Downloaded from http://qualitysafety.bmj.com/ on March 30, 2016 - Published by group.bmj.com SYSTEMATIC REVIEW What methods are used to apply positive deviance within healthcare organisations? A systematic review Ruth Baxter,1,2 Natalie Taylor,2,3 Ian Kellar,1,2 Rebecca Lawton1,2 ▸ Additional material is ABSTRACT involve staff and patients in all stages of the published online only. To view Background The positive deviance approach positive deviance approach. The efficacy and please visit the journal online (http://dx.doi.org/10.1136/bmjqs- focuses on those who demonstrate exceptional efficiency of positive deviance must be assessed 2015-004386). performance, despite facing the same constraints and compared with other quality improvement as others. ‘Positive deviants’ are identified and approaches. 1School of Psychology, University of Leeds, Leeds, Yorkshire, UK hypotheses about how they succeed are PROSPERO registration number 2Quality and Safety Research generated. These hypotheses are tested and then CRD42014009365. Group, Bradford Institute for disseminated within the wider community. The Health Research, Bradford, UK positive deviance approach is being increasingly 3Centre for Healthcare Resilience and Implementation Science, applied within healthcare organisations, BACKGROUND Australian Institute of Health although limited guidance exists and different Within healthcare, various approaches to Innovation, Faculty of Medicine methods, of varying quality, are used. This paper patient safety and quality improvement and Health Sciences, Macquarie systematically reviews healthcare applications of University, Sydney, New South exist. Traditionally these approaches are Wales, Australia the positive deviance approach to explore how deficit-based; they focus on identifying positive deviance is defined, the quality of and learning from past harm. Their Correspondence to existing applications and the methods used effectiveness is limited as only two-thirds Ruth Baxter, School of Psychology, University of Leeds, within them, including the extent to which staff of improvement projects achieve their Lifton Place, Leeds, Yorkshire and patients are involved. objectives and deliver sustainable LS2 9JZ, UK; Methods Peer-reviewed articles, published prior change.1 Improvements are often short- [email protected] to September 2014, reporting empirical research lived, fail to reach the most disadvan- Received 12 May 2015 on the use of the positive deviance approach taged and can create unintended conse- Revised 28 September 2015 within healthcare, were identified from seven quences.23Furthermore, various Accepted 4 October 2015 electronic databases. A previously defined four- challenges are faced while using these Published Online First stage process for positive deviance in healthcare 20 November 2015 approaches such as engaging front-line was used as the basis for data extraction. Quality staff, addressing their most pertinent assessments were conducted using a validated issues and adequately accounting for tool, and a narrative synthesis approach was context.23Change is often introduced followed. from the top of organisations and/or by Results 37 of 818 articles met the inclusion external experts, and additional resources criteria. The positive deviance approach was are rarely provided to support this.1 most frequently applied within North America, The need to ‘flip healthcare on its in secondary care, and to address healthcare- head’ has recently been suggested.4 Open Access associated infections. Research predominantly Scan to access more Despite our negativity, safe, high-quality free content identified positive deviants and generated care is reliably delivered the majority of hypotheses about how they succeeded. The the time.5 Asset-based approaches, which approach and processes followed were poorly focus on the strengths and resources of a defined. Research quality was low, articles lacked community, recognise this and explore detail and comparison groups were rarely how, and why, things go right in order to included. Applications of positive deviance learn from these successes. One such typically lacked staff and/or patient involvement, approach, ‘positive deviance’, is increas- and the methods used often required extensive ingly being applied within healthcare set- To cite: Baxter R, Taylor N, resources. tings and has the potential to address a Kellar I, et al. BMJ Qual Saf Conclusion Further research is required to number of the challenges faced when – 2016;25:190 201. develop high quality yet practical methods which trying to improve quality. 190 Baxter R, et al. BMJ Qual Saf 2016;25:190–201. doi:10.1136/bmjqs-2015-004386 Downloaded from http://qualitysafety.bmj.com/ on March 30, 2016 - Published by group.bmj.com Systematic review An alternative approach to quality improvement adherence rose by 25%, which, in turn, increased Positive deviance is a bottom–up approach which patient survival.7 identifies and learns from those who demonstrate Despite successes, current understanding of how the exceptional performance on an outcome of interest. positive deviance approach works, and evidence The approach assumes that problems can be overcome regarding its effectiveness is limited. Although Bradley using solutions that already exist within communi- et al’s healthcare-specific process exists, there is ties.67Despite facing the same constraints as others, limited guidance on how to operationalise each step.8 ‘positive deviants’ identify these solutions and succeed Positive deviants are identified using many different by demonstrating uncommon or different behaviours. methods, some of which appear to lack validity and/ Community involvement is integral to the approach, or reliability such as selecting annual award winners.10 for example, staff select the problem to address, iden- Furthermore, the extent to which each stage of the tify the positive deviants and explore how they process is implemented may be limited, hindering succeed. Solutions are internally generated rather than assessment of the approach’s efficacy.8 For example, externally imposed, ensuring that they are feasible Kim et al.11 explored how positively deviant nurses within current resources, acceptable to others and sus- and patients effectively communicated family planning tainable over time.8 issues, but did not explain how they would assess Specifically within healthcare, Bradley et al have whether these behaviours improved outcomes. proposed a four-stage process for adopting the posi- Further guidance is required to help identify and clas- tive deviance approach (figure 1).7 Positive deviants sify positive deviants, select the methods used at each with exceptionally high performance are identified stage, involve front-line staff and patients in the using widely endorsed routinely collected data process and effectively disseminate findings.8 (stage 1). Qualitative methods are used to generate hypotheses about how positive deviants succeed Objectives (stage 2). These hypotheses are tested within larger, A previous systematic review assessed the effectiveness more representative samples (stage 3) and, finally, the of positive deviance in reducing childhood malnutri- successful, positively deviant practises are dissemi- tion.12 Although the author described study methods, nated widely (stage 4). the research settings (rural villages and low/ middle-income countries) differed dramatically from Positive deviance in practise well-developed, complex healthcare organisations. The positive deviance approach originated within The current systematic review synthesises applications international public health. It has been used within of the positive deviance approach within healthcare settings such as business9 and more recently has been organisations to better characterise the challenges applied to healthcare.8 Bradley et al7 used the faced, and to provide guidance for those implement- approach to increase guideline adherence for the treat- ing the approach. The following questions will be ment of acute myocardial infarction. Positively deviant addressed: hospitals were identified using national registry data ▸ How is positive deviance defined? and factors that facilitated success were explored. ▸ What study designs and methods are used at each stage Those which statistically improved outcomes were dis- of the positive deviance process? seminated through a public campaign, and guideline ▸ What is the quality of existing research? ▸ To what extent are staff and patients involved in the approach? METHODS Search strategy This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA—see online sup- plementary file 1),13 and the protocol was published on PROSPERO.14 The search term, ‘positive devian*’, identified articles relating to positive deviance and positive deviants. Search terms for ‘high performance’ and ‘positive outliers’ were excluded as they lacked specificity and identified large numbers of irrelevant articles. Studies conducted within healthcare organisa- tions were selected for inclusion. The search strategy was applied to PsycINFO, MEDLINE, Web of Figure 1 The positive deviance process for healthcare Science, Cochrane Library, Embase, CINAHL and organisations (adapted from ref. 7). Global Health Database in January 2014 and updated Baxter R, et al. BMJ Qual Saf 2016;25:190–201. doi:10.1136/bmjqs-2015-004386 191 Downloaded from http://qualitysafety.bmj.com/ on March 30, 2016 - Published by group.bmj.com