VIEWPOINT BMJ Qual Saf: first published as 10.1136/bmjqs-2014-003115 on 21 July 2014. Downloaded from Positive deviance: a different approach to achieving patient safety Rebecca Lawton,1,2 Natalie Taylor,2,3 Robyn Clay-Williams,3 Jeffrey Braithwaite3 1Bradford Institute for Health Patient safety management within tend to be more readily accepted and Research, Bradford Royal healthcare systems globally can feel like a feasible within existing resources, thus Infirmary, Bradford, UK 2Institute of Psychological relentlessly negative treadmill. Mortality increasing the likelihood of success and, 8 Sciences, University of Leeds, reviews, incident reporting systems and potentially, of adoption elsewhere. The Leeds, UK audits all focus attention on what goes specific steps in the positive deviance 3 Faculty of Medicine, Centre for wrong and how often, why errors occur, approach, modified for our purposes to Clinical Governance Research, University of New South Wales, and who or what is at the root of the represent the organisation, team and indi- 7 Sydney, Australia problem. Sometimes these methods help us vidual, are outlined in figure 1. to understand why patients are harmed. Along with other more optimistic Correspondence to ‘ ’ Dr Natalie Taylor, Faculty of However, such find and fix approaches tell approaches to patient safety, such as iden- Medicine, Centre for Clinical us little about the presence of patient safety, tifying and empowering resilient indivi- Governance Research, University alerting us instead to its absence.These duals or teams,3 and developing methods of New South Wales, Sydney, efforts aim to prevent harm by striving to for capturing safety improvement work,9 NSW 2051, Australia; [email protected] reduce the number of things that go positive deviance is starting to be tested wrong,1 as opposed to identifying instances in healthcare settings, albeit intermit- Received 11 April 2014 when—often despite challenging circum- tently. For example, Gabbay et al10 iden- Revised 20 May 2014 stances and limited resources—things go tified five primary care practices Accepted 4 July 2014 Published Online First right. The focus on error detection and its demonstrating positive deviance for 21 July 2014 management has not produced the improvement in managing diabetic expected gains in patient safety,2 primarily patient care. Compared to teams whose because these methods are not well suited practices improved least, the positively to a complex adaptive system such as deviant groups had leaders who encour- http://qualitysafety.bmj.com/ healthcare.3 Behaviours that produce errors aged ownership and planned the imple- are variations on the same processes that mentation of change. There was a sense produce success, so focusing on successful of collective decision making and devel- practices may be a more effective tactic.4 opment of the team. Data were collected as a progress-monitoring tool and shared FOCUSING ON THE UPSIDE across the practice. One approach to focusing on success is The approach has also been used to positive deviance. While positive devi- promote hand hygiene.6 In Marra et al’s ance can be used to describe the behav- study, positively deviant individuals— on October 2, 2021 by guest. Protected copyright. iour of an exemplary individual, the term those who were particularly good at prac- Open Access Scan to access more can also be extended to describe the tising hand hygiene and who wanted to free content behaviours of successful teams and orga- improve further—stimulated others to nisations. Originating in international use antibacterial gel. Positive deviants public health projects,5 positive deviance recruited others to join the enterprise. It has recently been embraced to improve became a source of pride to be labelled as quality and safety of healthcare delivered such, elevating the importance of hand in organisations.67The premise is that hygiene, and the prestige of those solutions to common problems mostly working to improve it. Although a exist within clinical communities rather limited study, this work illuminated the than externally with policy makers or potential of such an approach to bring managers, and that identifiable members about improved safety outcomes. of a community have tacit knowledge In another recent study, Bradley et al7 To cite: Lawton R, Taylor N, and wisdom that can be generalised. demonstrated the spread of positively Clay-Williams R, et al. BMJ Moreover, because the solutions have deviant behaviour based on identifying Qual Saf 2014;23:880–883. been generated within a community, they and working with hospitals meeting the 880 Lawton R, et al. BMJ Qual Saf 2014;23:880–883. doi:10.1136/bmjqs-2014-003115 Viewpoint BMJ Qual Saf: first published as 10.1136/bmjqs-2014-003115 on 21 July 2014. Downloaded from to identify role models within its midst who use uncommon, but demonstrably successful, strategies to tackle common problems.8 Currently, there does not appear to be a well-defined strategy for achieving this. In the modern patient safety paradigm, unlike the instantaneous, negative and often publicised response to an adverse event,11 the consistent delivery of well- executed safe care under typically difficult circum- stances tends to go unrecognised; if, by chance, positively deviant individuals or teams are identified, they tend be labelled so retrospectively, after a success- ful enterprise has been proclaimed. Detecting posi- tively deviant safe patient care is particularly challenging because of the lack of reliable measures of safe care,12 and comparable patient safety perform- ance measures between individual healthcare profes- sionals,13 wards14 and organisations.13 15 It is also unclear how to define sustained safe patient care (eg, is it the extent to which effective processes for ensur- ing patient care are embedded within an organisa- tional system, or the length of time since a patient safety incident has occurred on a particular ward?).16 Another explanation is that humans tend to look for ‘problems to fix’17 rather than to ‘recognise and spread success’, and this predisposition is exacerbated Figure 1 Steps in the positive deviance approach. Modified by the presence of regulatory climates globally (eg, the from Bradley et al.7 UK’s Care Quality Commission; Australia’s Safety Alert Broadcasting Systems), which focus on mortality, 90 min door-to-balloon guideline for the treatment of reporting and analysing adverse events, and generally acute myocardial infarction. More specifically, by reducing harm. Most healthcare quality improvement using a positive deviance approach (ie, identification resources are allocated to interventions based on nega- of positive deviants, understanding how top perform- tive deviance approaches that have little chance of ance is achieved, statistically testing the hypothesis for diminishing risks or harms,118yet healthcare organi- http://qualitysafety.bmj.com/ achieving top performance, and working with key sta- sations continue to use such methods in their attempts keholders and adopters to disseminate evidence about to avoid patient safety incidents. Despite the accumu- best practice), there was an increase from 50% to lating evidence demonstrating its potential, engage- 75% in the number of hospitals meeting the 90 min ment via a positive deviance approach is lacking, or guidelines, and those hospitals which adopted best intermittent at best. practice (approximately 1000/1400) were significantly The spread of positively deviant behaviours to some more likely to meet the target time than those that degree relies on individuals, teams, or organisations to did not. In other words, the positive deviance share their own successful practice with others, and be approach allowed organisations to learn from others willing to consider adopting effective ideas from else- on October 2, 2021 by guest. Protected copyright. with the potential to save lives. where. It is also important to appreciate ways to address those factors that can inhibit sharing across PROBLEMS WITH THE ADOPTION OF THE boundaries, such as power differentials between POSITIVE DEVIANCE APPROACH groups (eg, doctors, nurses and allied health profes- Despite these encouraging findings, mobilising or sionals) and across organisations.19 For some, there is learning from positively deviant teams and organisa- a temptation to shield knowledge in pursuit of self- tions has not gained widespread acceptance by those interest due to, for example, provider organisations planning quality improvement interventions or man- who feel they are in competition for local resources, aging poor performance. Patient safety initiatives still or staff who feel insecure about their job due to effi- tend to focus mainly on the negative cases, and ciency drives.20 finding the problems, root causes, or the culprits responsible for adverse events (negative deviance), THE CHALLENGE rather than attempting to identify unusually effective In order to identify positively deviant individuals, practice. Why might this be? wards and organisations effectively, and diffuse their One possibility is that the success of positive devi- behavioural characteristics, a model is needed. This ance approaches relies on the ability of a community might include: guidance on how to identify positive Lawton R, et al. BMJ Qual Saf 2014;23:880–883. doi:10.1136/bmjqs-2014-003115 881 Viewpoint BMJ Qual Saf: first published as 10.1136/bmjqs-2014-003115 on 21 July 2014. Downloaded from deviants based on evidence gathered from