledging the challenges of the work we were trying to do. More importantly, thinking about how we change the culture so instead of saying things are always going to be the same around here, really trying to get people to think about how we want to really try to eliminate waste and training people and educating them about how we could look critically at our processes and then celebrate the successes.

 

So that’s the end of my presentation and we will take questions at the end.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you very much, Paul. We are going to move on to the next presentation and take questions at the end but before doing that again I want to thank you and this is a great example of adapting an intervention that worked in one setting and adapting it to work in a different environment also I think we heard some common elements that we heard in the previous presentation and that was how important ongoing communication is and celebrating successes. These are some common themes amongst others. So we thank you again and we are going to move on with our final presentation from Nancy Iversen.

 

Nancy is the Director of Patient Safety and Infection Control at Billings Clinic in Billings, Montana and has practiced nursing for 24 years. Her professional experience has been in the areas of critical care nursing, infection control, and patient safety. Her special interests include health care associated infection prevention, the culture of safety, teamwork, behaviors, and communication. She is currently the principal investigator for Billings Clinic who is participating in a Robert Wood Johnson Foundation, Plexus Institute-sponsored national collaborative working to eliminate MRSA transmission using the positive deviance approach to social and behavior change. She has presented at the Association of Professionals in Infection Control and Epidemiology, APEC Annual Conference, the American Nurses Credentialing Center and the National Magnet Conference, and the Institute for Health Care Improvement National Forum.

 

Nancy, welcome.

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

Thank you, Judi, and good afternoon everyone. I’m going to spend the next 10 to 15 minutes sharing our story of how we approach addressing a rising increase in health care-associated MRSA infection using an innovative approach called positive deviance.

 

The next slide just gives you an introduction to Billings Clinic. Here’s a picture of one of our entrances to the hospital. We are a multispecialty physician group practice with a 272-bed hospital, primary care and specialty clinics, and a long-term care facility. The only thing about this slide I wanted to point out is that when we were taking on a problem of this magnitude that we’ve had with MRSA, we have 3400 employees, we have 230+ employed physicians representing several specialty departments. So when we began this work it seemed a bit daunting and we’ll go through how we were able to achieve some early and very promising results.

 

The next slide just gives you an introduction to positive deviance and you can see the late Jerry Sternin there with some other workers as he’s used and pioneered positive deviance in significant intractable problems outside of the US. We have been partnered with five other beta sites in applying positive deviance to a most significant difficult problem in US health care called MRSA, methicillin-resistant Staphylococcus aureus infection. We’ve been working the last two years with Albert Einstein Medical Center in Philadelphia, Franklin Square in Baltimore, Johns Hopkins in Baltimore, the Pittsburgh VA and the University of Louisville. We’ve also partnered with the Centers for Disease Control in our work.

 

The next slide just kind of outlines what really is positive deviance and some key principles that I’ll refer to as we spend the next 10 to 15 minutes together. I heard the presenters speak earlier about trying to get buy-in and we work very hard to get buy-in. We really use this approach to achieve something else and we actually are going for ownership. What really results in ownership and the difference between ownership is that you involve the people who’ll be affected by the change in the very beginning. They will build the solutions. They will not have the normal immune system rejection response that we’ve used with traditional improvement method or best practice. They don’t have that response because they developed the program, they then make it a sustainable change so that’s one of the key principle of positive deviance.

 

The other positive deviance principle is self-discovery. We, as leaders, need to create experiences to allow people to self-discover for themselves the behavior changes that are needed and then people are truly the experts. There is an emphasis with positive deviance of the immediacy of actions. Again lots of practice and we’ll go through some experiences we did that really helped to promote practice. And then of course with the most improvement there is an ongoing measurement that reinforces the change.

 

The next slide just really talks a little and shows you certainly the overview and burden of MRSA that exists in the United States and we were not any different. We were out here in Billings, Montana. I think a lot of our stakeholders really didn’t think that we had much of a MRSA problem or denied that, didn’t really understand, and thought that we probably had either too much so why bother or too little so what are we doing this work for. So that’s one of the barriers and hurdles that we have.

 

The next slide shows you just how we began. It’s a sample of our stakeholders and it shows a visual of how we organize our work. We actually convened the group of people after the kickoff. We had a kickoff session -- that is a session where the personal stories were told of how MRSA harmed individual people and these are actually patients that we had that acquired health care associated infections at our facility and they came before a fairly large group and told the group how MRSA affected their life. And then following the kickoff, we then had an open invitation and really the people shows themselves to work on this problem which is a little bit different way of how we approached and how sometimes we can do a traditionally approached change. What you’ll see is the variety of inpatient units that began working. We primarily started our work in the intensive care units where we applied positive deviance over the whole house. The somewhat surprising and promising results that we have seen and then the elimination partners that we have are really those who are touchers in a hospital. When you think about your stakeholders, you really want to look at who are the touchers in your hospital. That is a great deal of people and when we look at that structured slides, we always try to follow our principle, nothing about me, without me, whose voice do we need, whose voices are not here because all voices are welcome and all voices are needed to tackle a problem like this.

 

Here’s a slide that shows you our strength with MRSA. You can see over time, we’ve actually been measuring MRSA since the 1980s at our facility and you can see how we incrementally increased health care associated infections up to where we peaked in 2005. The important thing in this slide is just to recognize the behaviors we needed to change with the behaviors that led to the problem. These are somewhat intractable problems, hand hygiene, how do you engage people in a way that they want to change their behaviors around hand hygiene and how do you get them to put on gowns and gloves each and every time and disinfect equipment because that’s what stops MRSA transmission.

 

This next slide just shows you when we first focused on the intensive care unit, which was our first intervention unit, we have very good results. What surprised us, was the slide you saw just moments before, is that we actually have house-wide impact on using the positive deviance approach.

 

The next slide just kind of reminds you of the key scientific interventions that if practiced, have been proven to reduce health care associated infections. Keep in mind as you saw the graph a couple of slides before. We were practicing hand hygiene and we thought we were educating people and measuring hand hygiene. We did feel that we are decontaminating the environment. We had beautiful policies and protocols outlined. We followed the Centers for Disease Control isolation guidelines. But what wasn’t happening is we didn’t have true engagement and we didn’t have people at the frontline truly engaged and as you know, MRSA is really a social problem.

 

The next slide talks a little bit about just general measurements. I’m not going to say too much about this other than positive deviance is bathed in data. It sounds and it feels very different. It is a very different innovative approach but you still have lots of metrics that are involved. We did a prevalence study. We performed this study about two years ago because we felt our stakeholders didn’t really know what MRSA burden was. They either felt that because we live in Montana, we don’t have MRSA or felt that we have so much MRSA, why even bother. But what we have found in the prevalence study is that we are at the same as the national levels of MRSA. We’re very similar to the national levels. I think it’s important that we did a very good feedback of data to help people to see the impact of their behavior change.

 

The next slide just shows you something that we had to help people because we had a lot of people that weren’t interested in continuing isolation for people that were just colonized and that was one of the things that we really had to do is find and recognize that unrecognized reservoir of MRSA.

 

The next slide outlines the cultural bundle. Positive deviance uses scientific interventions that are well proven and PD really isn’t about describing the ‘what’ anymore, it’s about how you engage people in a way that can effectively stop the transmission of deadly organisms.

 

In a cultural bundle, I want to spend just a little bit of time here. Some of the principles here were making the invisible visible. How do you help people understand MRSA and how people can actually transmit it by their behaviors. And so we use something called chocolate pudding to simulate contamination and I’ll go through that a little bit later. Obviously, reinforcing with feedback solutions are really co-created and owned and we did that through some PD tools, one called discovery and action dialogues and that really gets to the ownership versus buy-in that I mentioned before. You really need to have all the frontline staff involved in the front end and sometimes positive deviance goes slow. It is a little bit different than traditional process improvement where you have all of the didactic information, you can be in a team, and then you get going. This is very slow because again you only bring people who want to work on this and then your team grows as people are engaged in the work. And then acting your way into a new way of thinking and one of the innovations that we did was something called the improvisational theater and I’ll show you that in just a moment.

 

Another metric that I will not show you today but something I just want to mention, is that in our culture work, we did do a metric called social network mapping and we did a survey to see how our relationships were working throughout this innovation, how we were connected, who were the informal leaders, how do we make our network less dependent on your traditional infection control staff.

 

The next slide I’m just going through pretty quickly. This just shows you some of the metrics that we do measure. This information is sent into the CDC. The bottom graph on contact precautions, you can see where we didn’t necessarily have complete engagement in our intensive care unit and then we have what we call the ICU rebellion time and we had some data wars about whether these transmissions and how we were measure our data was accurate. And really that was an opportunity for us all to come together and have a conversation and agreement that were going to keep working for and you can see that the metrics beyond that are pretty solid.

 

The next slide just shows you what we did. One of the innovative things that we did was to allow people to experience and solve problems together as a group. This was showcased in the previous slide where you saw PD MRSA partnership group. This is where people come together. We come together every month and you can see that… this is a theatre in the round and people are kind of at the perimeter. We actually created a theater and we have different scenes that the staff develops that were difficult for them and they were exploring solutions together across the units in discipline and then following the improv or the different dialogues.

 

The next slide just shows you, it’s one of my favorite slides that shows, I think, the real culture change we had at Billings Clinic because you can see that we bumped along for years using about 2000 gallons per month and as we begin doing these improvs then you can see some improv pictures in the background with chocolate pudding to help you make the invisible visible. You can see at times our gallons, we’re running it about 14 and at one time about 17,000 gallons per month.

 

The next slide just again talks to you a little bit about the power of improvisation simulated learning. We’ve had… I think we’ve had some great success at Billings Clinic mainly because we’ve engaged people in a different way. Improvisational learning is very experiential. It allows self-discovery which is a positive deviance principle. It creates sustainable behavior change because people self-discover for themselves how they need to change their behavior and how they may be related to the issue of continued transmission. They also can see through data how their behaviors that they may change on a day-to-day basis because we feed that data to them weekly, they can see when they’ve changed their behavior the success they’ve had. And in it is just very, very fun people laugh. People actually stayed. We had some 1-1/2 hour sessions that actually last two hours because people are having fun.

 

I just want to go back to and talk to you about the experience that we’ve had. We’ve actually, since 2005, have been able to reduce health care associated MRSA infections by 88%. We also sent the metric to the CDC and have reached statistically significant decreases in MRSA infections. We’re beginning to changing… we’re actually changing our antibiogram and we’re seeing less resistance of our staph aureus isolates. But as you also can see, this data goes just through September and we’ve infected four people this year. So we certainly recognize that we are not done yet. We just had a planning session. We had a meeting, kind of a training, on our focus for 2009 and what our prevention partnership wanted to do after working together for two years. They know they can get to zero. We actually were at zero for three months out of this year and so they have experienced this and they are setting pretty significant goals for themselves. We’ve expanded active surveillance and we’re doing it in about 78% of our beds every day. People get swabbed and placed in isolation.

 

I think we’re just about done. Just quickly, there’s one slide I wanted to talk to you about which is the next slide. It’s the awareness iceberg that talks to you about the importance of having frontline folks involved in this; they’re the ones that know the problems, they are the ones that have to be at the table helping you to solve it.

 

The next slide then is about business as usual of how generally improvement works and then your frontline people are then to carry out the decisions that the leaders have made and positive deviance in the next slide really flips this, that really we have sat at the seat of our frontline health care workers and they have cracked at the solution and ideas and we, our role as leaders and managers, are kind of depicted on the next slide. You go and you ask the experts that you seek all of the textures that you know the solutions are in plain sight and that you really honor the mantra of nothing about them without them and that you live the solutions with their owners and I think that that’s why we have achieved the successes that we have.

 

So I think that that is the end of my presentation.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Before you go, thank you, Nancy. Can you talk a little a bit about how you see the difference between buy-in and ownership?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

Well, I think what you are trying to… this is my opinion about buy-in because I’ve done process improvement with a traditional approach where you bring in the evidence-based data, you have a PowerPoint presentation, you gather people, you share knowledge. But knowledge really doesn’t change behavior and what we do using positive deviance tool is that we really are trying to go for ownership so we try to engage the hearts of people by telling lots of stories, we involve the people who will be affected by the change and who have to make the changes on the frontline and in really they co-create the solutions. They look at the evidence but they decide the solutions and then they choose the actions of how they’re going to implement those solutions without having leaders and managers to tell them how to do that. They know and they do it if given the time and the space to make those decisions. What our roles are as leaders are a stream of barriers for them and to support them in implementing the changes that they have decided are necessary.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you. Thank you very much, Nancy. I want to thank you and all the presenters for joining us today; sharing your experiences for we’ve seen that various stakeholders come in many different sizes and forms. It differentiates across settings. Some are common but according to the setting, there are different ones in each setting and these were some great examples. Also for those of you who indicated that gaining buy-in and maintaining buy-in, we think those were the most replies we had earlier on our polling question. Again, I think we see differences across the settings.

 

Now, we’re going to open up the phone for your questions and to speak with us simply press *1 on your telephone keypad and then the operator will connect you to us. As I noted earlier, you can also send us your questions by using the Q & A feature on the website. Just click on the word questions, type in your question and click on send. We’ve already received some questions from you and we’ll make every effort to get them the most as well. We did have some questions come in. One is that… and before I go into this, some questions may come in directed particularly to one of the speakers, but if they’re just general questions, speakers if you want to jump in one of you or all of you, we’ll welcome whatever you have to share with us. So one of the questions was: early innovators seem to be an important way to initiate the programs. How do you identify them? Anyone want to take that?

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

Did you say early innovators?

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Yes.

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

This is Paul. I mean I guess the way we identify early innovators is we look at… across our clinic network, you can identify people who are trying things at their site compared to people who are not trying things. I guess it’s kind of like just going out and walking around and seeing who is trying these different things and at the least, that’s how we do it. We kind of have a sense among our clinic managers which ones are open to trying something different. I mean they’re the opposite of the people who every time go to them and say, “Oh, not again. Do we have to try something again?” I mean, you could get a sense of who in your organization is open to trying something different. That’s how we do it.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you, Paul. Anyone else? We have another question here, a general question. When partners change their interest, how do you re-engage them? Anyone care to try that?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

This is Nancy. I’ll try to take that question. How to re-engage them? I think how we have been able, we’ve had players change if you will. We have a group of about 20 to 40 people that are the core of our PD MRSA partnership team and we have a standing meeting every month and they come to that gathering. We have a variety of stakeholders from a variety of departments, from a variety of clinical departments and non-clinical and they’re very bright, very disciplined. And they come because the purpose of that is for sharing and problem solving and it almost functions as a support group because changing in a changing culture and leading change in a culture in a hospital where there’s a lot of hierarchical levels is very daunting and they need that level of support. We have all of our meetings with engaging activities and meetings are run very differently than traditional meetings. We don’t have tables. We have big circles with two chairs, everybody is at the same level. We have exercises and activities that help people experience things and we also have all of our meetings with personal stories of patients and how we’re doing, how they’re not doing, stories of harm, stories of success, and that tends to get spread when people leave those meetings and say, “Hi. I just went to a really unique meeting.” This is great and they invite people in. So even though we’ve had a few people move on and change, we keep having new faces and new representatives from units and that’s how we’ve been able to do it.

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

And I would add the other thing that we do is… often there are so many conflicting priorities that when partners change, their priorities are the ones that they want to honor or maybe they have a different idea of what the priority is and so I think having an honest discussion about what are the key things we are trying to address. I mean what we’re really here trying to do, can often reengage people to be clear about what the focus of our activity ought to be because if you really, I mean, strategically think about what is most important, what are you trying to achieve through your organization, it can often allow you to recognize some of the things that really divert you from achieving those more challenging but overriding goals.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you, Paul. Nancy, there was a question that came in specifically for you but I think you may have already answered that and that was how did you convince people to participate in your activities?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

Yes, basically we just had this kickoff. We invited 200 to 300 people, had a big splash, told stories. We took our 2005 and 2006 health care associated infection data and we talked to a few of those patients and we invited them in to talk to our group and announced that Billings Clinic was going to work on health care associated MRSA infections and we wanted people to hear how MRSA had affected them personally. We had four stories told. They’re very diverse stories. One was an emergency room nurse who worked at Billings Clinic who had bilateral total knee arthroplasty and one of her knees got infected. So she was able to tell her peers in the audience what that did to her and then called them to action. She said that we can do something about this because MRSA really is a social problem, MRSA is a transmission problem, and she really felt that there were lapses in infection control that led to her infection and how more poignantly can that be said? A didactic PowerPoint presentation cannot say what she was able to say to an audience. And then we had other presenters with different experiences come talk about MRSA in a personal way. After our kickoff, we had Jerry and Monique Sternin talk to us about positive deviance and we had an opportunity to use a very innovative approach to use with that kickoff. Then following the kickoff the next day, we just invited people and said, “If anybody is interested in doing this work, we invite you to come back.” And that’s the real key to PD which is different in other traditional approaches that you really are working with people who are volunteering because somehow they are engaged with MRSA. And I remember Jerry Sternin telling me, “Nancy, you have about nine people that will come back.” And I was somewhat overwhelmed, thinking we need more than nine people to tackle a social problem like this. And really we had about 9 to10 core people that expanded and expanded and now because we have had great results, and they’ve experienced this, we don’t have a problem with keeping people engaged and every month when, you know, the five minutes to the meeting time and you wonder if people are going to come and then all of a sudden people come and they’re engaged and they’re working and they’re working outside of those meetings and we just garner a lot of stories, and harvest stories, and tell stories, and that is really engaged interest.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you. Thank you, Nancy. I do have another question. Patria, can you comment on how you maintained support for efforts that are related but secondary to the core mission of the churches?

 

Patria Johnson – Memphis Healthy Churches – Program Manager

Okay, I’ll take a stab at that that question. Well, it’s important to just understand what the other partner is wanting to accomplish and you generally will find some common thread so we try to stick with our mission but there have been organizations that come to us with things that are health-related. They may not directly relate to our five disparities but its promoting health in general and so if it’s promoting health in general, we’re usually able to find some common thread to work into some type of partnership or provide some type of collaborative efforts.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you. And can any of you comment on patients as stakeholders and Nancy, you may have just touched on that. Do either of you have patients as stakeholders and what are any special challenges that you might face with patients as stakeholders?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

I can describe how we have used patients. Certainly, we involved patients in the kickoff to tell all of us what the experience was like for them to come in… one gal, she was in her 30s and came in for a benign implant laminectomy procedure and left with an MRSA infection. She spent several months fighting and she was raising five children and having to come in for vancomycin infusions. So certainly her voice is there. We also have patients who have come to our monthly meetings. We really tried to… and really everybody there somehow has been touched by MRSA which is very uncanny and we ask that… In fact, I think of a story where we had an employee whose son three or four years ago had an MRSA infection while he was a Pharmacy student after a back surgery here at Billings Clinic and it was about the time where our ICU just found this so daunting and so difficult to make some of these cultural changes that they kind of wanted out and this individual looked at them and said, “What do you mean? You can’t get out. You can’t stop this work. My son got an MRSA infection here and we must keep going.” She happens to be a data analyst in our department so she does a lot of the MRSA data for us but she was functioning as a patient. And that’s what’s beautiful about PD because you have people who come and she basically looked at the ICU and they looked at her because she was representing a patient. She was the mother of a son who got something here and she was right, we can’t stop working. And she actually… her comment was pretty powerful. We actually have… that’s kind of how we view the patients here at Billing’s Clinic.

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

In our clinics in Denver because we’re a federally-qualified health center, we have patients who are on our board. Half of our Board of Directors that I report to has to be users of our health centers so that’s a set of stakeholders that I didn’t mention, but clearly a very important set of stakeholders and we regularly report to them on our “Lean” activity and really try to lay out for them what we’re planning to do and elicit their feedback on how… whether we’re addressing the right areas, whether we’re on the right track. The other thing we’ve done… “Lean” is a great process. As I listened to Nancy talk about how improvement is really done at the front lines. “Lean” is a process where really the managers are not involved but the change… the people who are doing the work are involved with the change and the changed activities. We have frequently involved patients in some of our “Lean” activities. So when we’re doing it an event at a clinic, we may grab a patient from the waiting room and say, “Can you come back and we will tell you what we’re thinking about. Does this make sense to you? Is this what you’d like? Is this how you’d like to get your lab results reported to you?” Or sometimes we have involved patients for the entire “Lean” event or let’s say a four-day rapid improvement and then we’ll have a patient on the team. And so that has been very powerful when we’ve done that in terms of involving our patients as stakeholders and doers.

 

Georgia Oliver – Memphis Healthy Churches – Project Director

And we have a similar situation at Christ Community. We, too, are a federally-qualified health care center. So many of our board members, churches are members of Memphis Healthy Churches, and we have patients who are trained as health representatives and they participate in the programs at their church and what we have found is that many of our representatives and the churches as a whole have gone from buy-in to ownership. They actually have Health Ministries in their church. They provide funding for the activities and they also support many of the community-wide programs that we provide through Memphis Healthy Church. So we certainly involve our patients here.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Well, thank you. Thank you all.

 

Operator

Excuse me, Ms. Consalvo. We did have a question come in from the phone.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Okay.

 

Operator

The question is from the line of Laura Browky with MetroHealth Medical Center and your line is open, you may proceed.

 

Laura Browky – MetroHealth Medical Center

Thank you. When you do not have someone to share a personal story or you do not have a staff member to share a personal story, what sort of strategies can you suggest for obtaining employee engagement?

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Anyone of our innovators like to take that?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

I think at Billings Clinic I can tell you something that we’ve… it was very daunting for us as we began this work with a small group of people and we turned something. It seemed like we had to have a thousand conversations. So I do think data was helpful. Our prevalence study really did show as we walked that around our facility, “You know, we do have a MRSA problem here.” And sometimes it was one-on-one conversations and often it was exhausting because we had to have the same conversations over and over again with different people. But don’t underestimate that impact. Again, PD is sometimes slow to begin. We say we’re slow to start. We begin slow to go fast. So improvement work, you can either put it all at the beginning and then hopefully, you could get going fast and PD is a little bit different where it takes a little bit longer to get that movement and then it will just go and you have so many people working that you can hardly control anything and you don’t want to control anything. It is somewhat chaotic but look at the results we’ve had because the people are doing the work.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Thank you. Thank you, Nancy. We do have a few more questions but as we are addressing the last few questions, we have posted… I think they have posted a short evaluation questionnaire on the screen and we’d very much value your feedback and hope you can spend a few minutes completing the evaluation form.

 

Okay, so I do have another question for all of you, any of the innovators who would like to respond. How do you cope with a dysfunctional informal leader who is also the technical resource, someone negative and resistant to change, and if you have that problem?

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

Yes, we have that problem sometimes where the informal leader is very opposed to say the intervention that we’re doing. I mean the example I have given is that we do some… try to develop best practices in some clinics and then spread them to another clinic and what we have done in trying to spread where we have say an informal resistant team is to try to, as I mentioned earlier on, do some cross fertilization and add members from another clinic that are successful in achieving something and make them part of the intervention team at a new site because people can come in and be very excited about how things work at their clinic and how much better it’s made it often can negate the opposition of somebody who’s been there, who’s there at that site. That’s been somewhat… that’s been pretty successful at some of our sites doing something like that.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Now a question for all of you was, “What was a tactic with stakeholders that did not work? What do we not do? What should we stay away from?” Anyone?

 

Paul Melinkovich, M.D. – Community Health Services at Denver Health – Director

Well, I would say what really doesn’t work in our setting, and I don’t think it works in most settings is the style of management where the managers are the ones who come in and say, “This is how things need to be done.” The top-down sort of change process. I think innovation is most supported and most embraced when it’s at the team level where people who are involved on the front line feel like they have ultimate ownership of what you’re going to be doing from an innovation standpoint. And they bristle, I think, at others from the outside coming in and saying, or even their own managers saying, “This is the way to do it.” So I think supportive servant leaders are the way you can… the opposite of servant leader is what you don’t want to do.

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

I agree with what Paul had to say. The other thing I would mention, often in traditional process improvement approaches, we think if we can show a beautiful PowerPoint slides that people are going to walk out of the room and just begin working. And that’s an illusion. And so we have tried to do death by PowerPoint. We conduct very few meetings with PowerPoint. We only provide expert opinion and data if people ask for it. So we’re trying to go for a poll. So I think traditionally using some of those methods, and certainly what Paul had to say, would be tactics that really are not at all effective if you’re going to engage people in changing behaviors.

 

Georgia Oliver – Memphis Healthy Churches – Project Director

And one thing we did that I think was helpful; we had to support the University of Tennessee to help us do a self-assessment of each church. We did a survey, a surveillance, and it gave information about the congregation: what diseases did the members have, how much they knew about HIV/AIDS, and some other questions. And then each church received a profile that was confidential to their church and it gave them some information and then they decided what programs they needed to implement first and how they could help solve some of the problems within their own congregation. So we didn’t go in and say we need to teach you about diabetes, cancer, HIV/AIDS, obesity, and disorder. We allowed them to have input.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Okay thank you, Patria. One of the other questions that came in for you is and I again I think you’ve probably answered part of it with what you just said and that’s, “Who are stakeholders other than ministers and what would the different motives be for each group, each of the other stakeholder groups?”

 

Patria Johnson – Memphis Healthy Churches – Program Manager

So who are the other stakeholders besides the ministers? We did mention that they were the key that the actual congregation itself and the community in which the congregation resides. So many times we invite the congregation to do health workshops and wellness events to involve their entire community, not just their church membership, but other churches that may be from different denominations. There may be persons that are unchurched that have benefit of the health knowledge and awareness activities that we promote so I would say the other stakeholders are also the community organizations and also our funding partners are our stakeholders. They have to find stock in the work that we do in order to fund the projects that we have through Memphis Healthy Churches in which they rely largely on grants from government institutions and foundations.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Well, thank you.

 

Patria Johnson – Memphis Healthy Churches – Program Manager

You’re welcome.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

Let me just remind you all. If you have a specific question about a specific intervention, you can continue the conversation with each of these specific innovators through comments on their profile. And you can also e-mail us if you want more discussion on any specific area or topic. I think we are about… we may have time for one more question and I think we’re going to have to close and Nancy, there was one question about how did you overcome and achieve success in the data wars?

 

Nancy Iversen, RN, CIC – Patient Safety and Infection Control, Billings Clinic – Director

Well, sometimes you just need to sit down and have a conversation about what the data war is about and often that’s a challenge because we had it with our pulmonologist; they were just concerned. They’re questioning how we were calculating transmission. So we just sat down and shared with them the CDC algorithms that the beta sites co-developed and really just through the conversation because people really don’t know and they really… I mean we’re all so busy; we just don’t have conversations with people anymore. And so, we just sat down and showed them the data, what our algorithms were, and then we had that situation happen to me personally and the pulmonologist, we kind of have this e-mail thing going on. And finally he said, “Why don’t you come to our meeting?” And I said, “I will come to the meeting with a couple of agreements. I’m not going to come in and we’re not going to have statistics wars. We’re not just going to talk about math. We will talk about how we are going to make it safer for our patients. And if that’s what the purpose of the conversation will be and we have all the pulmonologists in the room with the ICU leadership, I’ll be there. But if the meeting is going to be about data and arguing over data, that’s not what I’m interested in.” And so he said, “Okay, I’ll facilitate the meeting.” He didn’t know some of the algorithms and some of the data and once he heard that and saw that and now, he is one of the biggest champions and proponents that we have and the ICU that day did a turnaround. We’re in the game. We’re here to play. Let’s go.

 

Judi Consalvo - AHRQ Center for Outcomes and Evidence - Program Analyst

I’m afraid we’re out of time and we have to bring this webinar to a close. I really would like to thank everyone who submitted such valuable questions. Again, as a reminder, we plan to continue this discussion more informally through a free conference call in the coming weeks. If you are interested in participation in this follow-up discussion, please e-mail us at info@innovations.ahrq.gov by Monday, February 2nd so that we can plan the call for mid February. And again, we want to thank you, all of our presenters, and to all the participants, I hope you have found some information that you were looking for and that you’ve heard quite a bit of information that could be applicable to your settings and again, you can visit our site, the innovation site and you can e-mail us at info@innovations.ahrq.gov. Thank you.

 

Operator

Thank you, ladies and gentlemen. This does conclude today’s teleconference. You may disconnect your lines at this time. Thank you very much for your participation. Have a wonderful day.