Fighting Infection: Making the Invisible Vibrantly Visible


Billings Clinic, in Billings Montana, is a community-owned non-profit healthcare organization with a 272 bed hospital, and a 90 bed skilled nursing and assisted living facility. It serves patients in Montana, Wyoming and the Western Dakotas.


In 2006 Billings joined the MRSA Prevention Partnership becoming one of six beta site health care systems led by Plexus Institute in a Robert Wood Johnson Foundation funded initiative to use the behavior change process Positive Deviance (PD) to fight MRSA.

The Positive Deviance Approach

Mentoring, coaching and information feedback engaged the entire workforce in fighting infection. Patients admitted to the ICU, the first pilot unit, were tested for MRSA, and throughout the hospital, isolation and contact precautions were required for patients infected or colonized with MRSA. Hand hygiene adherence was monitored, and staff tracked supply records showing increased use of gowns and gloves.

  • For a baseline on MRSA prevalence, 300 patients and caregivers were tested. Results showed 12% prevalence among patients, 8% among nurses and 17% among physicians.
  • Improvisations began for staff members who wanted a safe way to practice infection prevention protocols and difficult conversations.
  • Theater-style enactments exposed unexpected contamination possibilities, and workers experimented with solutions and conversations to educate patients and persuade noncompliant colleagues.

Impact and Outcomes

Staff discovered “seriously playful” ways to see the continual interplay between humans and their invisible bacterial adversaries. New practices emerged. Most doctors stopped wearing long sleeves and ties. Nurses disinfected more surfaces. A physician who returned in 2008 after four years away found a new attitude: workers had taken ownership of infection prevention and felt responsible for it.

  • By 2010, MRSA infections declined 80%.
  • Fewer staph infections that did occur were drug resistant.
  • Hundreds of frontline workers used improv sessions to explore room cleaning, patient transport and dozens of other workplace issues.
  • Network maps pre- and post initiative showed new relationships across disciplines and identified exceptionally knowledgeable and helpful staff members.
  • Meticulous records allowed immediate identification of new infections.
  • PD processes have been used for other quality and safety issues.