the power of positive deviance: leveraging for behavioural and social change
TRANSCRIPT
The Power of Positive Deviance
Katie Procter
Quality Forum Pre-Day March 1 2017
The Power of Positive Deviance
Katie Procter
Quality Forum Pre-Day March 1 2017
Narrative Flow 1. What is Positive Deviance? 2. Where did it start? 3. Where is it particularly successful? 4. Applying PD in Health Care 5. Some tools that can be used in the PD
approach
Small things people DO That most others do NOT do
That make a BIG difference
A
FOUNDATIONAL
POSITIVE
DEVIANCE
STORY
Positive Deviance Premise
• Solutions to problems exist • Stare us in the face • We do not see them • Incapable of seeing them • Expertise gets in the way • Don’t know where to look • Territory is completely uncharted
Traditional PD
• Problem definition and data gathering
• Focus Groups
• Finding the Positive Deviants – better solutions – same resources – survival of the fittest accessible to all - measurement
• Owners sharing the behaviors “People just like me”
• Community spread
• Sustainment over time
Characteristics of the PD Process
• Promotes behavior and social change because it is:
– Embedded in culture
– Generative – it builds on itself
– Based on strengths and assets
– Not expert driven – the people are the experts
It’s easier to ACT your way into a
new way of THINKING than to THINK your way
into a new way of ACTING!!
• Focus on practice rather than knowledge
When to use Positive Deviance
• The problem is not exclusively technical and requires behavioral or/and social change
• The problem is “intractable” – other solutions haven’t worked
• Positive Deviants exist – solutions are possible without any extra resources
• There is leadership commitment to address the issue – “PD champions” exist
When you want different outcomes •FROM
•Problems
•Best practices
•Buy-in
•Education
•Shame and Blame
•Knowledge
•Big initiatives
•Telling
•Periscoped purpose
•Prescription
•Top down
•Standard outcomes
•TO
•Solutions
•Local emergence
•Ownership
•Learning
•Celebrating local success
•Behavior
•Small changes
•Asking
•Shared purpose
•Discovery
•Unusual suspects
•Joyful, shared meaning & extraordinary results
When you want different conversations •Nothing will make a difference!
•We’re doing everything we can do!
•We don’t have time!
•We don’t have the resources!
•You’ll never get them to change!
•Just tell us what to do!
•Don’t tell me what to do!
•We will always have this problem!
•ETC ETC ETC
•We can make a difference!
•We can do more!
•We actually do have time!
•We don’t need anymore resources!
•We CAN change!
•We CAN do!
•We can fix this problem!
Inviting Everyone: Healing Healthcare through Positive Deviance
Tools or activities
• Map or create visual score boards
• Set your goal -What are you going to do, where/who with, by how much, by when
• How will you generate discussions ?
• Create new networks through activities
• Share stories broadly
• Measurement
Liberating Structures to use
• Discovery and Action Dialogues
• Improvisation
• Theory of Inventive Problem-Solving (TIPS) or TRIZ in Russian
Liberatingstructures.com Keith McCandless Henri Lipmanowicz
DISCOVERY & ACTION DIALOGUES
DISCOVER AND UNLEASH LOCAL SOLUTIONS TO CHRONIC PROBLEMS
A Discovery and Action Dialogue is a conversation.
• You can use this anywhere • Discover what people are already doing that works
• These guys face the same restrictions as everyone else but find their own solutions
Hidden and untapped solutions
• They gain support as colleagues see the solutions working and then adapt the new thinking/behaving Through social proof, momentum spreads
1. What do you know about (the problem) / how do you know when it’s present?
2. What do YOU personally do about it?
3. What are the BARRIERS that prevent you from doing (the right thing/process) 100% of the time?
4. Is there a person/unit/group that are successful in overcoming these barriers? How do they do it?
5. Do you have any ideas?
6. What steps would start to bring these ideas to life? Any volunteers?
7. WHO ELSE needs to be part of this conversation? (“Don’t decide about me without me.”) How do we invite them to join the action?
The “DAD”: 7 Questions
Q1:
We are here to talk about
the spiritual needs of our
patients/residents/clients.
How do you know when the
spiritual needs of
patients/residents/clients are
being neglected? (the problem is
present)
• Affirm that we all have
existing knowledge of the
problem
• Provide opportunities to get
questions on the table
The Details …
Q2:
How do YOU attend to your
own spiritual needs and the
spiritual needs of
patients/residents/clients?
(solving the problem)
• Focus on personal practices,
NOT on what other people
don’t do
• Amplify / confirm the
participant’s knowledge of
effective practices
The Details …
Q3:
What prevents you from
doing this or taking these
actions all the time?
• Identify real barriers and
constraints
• Ask: What prevents you?
vs
Why don’t you?
The Details …
Q4:
Is there a person or a
unit/group you know who is
particularly successful at
attending to spiritual needs?
How do they do it?
(solve the problem,
overcome barriers)
• Establish that getting around
barriers is possible
• Identify the existing-but-
uncommon successful
strategies
The Details …
Q5:
Do you have any ideas?
• Identify the supports that make
the desired behaviour more
likely
• Provide an opportunity for
participants to generate and
share new ideas for enabling
the desired behavior
The Details …
Q6:
What steps would start to
bring these ideas to life? Any
volunteers?
• Identify action steps, target
dates & feedback loops for
metrics
• Invite volunteers for each
action step (capture ideas that
don’t yet have an identified
action plan or volunteer)
The Details …
Q7:
Who else needs to be
involved?
• Who else can we bring in?
• Widen the circle of people
involved in discovering
solutions, drawing in unusual
suspects
The Details …
• DADs take place in a local setting or work place
• Groups can be standing or sitting around a table/desk/work area
• Everyone who is around is invited to join and be included – diversity in roles and experience is a huge asset – with equal opportunity to contribute – brief introductions
• Group size can be 5 – 15 people
• Facilitator works with a partner who is a recorder – notebook/paper to record insights, ideas to action/volunteers, who else needs to be there
Getting Started with a DAD
• Start with the purpose “We are here to _______________!”
• “Give” the questions to the group, then wait at least 20 seconds for a response Sing Happy Birthday to yourself
• Encourage quiet people to talk
Facilitator Tips
• Work through all or some of the questions without worrying about the order
AND/OR
• Follow the conversation with other questions
• When questions arise - Ask the group members to provide an answer (they are the wise ones who will have the answers)
• “If I understand you correctly, no one has ever done this successfully or well.”
• “What would you do if there was an opportunity for change?”
• “Can you please re-frame what you just said with a question beginning with ‘what’ or ‘how’? Include some kind of action. Eg. What could I do to ensure that I always wash my hands?
How do you handle cynical responses?
Practice – 20 minutes
• Pick a topic that you would like to explore with your project team or your staff or use the example already given
• You will need a leader at your table and some people to role play
• There are DAD sheets at your tables
Min Specs
Don’t attempt to define the outcome or behavior of the system in detail
Few rules
TRIZ теория решения изобретательских задач, teoriya resheniya
izobretatelskikh zadatch)
or
The Theory of Inventive Problem-Solving
DESIGNING A PERFECTLY ADVERSE SYSTEM – A VERY UNWANTED RESULT OF YOUR WORK
DESIGNING A VERY UNWANTED RESULT OF YOUR WORK
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Through creativity and idea generation, what can we discover together about our practices that contribute to
the problem, and what must we stop doing to make progress around our purpose. 40
2 key areas where we use TRIZ (there is nothing to say that you can’t use this at home)
• For reducing harm to patients experiencing a safety lapse (wrong side surgery, patient falls, medication errors, health care acquired infections) with cross-functional groups. “How can we reliably make sure that every patient receives medication error? A poor transition outcome in community?
• For helping institutional leaders notice how it is they inadvertently exclude diverse voices. “How can we devise policies that only work for a select few?” “How can we build an IT system that no one will use?”
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Example: TRIZ – First Step
• First reflect alone, then in your small group, make a list of “to do’s” in answer to:
• How can we ensure 100% of the time that we get
an unwanted result? An ideal, reliable adverse system?
• E.g. How can we ensure that every community member sent to hospital has a poor transition
coming home?
• GO WILD!! Be CRAZY!! Be NASTY!! 42
TRIZ – Second Step – Most Important part!
First reflect alone, then in your group. Go down the list and ask:
Is there anything on this list that we currently practice, even remotely? Is there an element of truth in here? Jot
down the notes of truth. You will need these notes for your work list!
• Cross out the ones that you aren’t doing EVER
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TRIZ – Third Step
• How can you begin to tackle this list? Would it be useful to do some dot voting and tackle your top 3 priorities. Are there some quick wins that you can get rid of quickly so you can give the team confidence and that social proof.
• Identify who else is needed to stop the activity
• Do you need leadership or organizational help? Have you uncovered an organizational can of worms?
• What needs to stop or change. Be as concrete as you can
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TRIZ – why use it?
• You can speak the unspeakable – get elephants into the room
• Make room for innovation and change
• You stop doing nasty things – creative destruction – doing hard work in fun way
• Substitute for visioning sessions
• Builds trust
• Builds momentum and commitment
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TRIZ Success • Begin with spirit of serious fun
• Don’t accept ideas to start something new– be sure suggestions are about stopping
activities and behaviors
• You can do it in minutes, or hours in a big project
• Begin with a very unwanted result
• Take time to check out and be honest with what you are currently practicing that contributes to the harm
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• Include the people that will be involved in stopping the activities that will be brought forward
• Make real committed decisions about what will be stopped
• Set a time-line – Now, tomorrow, in a month
• You can re-TRIZ each statement to really go deeper into each issue
IMPROV
