Positive deviance

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In quality improvement, Positive deviance is a "bottom-up" approach to quality improvement[1]. An description of this method was[2]:

  • "Develop case definitions"
  • "Identify four to six people who have achieved an unexpected good outcome despite high risk"
  • "Interview and observe these people to discover uncommon behaviours or enabling factors that could explain the good outcome"
  • "Analyse the findings to confirm that the behaviours are uncommon and accessible to those who need to adopt them"
  • "Design behaviour change activities to encourage community adoption of the new behaviours"
  • "Monitor implementation and evaluate the results"

A more recent listing of the steps is[3]:

  • Identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care)
  • Study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance
  • Test hypotheses statistically in larger, representative samples of organizations
  • Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practice

Positive deviance is consistent with complexity leadership[4][5][6].

Positive deviance may include grounded theory, ethnography methods, guided conversations/interviews, and focus groups[7].

Not all QI measures may be appropriate[8].


Methods

Overviews of methods are available[3][9].

Positive deviance is a viable strategy with variation in performance is present. Variation in performance has been measured with the coefficient of variation[10].

1. Identifying deviants

Ideally, positive deviants should be identified by blinded comparison to control groups[11], yet this is infrequently done[1] and instead deviants are informally identified by reputation[12][13].

Various statistical approaches are used to identify the true deviants[14][15][16][8].

Performance rates may need adjustment before comparison[17].

Inadequate sample may hinder identifying deviants[18]. Regression to the mean may confound identifying postive deviances and the assessment of improvement[19].

Psychology, barriers and promoters of shared learning

Main article: https://www.wikidoc.org/index.php/Industrial_and_organizational_psychology § Personality_traits

Learning of success can inspire others[20] to perform. On the other hand, "Individuals with higher levels of [Performance‐prove goal orientation] PPGO have decreased self-efficacy and performance when observing higher performing coworkers"[21]

Interventions and assessments using positive deviants

Clinical problem Variation found Organizational issues among causes found
Acute myocardial infarction[22] Adjusted mortality: mean 15.4% (SD, 1.5%; range, 11.5% to 21.7%) Fostering an organizational environment in which clinicians are encouraged to solve problems creatively
Having physician and nurse champions rather than nurse champions alone
Sepsis[10] Length of stay: median (IQR) 4.9 (3.0-7.9) Not queried
Beta-blockers after myocardial infarction[23] Rates not reported shared goals for improvement
substantial administrative support
strong physician leadership advocating beta-blocker use
use of credible data feedback
Dabigatran adherence[24] 74% (IQR: 66%-80%) Organizational strategies not assessed

Reports of using positive deviance to assess the tactics behind successful performance have been published:

Reports of using positive deviance to assess and improve performance have been published[9] Specific examples include:

See also

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References

  1. ↑ 1.0 1.1 1.2 Baxter R, Taylor N, Kellar I, Lawton R (2016). "What methods are used to apply positive deviance within healthcare organisations? A systematic review". BMJ Qual Saf. 25 (3): 190–201. doi:10.1136/bmjqs-2015-004386. PMC 4789698. PMID 26590198.
  2. ↑ Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M (2004). "The power of positive deviance". BMJ. 329 (7475): 1177–9. doi:10.1136/bmj.329.7475.1177. PMC 527707. PMID 15539680.
  3. ↑ 3.0 3.1 3.2 3.3 Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM (2009). "Research in action: using positive deviance to improve quality of health care". Implement Sci. 4: 25. doi:10.1186/1748-5908-4-25. PMC 2690576. PMID 19426507.
  4. ↑ Belrhiti Z, Nebot Giralt A, Marchal B (2018). "Complex Leadership in Healthcare: A Scoping Review". Int J Health Policy Manag. 7 (12): 1073–1084. doi:10.15171/ijhpm.2018.75. PMC 6358662. PMID 30709082.
  5. ↑ 5.0 5.1 Lindberg, Curt; Clancy, Thomas R. (2010). "Positive Deviance". JONA: The Journal of Nursing Administration. 40 (4): 150–153. doi:10.1097/NNA.0b013e3181d40e39. ISSN 0002-0443.
  6. ↑ 6.0 6.1 Lindberg, Curt; Schneider, Marguerite (2013). "Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance". Leadership. 9 (2): 229–253. doi:10.1177/1742715012468784. ISSN 1742-7150.
  7. ↑ Curry LA, Nembhard IM, Bradley EH (2009). "Qualitative and mixed methods provide unique contributions to outcomes research". Circulation. 119 (10): 1442–52. doi:10.1161/CIRCULATIONAHA.107.742775. PMID 19289649.
  8. ↑ 8.0 8.1 O'Hara JK, Grasic K, Gutacker N, Street A, Foy R, Thompson C; et al. (2018). "Identifying positive deviants in healthcare quality and safety: a mixed methods study". J R Soc Med. 111 (8): 276–291. doi:10.1177/0141076818772230. PMC 6100151. PMID 29749286.
  9. ↑ 9.0 9.1 Rose AJ, McCullough MB (2017). "A Practical Guide to Using the Positive Deviance Method in Health Services Research". Health Serv Res. 52 (3): 1207–1222. doi:10.1111/1475-6773.12524. PMC 5441507. PMID 27349472.
  10. ↑ 10.0 10.1 10.2 Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C; et al. (2016). "Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality". JAMA. 316 (10): 1061–72. doi:10.1001/jama.2016.12226. PMID 27623461.
  11. ↑ Bock, L. (2015). The Two Tail. In: Work rules!: Insights from inside Google that will transform how you live and lead. Twelve.
  12. ↑ McAlearney AS, Garman AN, Song PH, McHugh M, Robbins J, Harrison MI (2011). "High-performance work systems in health care management, part 2: qualitative evidence from five case studies". Health Care Manage Rev. 36 (3): 214–26. doi:10.1097/HMR.0b013e318201d1bf. PMID 21646881.
  13. ↑ Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T (2013). "In search of joy in practice: a report of 23 high-functioning primary care practices". Ann Fam Med. 11 (3): 272–8. doi:10.1370/afm.1531. PMC 3659145. PMID 23690328.
  14. ↑ Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM (2018). "A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems". Health Serv Res. 53 (3): 1851–1869. doi:10.1111/1475-6773.12693. PMC 5980166. PMID 28384376.
  15. ↑ Berlowitz DR, Christiansen CL, Brandeis GH, Ash AS, Kader B, Morris JN; et al. (2002). "Profiling nursing homes using Bayesian hierarchical modeling". J Am Geriatr Soc. 50 (6): 1126–30. PMID 12110077.
  16. ↑ Rubens, Fraser; Chen, Li; Ramsay, Tim; Forster, Alan; Wells, George; Sundaresan, Sudhir (2018). "The development of a positive deviancy strategy to identify excellence in patient experience". European Journal for Person Centered Healthcare. 6 (4): 540. doi:10.5750/ejpch.v6i4.1542. ISSN 2052-5656.
  17. ↑ Wholey DR, Finch M, Kreiger R, Reeves D (2018). "Public Reporting of Primary Care Clinic Quality: Accounting for Sociodemographic Factors in Risk Adjustment and Performance Comparison". Popul Health Manag. 21 (5): 378–386. doi:10.1089/pop.2017.0137. PMID 29298402.
  18. ↑ Singh S, Goodwin JS, Zhou J, Kuo YF, Nattinger AB (2019). "Variation Among Primary Care Physicians in 30-Day Readmissions". Ann Intern Med. 170 (11): 749–755. doi:10.7326/M18-2526. PMC 6743324 Check |pmc= value (help). PMID 31108502.
  19. ↑ Joshi S, Nuckols T, Escarce J, Huckfeldt P, Popescu I, Sood N (2019). "Regression to the Mean in the Medicare Hospital Readmissions Reduction Program". JAMA Intern Med. doi:10.1001/jamainternmed.2019.1004. PMC 6596330 Check |pmc= value (help). PMID 31242277.
  20. ↑ Quinn, Ryan W; Myers, Christopher; Kopelman, Shirli; Simmons, Stefanie A. (2020). "How Did You Do That? Exploring the Motivation to Learn from Others' Exceptional Success". Academy of Management Discoveries. doi:10.5465/amd.2018.0217. ISSN 2168-1007.
  21. ↑ Downes PE, Crawford ER, Seibert SE, Stoverink AC, Campbell EM (2020). "Referents or role models? The self-efficacy and job performance effects of perceiving higher performing peers". J Appl Psychol. doi:10.1037/apl0000519. PMID 32463258 Check |pmid= value (help).
  22. ↑ 22.0 22.1 Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP; et al. (2012). "Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction". Ann Intern Med. 156 (9): 618–26. doi:10.7326/0003-4819-156-9-201205010-00003. PMC 3386642. PMID 22547471.
  23. ↑ 23.0 23.1 Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM (2001). "A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed?". JAMA. 285 (20): 2604–11. PMID 11368734.
  24. ↑ 24.0 24.1 Shore S, Ho PM, Lambert-Kerzner A, Glorioso TJ, Carey EP, Cunningham F; et al. (2015). "Site-level variation in and practices associated with dabigatran adherence". JAMA. 313 (14): 1443–50. doi:10.1001/jama.2015.2761. PMID 25871670.
  25. ↑ Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL; et al. (2018). "How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study". Circulation. 138 (2): 154–163. doi:10.1161/CIRCULATIONAHA.118.033674. PMC 6245659. PMID 29986959.
  26. ↑ Ritchey MD, Hannan J, Wall HK, George MG, Sperling LS (2020). "Notes from the Field: Characteristics of Million Hearts Hypertension Control Champions, 2012-2019". MMWR Morb Mortal Wkly Rep. 69 (7): 196–197. doi:10.15585/mmwr.mm6907a5. PMC 7043391 Check |pmc= value (help). PMID 32078589 Check |pmid= value (help).
  27. ↑ 27.0 27.1 27.2 Tanenbaum J, Cebul RD, Votruba M, Einstadter D (2018). "Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations". Health Aff (Millwood). 37 (2): 266–274. doi:10.1377/hlthaff.2017.1209. PMC 7003658 Check |pmc= value (help). PMID 29401005.
  28. ↑ Greene J, Hibbard JH, Alvarez C, Overton V (2016). "Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels". Ann Fam Med. 14 (2): 148–54. doi:10.1370/afm.1904. PMC 4781518. PMID 26951590.
  29. ↑ Sreeramoju P, Dura L, Fernandez ME, Minhajuddin A, Simacek K, Fomby TB; et al. (2018). "Using a Positive Deviance Approach to Influence the Culture of Patient Safety Related to Infection Prevention". Open Forum Infect Dis. 5 (10): ofy231. doi:10.1093/ofid/ofy231. PMC 6166267. PMID 30288392.
  30. ↑ D'Agata EMC, Lindberg CC, Lindberg CM, Downham G, Esposito B, Shemin D; et al. (2018). "The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities". Infect Control Hosp Epidemiol. 39 (12): 1400–1405. doi:10.1017/ice.2018.237. PMID 30253815.
  31. ↑ Lindberg CM, Lindberg CC, D'Agata EMC, Esposito B, Downham G (2019). "Advancing Antimicrobial Stewardship in Outpatient Dialysis Centers Using the Positive Deviance Process". Nephrol Nurs J. 46 (5): 511–518. PMID 31566346.
  32. ↑ Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA; et al. (2017). "Results of a Regional Effort to Improve Warfarin Management". Ann Pharmacother. 51 (5): 373–379. doi:10.1177/1060028016681030. PMID 28367699.
  33. ↑ Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM; et al. (2012). "Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration". Health Serv Res. 47 (4): 1541–60. doi:10.1111/j.1475-6773.2011.01377.x. PMC 3401398. PMID 22299722.
  34. ↑ Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC (2013). "A positive deviance approach to understanding key features to improving diabetes care in the medical home". Ann Fam Med. 11 Suppl 1: S99–107. doi:10.1370/afm.1473. PMC 3707253. PMID 23690393.
  35. ↑ Katz SH, Hediger ML, Valleroy LA (1974). "Traditional maize processing techniques in the new world". Science. 184 (4138): 765–73. doi:10.1126/science.184.4138.765. PMID 17783464.
  36. ↑ Ederhof M, Chin AL, Jopling JK. Hospital cost accounting data: a valuable underused resource. Health Affairs Blog. July 2, 2018 (https://ramaonhealthcare.com/hospital-cost-accounting-data-a-valuable-underused-resource/).
  37. ↑ Ivanovic J, Anstee C, Ramsay T, Gilbert S, Maziak DE, Shamji FM; et al. (2015). "Using Surgeon-Specific Outcome Reports and Positive Deviance for Continuous Quality Improvement". Ann Thorac Surg. 100 (4): 1188–94, discussion 1194-5. doi:10.1016/j.athoracsur.2015.04.012. PMID 26188970.
  38. ↑ Ivanovic J, Mostofian F, Anstee C, Gilbert S, Maziak DE, Shamji FM; et al. (2018). "Impact of Surgeon Self-evaluation and Positive Deviance on Postoperative Adverse Events After Non-cardiac Thoracic Surgery". J Healthc Qual. 40 (4): e62–e70. doi:10.1097/JHQ.0000000000000130. PMID 29315152.
  39. ↑ Ferracini FT, Marra AR, Schvartsman C, Dos Santos OF, Victor Eda S, Negrini NM; et al. (2016). "Using Positive Deviance to reduce medication errors in a tertiary care hospital". BMC Pharmacol Toxicol. 17 (1): 36. doi:10.1186/s40360-016-0082-9. PMC 4976064. PMID 27497977.


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