positive deviance in intermediate care services
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
To celebrate the Network’s 25 year anniversary, we are developing a series of Thought Leadership, recognising and sharing exceptional performance, providing insight for improvement, and evidencing impact.
We are dealing with a pandemic which will leave its mark for decades to come, significantly impacting the demand for services and the health and wellbeing of the population. This report is the first of a series which will embody the Network’s mission: to raise standards through sharing excellence.
Introducing positive deviancePositive deviance methodology challenges the status quo of focusing on poor performance in healthcare, by recognising exceptional (‘positively deviant’) performance, despite services facing the same constraints as others. Developed by Bradley et al. in 2009, research in action determined how the process of focusing on successful practice could improve quality of healthcare, and provided an opportunity to characterise and disseminate strategies for service review.
An anachronismDespite being a piece in time, prior to the Coronavirus pandemic and the subsequent magnitude of changes that occurred, the positive deviance methodology remains incredibly relevant, if not more so, with the importance of focusing on the positive. The methodology has not been tested by the Network since the initial analysis of 2016 and 2018 National Audit of Intermediate Care (NAIC) datasets but is encouraged to continue to improve services in line with national targets.
Supporting Intermediate Care services to attain national targetsThe NAIC outputs presented a unique opportunity to apply the positive deviance methodology, to determine characteristics of high performing home and bed-based intermediate care services, in the aim that they can be adopted by others. The comprehensive nature of the dataset, with high levels of participation across England, Wales, and Northern Ireland, contributed to the NAIC being a suitable vehicle to test the positive deviance methodology.
The NHS Benchmarking Network (Network) delivered the NAIC from 2012 to 2018. The audit was funded by either a subscription model or by NHS England, the Welsh Government, and the Northern Ireland Public Health Agency and Health & Social Care Board. Its scope was far-reaching, collecting standardised clinical outcome measures, a full organisational dataset, and a Patient Reported Experience Measure (PREM). The lack of research in community-based care and gaps in evidence-based practice contributed to an allocation of funds to explore ‘What good looks like’ using the positive deviance methodology on home and bed-based intermediate care.
The main aims of intermediate care are to prevent unnecessary hospital admissions, aid and encourage people to be as independent as possible following a hospital admission, and prevent people having to move into a residential home unless necessary. The positive deviance approach would offer a new analysis of the NAIC findings, following a four-step process:
Positive deviance in intermediate care services
1. Identify positive deviants2. Study positive deviants in depth applying
qualitative methods to generate hypotheses about practices in high performing teams
3. Test hypotheses statistically in larger, representative samples of organisations
4. Disseminate the evidence about newly characterised best practice
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
With the greater focus on intermediate care services in the NHS Long Term Plan (the Urgent Community Response Services) and Five Year Forward View, this analysis would support community services, hospitals, GPs and social care to deliver on the aims set out by national guidance and targets and help deliver optimal patient outcomes.
Service category definitionsHome based intermediate care services are community-based services provided to service users in their own home/care home. Home based intermediate care services offer intermediate care assessment and interventions supporting admission avoidance, faster recovery from illness, timely discharge from hospital and maximising independent living.
Bed based intermediate care services are provided within an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, Local Authority facility or other bed-based setting. Their primary function is prevention of unnecessary acute hospital admissions and premature admissions to long term care and/or to receive patients from acute hospital settings for rehabilitation and to support timely discharge from hospital.
Collaborative effortsIn March 2016, a workshop between the Universities of Leeds and York and the Network culminated in the hypothesis that positive deviants could be identified from intermediate care services which demonstrated positively deviant performance in terms of both clinical outcome for the patient (as measured by a positive change in dependency levels), and in patient experience (as measured by the patient themselves, through the PREM).
Methodology into practice: Home-based servicesIt was agreed that the initial focus for trialling the positive deviance methodology within intermediate care services would be those services delivered in the community by home-based intermediate care services, given the relative lack of research available in community settings.
For step 1 of the methodology, identifying positive deviants, the Network investigated intermediate care services which appeared to affect the greatest improvement in patient dependency as measured by the change in the Sunderland Community Re-ablement Scheme score (scored out of 35) and received positive service user experience of intermediate care services as measured by the PREM summary score.
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Figure 1: % change in Sunderland Score (home-based)
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
The University of Leeds, a critical friend in the application of the process, supported the Network’s analysis with a recommendation of utilising funnel plots, further statistical analysis, and suggesting that the control site should be a slightly higher than average performing service to explore how positive deviants achieve exceptional performance, rather than ‘good’ or ‘high’ performance.
For home-based services, three ‘positively deviant’ sites and one control site were selected, and a workshop was arranged to meet the teams at each location, with none knowing their categorisation of either ‘positively deviant’ or control site. Figure 1 shows the funnel charts, distinguishing the three positively deviant sites (A-C) and control site (D).
Key themes – Home-based servicesFive main themes emerged from the workshops held at the sites. 1. The value of team working shone through as essential to positively deviant services. A
multidisciplinary team was perceived to make a huge difference to service users in respect of being able to offer a variety of therapeutic interventions.
2. Although all teams operated under different organisational forms, with both health and local government as employing organisations, all sites agreed that feeling valued and ‘listened to’ was a contributing factor to their exceptional performance.
3. Furthermore, in an uncertain environment where health and social care services were in a state of flux, staff at positive deviant sites felt they performed better when their relationship with their commissioners was positive, and they felt protected from potential internal cost improvement programmes.
4. Moreover, workforce indicators, such as low staff turnover and high retention rates contributed to a cohesive team working towards the same patient-oriented goals and consequently a higher performing service. This involved the development of competency-based programmes to ensure staff were trained to deliver the full range of intermediate care interventions effectively.
5. Lastly, clear structures, both with regard to workforce and patient care such as individualised packages of care and referral routes, were identified as good practice in the positively deviant sites.
Analysis of bed-based servicesThe scoring system for bed-based services was the Modified Barthel Index (MBI), which assesses the function of patients with disabling conditions in relation to activities of daily living (scored out of 100). The Network team repeated the process outlined above, visiting four positively deviant bed-based sites (A-D) and two control sites (E-F) as demonstrated in Figure 2.
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Figure 2: % change in Modified Barthel Index (bed-based)
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
Key themes – Bed-based servicesThe key themes listed for home-based services were evidenced in the feedback provided by bed-based positively deviant sites; however, a further eight themes were also recognised from the site visits. 1. Several of the sites explained that exploiting alternative funding streams, such as easy access
to charitable funds or local schemes, contributed to their high performance. 2. As expected, good communication was identified as a key theme for bed-based services,
especially with links to other providers in the ‘ecosystem’. Communication was further improved by access to shared patient records.
3. Positively deviant sites also reported straightforward commissioning arrangements, contributing to their strong relationships and mutual respect.
4. Linking with the theme of feeling valued listed above, bed-based services identified that opportunities to feedback to management and proactive action were present in positively deviant sites.
5. Workforce indicators were recognised in bed-based positively deviant sites, with retention of staff attributed to exercises such as upskilling of staff, internal staff-development, and rotation.
6. Whilst all six sites reported that care planning and goal setting was in place and routinely used, the positively deviant sites all commented on the importance of involving family in care planning and goal setting from the beginning of service provision.
7. Access to internal training and awareness programmes for caring for people with cognitive impairment was acknowledged during site visits, with all sites reporting that patient caseload was becoming more complex. Specialist support had a positive impact on both the team and patient care.
8. Routine home visits prior to or shortly after discharge were also recognised as a key theme across the positively deviant sites.
Coordinating further analysisThe Network completed multivariable regression analysis to explore the qualitative data in more detail, pinpointing the metrics which produced the best outcomes for patients.
The two metrics showing significant positive association for home-based services were a review of the care plan by the multidisciplinary team, and the number of disciplines who saw the patient.
As shown in Figure 3, services that had a care plan in place and reviewed this care plan for a higher proportion of service users typically produced better outcomes. When modelled together, 15% of the variability in outcome measure can be explained by the review of the care plan variable.
Figure 4 represents the model where the average number of different staff disciplines that a service user comes into contact with during their episode of intermediate care per service is tested against the outcome measure variable. When tested,
Figure 3: Care plan in place
Figure 4: Average number of different staff disciplines
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
1 - PREM Summary score – a composite measure of the various questions asked in the Patient Reported Experience Measure (PREM)
services where service users who came into contact with a greater number of staff disciplines typically had better outcomes. When modelled together, 15% of the variability in outcome measure can be explained by the staff disciplines variable.
Multivariable regression analysis was used to investigate whether multiple variables could be modelled together to explain the variation in outcomes. Figure 5 demonstrates, when the different variables were combined, a positive significant relationship was identified between number of disciplines, review of the care plan, and outcomes. When combined, the two independent variables explain 23% of the variation in change in outcome measure.
For bed-based services, there were four metrics which demonstrated a significant positive relationship with outcomes; including number of disciplines who saw the patient, PREM summary score¹, screening service users for cognitive impairment, and review of the care plan by the multidisciplinary team.
Although these four measures show a significant relationship with outcome measures, less variability in outcomes is explained in comparison with the measures identified for home-based services. This is possibly due to the smaller scale used for the home based standardised clinical outcome measure (Sunderland Score measured out of 35 compared with the MBI measured out of 100).
Using multivariable analysis, combining the PREM summary score metric and the number of disciplines who saw the patient demonstrated a significant relationship with outcomes. This model represents 9.5% of the variation in outcome measure and is illustrated in figure 6.
Figure 5: Multivariable regression analysis 1
Figure 6: Multivariable regression analysis 2
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CHARACTERISING HIGH PERFORMANCE
Understanding how exceptional performance can transform Intermediate Care
What next?Step four of the positive deviance methodology involves disseminating the evidence to support the implementation of standardised good practice. The Network presented the findings at a series of workshops around the country in May 2019, where there was considerable interest in the methodology with delegates commenting on the value of building on success rather than on negative aspects of performance. Although several organisations volunteered as early adopters of the study findings, the positive deviance methodology did not progress due to funding constraints.
It is recognised that the success of the methodology is in the repetition of the process, and the effectiveness of scaling up or adopting new practices. Despite the recent impacts of the pandemic on all health and social care services, the findings from the intermediate care positive deviance analysis remains of significance and is fundamental to the success of home and bed-based services.
The NAIC is no longer a funded project delivered by the Network; however, a new benchmarking project for providers of intermediate
care services was introduced in the 2020/21 work programme. The project is in its second iteration with good participation levels. Data collection closes for the Intermediate Care project on 20th August 2021, covering five intermediate care services; Crisis response, Re-ablement, Home-based intermediate care, Bed-based intermediate care, and Integrated multidisciplinary teams (new for 2021). Please direct any project queries to our Contact page.
Take away questions for you to consider:• Does your organisation have any focus on internal reporting systems which focus on the positive? • How could the positive deviance approach be supported and disseminated through healthcare
organisations?• How can we encourage and enable individuals, teams, and organisations to be transparent and
to share best practice to achieve the common goal of safe/ quality patient care?• Do you have a system for recognising (and rewarding) positive individuals/ teams within your
organisation?• How can more time and effort be given to when things go right (very often)?• What role do healthcare regulators have in this arena of positive practice? Could more be done?
© NHS Benchmarking Network (NHSBN)
Citation for this document: NHS Benchmarking NetworkCharacterising High Performance. August 2021