Tiny Changes Making A Huge Difference: Responding to COVID-19

Including and Unleashing More People with Liberating Structures

By Keith McCandless and friends,

Preamble: In this article, I share personal experience with preventing the spread of MRSA superbugs in hospitals and how lessons learned may inform next steps in response to COVID-19. Liberating Structures are featured because they are particularly well matched to challenges that require everyone to change routine behaviors in their work and home life.

My “flashback” started when a colleague (Douglas Ferguson) reached out from Austin, “Can you help me think through a ½ day session with 150 or more Austin folks who want to thoughtfully handle a COVID-19 response for SXSW? The meeting is March 7th, this Friday.” Douglas regularly convenes people working in the technology/arts domain and there were worries the much anticipated event would be cancelled. This is a very big deal in Austin.

His request immediately brought me back to challenges we faced when preventing the transmission of MRSA and other superbugs in hospitals. [Read about Canadian and US multisite action research projects circa 2008–2012. Comments from colleagues involved in the work are included at the end of this article]. Turns out that many Liberating Structures were forged in response to this big challenge. I want to share my on the ground lessons learned that may apply to COVID-19 responses.

Below, in italics, are the emails and texts in response to the request: from me and one by Fisher Qua. All edited slightly to create a little more flow. Spoiler alert: the Austin City government decision to postpone SXSW came 60 minutes into the very afternoon the session was held.

[Keith] March 6

Here are a few quick first thoughts… Sharp + playful language like, “We are here to prevent transmission of COVID-19 during SXSW… and to make it easy or even fun doing so” might be productive. Your purpose could be linked to each organizer protecting themselves and preventing unwitting spread across the community.

In our MRSA prevention work with Liberating Structures (LS), we tried many approaches to overcome hopelessness, inaction, and cynicism. Despite nearly everyone in the hospital being aware of the scientific evidence for prevention — wash your hands thoroughly, clean surfaces with bleach, isolate patients in precaution rooms, and identify infected patients as quickly as possible — we witnessed a wide range of safe and unsafe behaviors on the hospital units. And, the numbers of infections were going up across many units.

Coaches and working groups from hospitals across the US preparing to launch MRSA and superbug prevention projects.

This was not a new problem. A handful of conventional strategies were already deployed. They included: telling people (or bribing people with coffee coupons) to wash their hands and follow all the protocols; and, conducting surveillance studies to record the error rate on different units. These were not working. Through interviews I was told in confidence, “It is just inevitable that we spread superbugs to patients.” This made me crazy and provided motivation to liberate with more verve. I was thinking, these are people in the health profession: their credo is first, do no harm.

An improv prototyping scene at a Montana hospital depicting unsafe handshake between a doctor and patient. Immediately, the audience was invited to replay the scene SAFELY in small groups.

We needed to dig deeper and cast a wider net. We started to liberate the creative adaptability of a vast array of people playing different roles (e.g., nurses, cleaners, clerks, doctors, family members, infection control professionals, chaplains, transporters). So many different people enter rooms, touch surfaces, and transport material in the everyday operations of a hospital (e.g., chaplains carry a bible from room to room). We needed everyone to change their behavior to eliminate transmissions. The superbugs did not respect the hierarchy; everyone in the hospital could carry, transmit, or suffer life threatening infection.

Core leadership team from a hospital in Montana, showing off their good hand hygiene.

A few principles that guided our practice included:

  • we must seek out positively-deviant behaviors and practices in hidden in plain sight (see more about Positive Deviance here);
  • we must practice deep respect for people and local solutions (not deploy imported “best” practices but rather rely on local inventiveness);
  • we must practice self-discovery in a group (very few people respond well to being told or coerced into compliance but rather love learning and experimenting); and,
  • we must include and unleash everyone to shape next steps as the work unfolded (focusing on the unusual suspects as well as the more privileged people)

We engaged in rapid-cycle trial and error. There were dark moments when all our efforts seemed to come to nothing. We had difficulty revealing positively deviant behaviors from a distance. No one had time for exploring or inventing anything new. We were trying so seriously hard.

The first glimmers of hope included use of early versions of LS methods. And, we started to take bigger risks to unleash more people.

We walked into ICUs and invited anyone who would listen, “How could you be sure that every patient left this unit with MRSA or another superbug?” Nervous laughter, then a flood of creative ideas that were all too familiar because they resembled what was actually happening. More people gathered around to laugh… and cry. Getting a commitment to stop unsafe practices and ineffective management strategies (e.g., laminated signs with WASH YOUR HANDS) was suddenly easier. It was very important that we came to their unit. This showed we respected their ability to discover and generate solutions.

Infection prevention leaders from Toronto boldly launching a Canada-wide action research project.

When we could gather a few people together, we tapped the LS called DAD. It started with the invitation, “When do you know a patient or staff member is at risk of acquiring MRSA?” Everyone had answers and they immediately learned from one another. The next invitation, “What you do to protect yourself and patients from MRSA? How do you encourage others to do the same things?”

Student nurse celebrated for reminding a doctor colleague to follow room precautions. She attended an improv prototyping session featuring this theme… and then brought it to real life on a unit.

Again, everyone had answers, some more scientifically grounded than others. However, group members started to discover solutions generated by people like them and got interested in inventing new practices that could help solve the problem. Many units immediately started to place Purell dispensers where newly activated staff members wanted them. That was just the beginning. Trust in each other and hopes for eliminating transmissions were building.

When we had a little momentum, we staged performances to share local solutions and spark more invention. No professional actors. Only clerks, nurses and doctors committed to eliminating transmissions. For example, our core group of action researchers offered improv scenes to 70 folks during their lunch break. Themes included the complex challenges faced in everyday practice. For example, What Do I Wear? How Do I Break The Bad News To A Patient? How Do I Speak Truth To Power (when a more powerful person exhibits unsafe behavior); and, Hand Hygiene Dance Routines (how do we make hand hygiene cool?). Other examples of Improv included participatory fashion shows to demonstrate the newest available protective gear and how to be fashionably safe, and how to safely remove and dispose of used gowns and gloves [source: Sharon Benjamin].

Infection prevention team performing a safe practice dance routine.

The conventional practices in use — experts or managers telling people what to do, giving away free coffee coupons for good behavior, or repeating stale messages about handwashing — began to fade away. Instead, we included and unleashed every person’s imagination and inventiveness with LS. The projects were wildly successful in reducing and eliminating superbug transmissions at multiple sites across the US and Canada.

So, back to Austin, SXSW, and advice about responding to COVID-19…

[Keith] LS to think about:

Improv Prototyping: getting each person to practice engaging others in prevention practice can be serious fun! Here are scenes that may make sense to stage (first in the front of the room, then distributed to the whole room via groups of three — two players and one observer — replaying the same scene to develop more effective responses.

# 1: you notice someone with risky behavior (e.g., an inappropriate sneeze), improv your verbal or non-verbal exchange;

# 2, you are asked for help from someone feeling feverish or fearful;

# 3, you are planning your stylish outfit for SXSW, have a convo about what you will help you prevent transmission to others.

# 4, you need to escort someone into an isolation room or location to get medical attention…

You get the idea. Also, TRIZ and Critical Uncertainties also come to mind for generating strategies to stop or start.

[Fisher Qua] March 6

First things that come to mind:

LS-TRIZ would sting and probably be helpful. Same with Critical Uncertainties — though it’d have been more helpful perhaps in anticipating the situation. The uncertainties will be sharper now and fractal from the individual up to the global community. Discovery-and-Action Dialogue could play a role.

Minimum Specifications/ Min Specs would help sort the chaff amid the complexity (and chaos) — here are the simple rules or protocols we need to follow.

Depending on the group — if it’s the core organizing/functional teams, a WINFY might be really helpful. Be incredibly clear what kinds of needs you have from each other — especially emotionally, logistically, etc. if certain decisions are made.

In terms of a string or sequence, the cycle might be something like:

Affirmation — Why is this important to take seriously and what’s personally at stake for you? (Impromptu Networking or Conversation Cafe)

Despair — What is hard, complex, or difficult about this? (TRIZ and Critical Uncertainties)

Reconnection — How do we figure out our way through this? Where do we have control? (Minimum Specifications)

Action — What will be our responses and moves forward? (WINFY, harvesting actions from TRIZ, Critical Uncertainties)

Edited convo between me [Keith] and the Austin organizer [Douglas] post-event (March 8).

We did five rounds of improv prototyping before the Mayor announced on TV that SXSW cancelled. There was so much goodness from improv prototyping. I felt like we were in a good place to start TRIZ, and then the Mayor came on… for 45 minutes! Only 20 people stayed after the announcement. We had a Conversation Cafe to close.

[1] Inappropriate sneeze response/conversation [2] Talking with someone debating “go to the event or stay home” [3] What to wear? (to keep yourself safe and not spread to others) [4] Someone in your house is becoming symptomatic (this was proposed by the participants) [5] I suggested one more… If you have thirty seconds to share one thought with the Mayor [you just ran into him on the street] whatareyougonnasay?

And, I shared a link to the fabulously creative former Mayor of Bogota Antanas Mokus. He believes and acts on the idea people can change their own behaviors to solve BIG social challenges ( 15% Solutions )

Everyone agreed these were very good topics to talk about now. People were a bit puzzled about what to wear… I think they will do more research on this. Oh, I saw someone coughing yesterday and I realized how hard it is to say something about it.

There are differences and similarities between these experiences and our first responses to COVID-19. However, the principles and LS methods for engaging everyone in finding solutions seem to translate well. However imperfect or impractical or clumsy it feels, I recommend:

  • practicing deep respect for people and local solutions, not expecting that imported “best practices” will solve local problems;
  • seeking out positively-deviant behaviors and practices in hidden in plain sight;
  • practicing self-discovery in a group, not expecting people to respond well to being told or coerced into compliance; and,
  • including and unleashing everyone to shape next steps as COVID-19 unfolds… with an emphasis on the unusual suspects.
Focusing on unusual suspects (hospital volunteers) and making hand washing fun across many different units and settings in a Canadian hospital.

OK, that is all from me… for now.

Keith, your writing made me think about families because a major proportion of virus transmission takes place via family. One member brings the virus home, infects other family members. They in turn may go out and transmit it to other people. Getting everybody in the family, adults and children, involved and supporting each other in reducing transmissions makes a big difference. This means that every family member must know precisely what to do personally and to help others. This is what excellent teamwork is all about. However, children, like adults, don’t like being told what to do and reflexively resist doing what is imposed on them. Fortunately children, like adults, will follow rules when they are generated with their full participation and they agree with and understand their rationale.

The challenge for parents is how to include all family members, children included, in productive interactions that will generate effective practices for everybody. The good news is that there are methods used to facilitate inclusion and participation that are so simple that parents can easily use them with their children, learning as they use them. A few that are used all around the world are described in the following Medium article: To cope with C-19 you need a high-performing family team — Here is how to build it.

I love what Dr. Michael Ryan from the WHO says: “in an emergency response; if you need to be right before you move — you will never win”.

Our health systems and bureaucracies are generally steeped in a research paradigm — which entails careful planning, usually linear in nature and having an abundance of evidence to inform our decisions. We don’t have that luxury right now. It’s like this crisis is shining a light on how our draconian ways of working do not work.

I am seeing things being approved in hours that were never thought possible; however I also see that many people that are still in an old power mindset. LS offer excellent ways to reframe, reflect and move us to action and speed. For example: We were told that we had to deploy our non clinical staff to go to the airport to hand out pamphlets on COVID (yep, the opposite of social distancing). Most people nodded and said — “OK — sign me up”. It took a few of my teammates to ask “How could this directive ensure that there are more viral transmissions?” — instantly the light bulbs went off “oh yah — handing out flyers would increase social crowding and risk for transmission”.

Be ready to receive criticism and disapproval when you are the contrarian in the group (using a LS will not save you from that). The favourite LSs that come to mind for our team are TRIZ, 9 Why’s and What/So What and Now What and of course 25/10 Crowdsourcing. Everyone wants to do the right thing in this crisis and using LS framing can change the direction of the decisions in this time of crisis where speed is the name of the game.

My “flashback” regarding the MRSA transmission work was about the need to disrupt the inevitability of transmission. The mindset that there was no way to successfully combat the thousands of ways that MRSA transmission could occur. Employing the power of LS to engage everyone in all aspects of the transmission process to make micro changes to each and every aspect of the routes for transmission was key to eradication. We did get to zero!

It took a messy, non linear use of LS micro-structures to provide the playground for surfacing and identifying all the ways transmission could occur — a prime example was when the respiratory therapists had their “ah-ha” moment around the placement of their drugs, uncovered and possible contaminated, into the general medication distribution system.

Thinking through how COVID-19 is challenging us to rethink how we are doing everything, from getting food, to educating children, to allocating medical care, requires all of us to identify and problem solve the best ways to do this without creating a transmission risk. Starting this work within our own families, work organizations, faith communities will be powerful!

Flashback some dozen years ago to the various pilot sites for our MRSA prevention work. The upshot: as with the use of LS, the wisdom to stop the virus is distributed and often lurks (as does the virus) in places one least expects. I am remembering how discovery and action dialogues (DAD) allowed the on-site teams to discover the hidden wisdom of:

Darryl, a 30-something MRSA-infected patient, who had come up with an ingenious strategy to ensure that attending nurses and doctors washed their hands before touching him. When doctors or nurse entered his room and did not wash their hands, Darryl refused to make eye contact with them. Instead he just kept looking at the sink. If they did not get the message, Darryl would playfully — with a wink and a nod — look back at them, and then back at the sink, until they got the message. DAD allowed the VAPHS team to discover that patients — who typically are looked upon as being the “problem” — embodied the potentiality and agency for self-protection.

Transporter Jasper Palmer’s techniques for removal of gowns and gloves to virtually eliminate infectious splatter and reduce the burden of removing infectious waste.

Nurse Risa’s positively-deviant use of “the knuckle.” Nurse Risa pushed the elevator button at VAPHS with her knuckle, not a fingertip — a highly potent vector of infection transfer. Imagine a keyboard at an ICU used by a dozen nurses, each with ten fingertips, 105 computer keys, and hundreds of daily entries. Similarly, do the math for the MRSA transmission potential of a panel of buttons on multiple elevator cars — each used by hundreds of people, around-the-clock, day after day. Similarly, LS processes helped discover nurses who carried hand-sanitizers in a “holster” (clipped to their belt) or as pendants strung around a neck strap. Once such uncommon practices were discovered at the VAPHS, they were vetted internally by frontline staff for ease of replicability and then accordingly amplified.

Our use of LS and PD processes made it abundantly clear that MRSA prevention was not just the exclusive domain of experts and infectious disease specialists, but such wisdom was distributed among “unusual suspects,” including patients, housekeepers, transporters, chaplains, nurses, and doctors. The key was engaging and Inviting Everyone (also the title of a book that documented our MRSA prevention and control work).

Preventing the transmission of COVID-19 and its containment and mitigation will require us to invite and engage everyone. The virus does not discriminate.

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