David Hares is a popular guy on the sixth floor of the Albert Einstein Medical Center in Philadelphia. Nurses, housekeepers, and hospital administrators smile and greet him as he walks down the corridor, some reaching out with an affectionate squeeze. At the end of a hall, Hares tries to exit though a locked door, and a nurse tsk-tsks him as he playfully jiggles the handle. “You gotta wait till I buzz you!” she says, and grins as she waves him through.
However light the mood at Einstein today, Hares has a serious job. As the hospital’s quality manager, he is responsible for making good medical practices cost-efficient. In this era of drastic budget cuts and bleak fiscal forecasts, this is no easy task. Yet Hares and his colleagues have experienced extraordinary success combating one of the most intractable problems facing modern health care: the Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant “superbug.”
MRSA clings to anything it touches—hands, gloves, doorknobs, pens, dining ware, shoes, and so on. To make matters worse, the bacteria can lie inert on surfaces for weeks without a human host. And then an innocent sweep of a mop can send the pathogen along its infectious journey. In 2005, MRSA caused an estimated 94,000 infections and 18,650 deaths in the United States, report researchers in The Journal of the American Medical Association. That’s more deaths than HIV/AIDS caused nationwide in the same year.
And although MRSA is not relegated to hospitals alone—it can be found in jails, schools, gyms, and anywhere else that people congregate—patients with compromised immune systems are at a much greater risk of infection. Hence the conundrum of the modern hospital: how to heal people without introducing new bugs that might very well kill them.
Einstein hired Hares as it was trying out a new method for tackling MRSA . Called positive deviance (or PD), the method is a problem-solving approach for difficult, systemic challenges—especially when top-down, expert-vetted approaches have failed.
“The premise is simple,” says Jon Lloyd, a retired vascular surgeon who uses PD to combat MRSA in hospitals. “The solutions to seemingly impossible problems already exist in the communities that are facing those problems.” Commonly referred to as the “anti-consultant” method, PD helps the people closest to the problem discover their own ways of solving it, instead of sending outsiders to tell the insiders what to do. PD practitioners usually look for outliers, or “positive deviants,” who buck the odds and fare better than others in the community. “With PD, instead of looking for things that aren’t working, you start from the solution,” says Hares.
To learn PD techniques, Hares first had phone trainings with PD coaches every week. He then invited all employees at Einstein—doctors, nurses, housekeepers, chaplains—to voluntary weekly meetings, where he facilitated an equal exchange between people, no matter their rank. The meetings had only two rules: no talking about people who were not present, and everyone is welcome to speak. In this way, the meetings gradually shifted the top-down hierarchical culture of the hospital to one that was more open. As a result, nurses felt free to remind doctors to wash their hands, and housekeepers felt empowered to share their secrets for staying clean and healthy.
Since PD came to Einstein in 2006, MRSA infection rates have dropped more than 32 percent. “We didn’t change the science,” says Hares. “We implemented things that were already proven”—hand hygiene, consistent use of gloves and gowns, clear signage for infected patients—“and changed the behavior attached to the science.”
The Albert Einstein Medical Center is not the only organization to benefit from PD. For nearly two decades, PD has helped hundreds of communities in dozens of countries harness on-the-ground genius to solve their own problems. PD has been instrumental in tackling such disparate problems as female genital cutting in Egypt and student under-performance in New Jersey schools.
To amplify the impact of PD worldwide, proponents of the method founded the Positive Deviance Initiative (PDI) in 2008 at Tufts University Friedman School of Nutrition Science and Policy in Boston. With a $3 million grant from the Rockefeller Foundation, the organization is now taking PD to scale. Although still a small operation, PDI already has a long list of successes to its credit.
Escape From the Ivory Tower
In the late 1980s, Marian Zeitlin, a professor of nutrition at Tufts University, coined the term “positive deviance.” She was conducting research on why some children fared better than others in communities with rampant malnutrition. But it wasn’t until Monique and Jerry Sternin, a husband-and-wife team working for the nonprofit Save the Children, were given the task of alleviating malnutrition in Vietnamese children that PD escaped the confines of academe.
When the Sternins visited Vietnam in 1990, more than 65 percent of the children under the age of 3 were malnourished. According to Monique, the Vietnamese government told the Sternins that they had six months to show impact or their visas would not be renewed. “We had an interpreter and a black Volga car, that was it,” recalls Monique, an anthropologist who is now director of PDI. (Jerry Sternin died in December 2008 after a short battle with cancer.) Faced with a seemingly insurmountable task, the Sternins, who had been following Zeitlin’s work, decided to experiment with PD in the field.
They started small, in four villages, using three basic principles: 1) The community itself needs to discover what works for it (“That’s why the immune system of the community doesn’t reject it,” says Sternin.); 2) everybody is invited to participate (When everyone brings a voice to the table, says Sternin, “they have ownership [of the ideas] from day one.”); and 3) the community develops its own monitoring and evaluation tools, which work best because they are tailored to the community’s particular needs.
In the case of the Vietnam nutrition project, the Sternins first helped the villagers establish their own standards for what counts as “well nourished” by training health volunteers to weigh children and evaluate their nutritional status on a UNICEF growth chart. They then helped the villagers discover that families with well nourished children were feeding them tiny shrimp and crabs collected from rice paddies, along with sweet potato greens—foods that local wisdom maintained were unhealthy for children. These families were also feeding their children many small meals a day, as opposed to the traditional two meals per day.
The real challenge, however, was to help parents of malnourished children sustain the healthy weight-gaining practices; good changes often revert to the status quo after the experts leave. So the Sternins invited the parents of malnourished children to prepare and eat meals with the parents of the well-nourished children. After a few weeks of this practice, the new cooking and feeding habits took hold in many families. For those families whose children did not gain enough weight, the Sternins invited them to participate in the communal meal preparation program again.
After six months, observers determined that more than 40 percent of the children were well nourished, and that another 20 percent had moved from severe to moderate malnutrition. The government then spread the program throughout the country (and renewed the Sternins’ visas). Since that time, the program has had a direct impact on the lives of 2.2 million people in Vietnam.
Let the Mice Roar
Upon returning to the United States in 2001, the Sternins set up camp at Tufts University, where they slowly expanded the scope of their program. Both Monique and Jerry Sternin, the respected and beloved “Father of Positive Deviance,” were personally involved in training the many people they reached over the years.
Now, PDI employs experienced coaches who train people to execute PD within their organizations. A typical nine-month PD course involves three face-to-face trainings for three days each, phone coaching once a week for six weeks, and then one phone check-in every month after that. Thousands of people have been trained in PD all over the world more or less in this fashion. But because PDI is a new organization, it is much smaller than the scope of its influence would suggest: It currently has only four full-time staffers, and the lion’s share of its budget comes from grants.
PD has since racked up enough successes to attract the interest of prominent philanthropic organizations like the Rockefeller Foundation. “[PD] doesn’t work in every situation, but I think it is an important tool,” says Maria Blair, associate vice president of the Rockefeller Foundation. “Creating effective and efficient solutions to social problems requires a toolbox of approaches and methods.”
Back at Einstein, signs of PD in action are everywhere. Many rooms have supply racks stocked with gloves, gowns, and masks by the door. Hand cleanser is abundant: Hares squirts some into one hand and rubs it under his fingernails, demonstrating the proper technique for hand sanitization. Patricia Cooper, a housekeeper, pushes by with a large cleaning supply cart. “I clean this whole floor, and I’m always telling people to wash their hands, flush the toilet, things like that,” she says. “Doctors have a lot on their minds, and they might just walk out and forget something.” She laughs, adding, “They call me ‘the tyrant,’ and that’s okay with me!”
Adrienne Day is a freelance writer, editor, and occasional Web monkey. She lives in New York City.
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