Learning from positive deviants to improve the quality and safety of healthcare. Ruth Mary Baxter Submitted in accordance with the requirements for the degree of Doctor of Philosophy The University of Leeds School of Psychology November 2016 ii The candidate confirms that the work submitted is her own, except where work which has formed part of jointly authored publications has been included. The contribution of the candidate and the other authors to this work has been explicitly indicated below. The candidate confirms that appropriate credit has been given within the thesis where reference has been made to the work of others. The systematic review reported in Chapter 2 and a protocol paper for the secondary care study (Chapters 3 and 4) have been published: Baxter, R., Taylor, N., Kellar, I., & Lawton, R. (2015). What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Quality and Safety, Published online first 20th November. doi: 10.1136/bmjqs-2015-004386 Baxter, R., Taylor, N., Kellar, I. and Lawton, R. (2015). Learning from positively deviant wards to improve patient safety: an observational study protocol. BMJ Open; 5:e009650. doi:10.1136/bmjopen-2015-009650 All authors developed the concept for the systematic review. RB designed the study and conducted the searches, screening, data extraction and analysis with input from IK, NT and RL. RB drafted the publication and thesis manuscript. All authors provided comments and approved final versions. All authors contributed to the conception of the secondary care study. RB designed the study which was critically assessed and approved by all the other authors. RB set up the study, gained ethical approvals and collected all data. RB drafted the publication and thesis manuscript. All authors provided comments and approved the final versions. This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement. The right of Ruth Baxter to be identified as Author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. © 2016 The University of Leeds and Ruth Baxter i Acknowledgements I would like to start by expressing a huge thank you to my supervisors, Rebecca Lawton, Natalie Taylor, and Ian Kellar. This PhD has been such a wonderful experience and it has been a great privilege to work with you all. Thank you for all of your support and guidance, for helping me to develop confidence in my abilities, and for the opportunities you have provided. I am truly grateful. Thank you to The Health Foundation for funding this PhD and for supporting my development. I am also eternally grateful to all of the staff and patients who have participated in my research. Without you this thesis would not have been possible. Lots of people have supported and guided me along the way. Thank you to everyone in the Yorkshire Quality and Safety Research group who have taught me so much and helped me to navigate through the dynamics of NHS research. I have loved being a part of this wonderful team. Thank you to Ali Cracknell, Robbie Foy, Robert West, Mohammed Mohammed, Victoria Pye, and everyone in the CLAHRC EBT theme. You have all been extremely generous with your time and wisdom. Throughout this PhD I have made some wonderful friends. Firstly to Liz … we’ve only blooming gone and done it! We’ve been through it all - the highs, the lows and a couple of tears, but mainly there have been lots of laughs. Thank you so much for everything - you have been a fantastic friend and this PhD would have been a very different experience without you. Thank you also to Abi, Raginie, Amy, Sarah, and Jack whose friendships have provided a source of motivation, procrastination, coffee, and chocolate exactly at the times when I’ve needed them the most! Thank you to all my amazing friends and family. To the girls near and far – despite not really knowing what it is about (!), your enthusiasm for my PhD has been incredible. Thank you for being there … predominantly with wine or gin! Alice – your phone calls, the London getaways, and of course your drama have kept me going more than you’ll ever know. Mum – your support has always been incredible. Whatever I’ve chosen to do you’ve always believed in me and encouraged me keep going. Thank you for listening to me prattle on, for the cups of tea / glasses of something stronger, and for all the left-over food parcels! My final thanks are saved for Carl. We made it! You have always been there to encourage and motivate me and on many occasion you have given me the strength to carry on. Thank you for sharing this experience with me, and for everything that you have done to get me here – it is truly appreciated! ii Abstract Every day around the globe, patients are harmed within healthcare organisations. Attempts to improve the quality and safety of healthcare traditionally focus on past errors and harm, yet there is little evidence of widespread improvement. In contrast, the positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance despite facing the same constraints as others. Bradley et al. (2009) have proposed a four stage process to apply positive deviance within healthcare organisations: 1) positive deviants are identified using routinely collected data; 2) hypotheses are generated about how they succeed; 3) these are tested within representative samples; and 4) the successful strategies are disseminated. Despite this, limited guidance exists to support applications. This thesis sought to test a robust and pragmatic method for applying the positive deviance approach within multidisciplinary healthcare teams. Study 1 systematically reviewed the methods used to apply positive deviance within healthcare. Previous applications identified positively deviant organisations or individuals and focused on narrow outcomes or processes of care. Applications lacked quality and used extensive resources. Study 2 analysed NHS Safety Thermometer data to identify five positively deviant and five matched comparison elderly medical wards. In the main, staff and patient perceptions of safety on these wards supported their identification. During study 3, multidisciplinary staff focus groups were conducted to explore how these wards delivered exceptionally safe care. In total, 14 behaviours and cultures were hypothesised to facilitate positive deviance at ward level. Study 4 assessed the feasibility of applying positive deviance within a general practice setting. Findings highlighted challenges of selecting data to identify positive deviants, recruiting general practices to participate, and generating hypotheses about success strategies that were unique to positive deviants yet common among them. In combination, these studies generated guidance to support rigorous applications of the positive deviance approach within healthcare organisations. The evidence suggested that, in the future, it may be possible to improve the quality and safety of care by focusing on those that demonstrate exceptional rather than poor outcomes of care. - iii - Table of Contents Chapter 1: Introduction: Overview of the literature, thesis aims and objectives 1.1 Chapter summary .......................................................................................... 1 1.2 The quality and safety of patient care ............................................................ 1 1.3 Improving the quality and safety of care......................................................... 2 1.4 Reframing patient safety................................................................................ 4 1.5 The positive deviance approach .................................................................... 5 1.6 How is the positive deviance approach applied?............................................ 6 1.6.1 Why might it be beneficial to apply the positive deviance approach within healthcare organisations?......................................... 8 1.6.2 What are the challenges to applying the positive deviance approach within healthcare organisations?....................................... 10 1.7 Theoretical, methodological, and epistemological perspective..................... 11 1.8 Thesis aims ................................................................................................. 13 1.9 Thesis overview........................................................................................... 14 Chapter 2: What methods are used to apply positive deviance within healthcare organisations? A systematic review. 2.1 Chapter summary ........................................................................................ 17 2.2 Introduction.................................................................................................. 17 2.2.1 Healthcare applications of positive deviance .................................... 18 2.2.2 Aims and research questions ........................................................... 19 2.3 Methods....................................................................................................... 20 2.3.1 Search strategy ................................................................................ 20 2.3.2 Eligibility criteria and study selection ................................................ 20 2.3.3 Study quality assessment................................................................. 21 2.3.4 Data extraction and synthesis..........................................................