Positive deviance: a differentapproach to achieving patient safety

Rebecca Lawton,1,2 Natalie Taylor,2,3 Robyn Clay-Williams,3

Jeffrey Braithwaite3

1Bradford Institute for HealthResearch, Bradford RoyalInfirmary, Bradford, UK2Institute of PsychologicalSciences, University of Leeds,Leeds, UK3Faculty of Medicine, Centre forClinical Governance Research,University of New South Wales,Sydney, Australia

Correspondence toDr Natalie Taylor, Faculty ofMedicine, Centre for ClinicalGovernance Research, Universityof New South Wales, Sydney,NSW 2051, Australia;natalie.taylor@unsw.edu.au

Received 11 April 2014Revised 20 May 2014Accepted 4 July 2014Published Online First21 July 2014

To cite: Lawton R, Taylor N,Clay-Williams R, et al. BMJQual Saf 2014;23:880–883.

Patient safety management withinhealthcare systems globally can feel like arelentlessly negative treadmill. Mortalityreviews, incident reporting systems andaudits all focus attention on what goeswrong and how often, why errors occur,and who or what is at the root of theproblem. Sometimes these methods help usto understand why patients are harmed.However, such ‘find and fix’ approaches tellus little about the presence of patient safety,alerting us instead to its absence. Theseefforts aim to prevent harm by striving toreduce the number of things that gowrong,1 as opposed to identifying instanceswhen—often despite challenging circum-stances and limited resources—things goright. The focus on error detection and itsmanagement has not produced theexpected gains in patient safety,2 primarilybecause these methods are not well suitedto a complex adaptive system such ashealthcare.3 Behaviours that produce errorsare variations on the same processes thatproduce success, so focusing on successfulpractices may be a more effective tactic.4

FOCUSING ON THE UPSIDEOne approach to focusing on success ispositive deviance. While positive devi-ance can be used to describe the behav-iour of an exemplary individual, the termcan also be extended to describe thebehaviours of successful teams and orga-nisations. Originating in internationalpublic health projects,5 positive deviancehas recently been embraced to improvequality and safety of healthcare deliveredin organisations.6 7 The premise is thatsolutions to common problems mostlyexist within clinical communities ratherthan externally with policy makers ormanagers, and that identifiable membersof a community have tacit knowledgeand wisdom that can be generalised.Moreover, because the solutions havebeen generated within a community, they

tend to be more readily accepted andfeasible within existing resources, thusincreasing the likelihood of success and,potentially, of adoption elsewhere.8 Thespecific steps in the positive devianceapproach, modified for our purposes torepresent the organisation, team and indi-vidual, are outlined in figure 1.7

Along with other more optimisticapproaches to patient safety, such as iden-tifying and empowering resilient indivi-duals or teams,3 and developing methodsfor capturing safety improvement work,9

positive deviance is starting to be testedin healthcare settings, albeit intermit-tently. For example, Gabbay et al10 iden-tified five primary care practicesdemonstrating positive deviance forimprovement in managing diabeticpatient care. Compared to teams whosepractices improved least, the positivelydeviant groups had leaders who encour-aged ownership and planned the imple-mentation of change. There was a senseof collective decision making and devel-opment of the team. Data were collectedas a progress-monitoring tool and sharedacross the practice.The approach has also been used to

promote hand hygiene.6 In Marra et al’sstudy, positively deviant individuals—those who were particularly good at prac-tising hand hygiene and who wanted toimprove further—stimulated others touse antibacterial gel. Positive deviantsrecruited others to join the enterprise. Itbecame a source of pride to be labelled assuch, elevating the importance of handhygiene, and the prestige of thoseworking to improve it. Although alimited study, this work illuminated thepotential of such an approach to bringabout improved safety outcomes.In another recent study, Bradley et al7

demonstrated the spread of positivelydeviant behaviour based on identifyingand working with hospitals meeting the

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90 min door-to-balloon guideline for the treatment ofacute myocardial infarction. More specifically, byusing a positive deviance approach (ie, identificationof positive deviants, understanding how top perform-ance is achieved, statistically testing the hypothesis forachieving top performance, and working with key sta-keholders and adopters to disseminate evidence aboutbest practice), there was an increase from 50% to75% in the number of hospitals meeting the 90 minguidelines, and those hospitals which adopted bestpractice (approximately 1000/1400) were significantlymore likely to meet the target time than those thatdid not. In other words, the positive devianceapproach allowed organisations to learn from otherswith the potential to save lives.

PROBLEMS WITH THE ADOPTION OF THEPOSITIVE DEVIANCE APPROACHDespite these encouraging findings, mobilising orlearning from positively deviant teams and organisa-tions has not gained widespread acceptance by thoseplanning quality improvement interventions or man-aging poor performance. Patient safety initiatives stilltend to focus mainly on the negative cases, andfinding the problems, root causes, or the culpritsresponsible for adverse events (negative deviance),rather than attempting to identify unusually effectivepractice. Why might this be?One possibility is that the success of positive devi-

ance approaches relies on the ability of a community

to identify role models within its midst who useuncommon, but demonstrably successful, strategies totackle common problems.8 Currently, there does notappear to be a well-defined strategy for achieving this.In the modern patient safety paradigm, unlike theinstantaneous, negative and often publicised responseto 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 particularlychallenging because of the lack of reliable measures ofsafe care,12 and comparable patient safety perform-ance measures between individual healthcare profes-sionals,13 wards14 and organisations.13 15 It is alsounclear 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 patientsafety 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 andspread success’, and this predisposition is exacerbatedby the presence of regulatory climates globally (eg, theUK’s Care Quality Commission; Australia’s SafetyAlert Broadcasting Systems), which focus on mortality,reporting and analysing adverse events, and generallyreducing harm. Most healthcare quality improvementresources are allocated to interventions based on nega-tive deviance approaches that have little chance ofdiminishing risks or harms,1 18 yet healthcare organi-sations continue to use such methods in their attemptsto avoid patient safety incidents. Despite the accumu-lating evidence demonstrating its potential, engage-ment via a positive deviance approach is lacking, orintermittent at best.The spread of positively deviant behaviours to some

degree relies on individuals, teams, or organisations toshare their own successful practice with others, and bewilling to consider adopting effective ideas from else-where. It is also important to appreciate ways toaddress those factors that can inhibit sharing acrossboundaries, such as power differentials betweengroups (eg, doctors, nurses and allied health profes-sionals) and across organisations.19 For some, there isa temptation to shield knowledge in pursuit of self-interest due to, for example, provider organisationswho feel they are in competition for local resources,or staff who feel insecure about their job due to effi-ciency drives.20

THE CHALLENGEIn order to identify positively deviant individuals,wards and organisations effectively, and diffuse theirbehavioural characteristics, a model is needed. Thismight include: guidance on how to identify positive

Figure 1 Steps in the positive deviance approach. Modifiedfrom Bradley et al.7

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deviants based on evidence gathered from the existingmeasurement and positive deviance literature, inclu-sion criteria for defining deviant practice, and sug-gested methods for statistically testing the ‘deviance’hypothesis. Such progress will facilitate more accuratecompletion of the first three steps in a positive devi-ance framework (see figure 1).To support the adoption and spread of the positive

deviance approach (step 4), existing and new methodsfor encouraging and enabling individuals, teams andorganisations to be transparent and to share best prac-tice to achieve the common goal of safe patient caremight be developed. Given the potency regulatorybodies have in coercing healthcare organisations toprovide information from patient safety incidentreporting, analysis and actions, perhaps they have aduty to make use of this information in a way thatencourages sharing of knowledge across boundaries tospread examples of success. Less regulation and moresupport of positive behaviours are key, but thisrequires a change in the prevailing mindset. It mayalso be worth considering how we can learn throughexamples from the negative deviance approach forengaging healthcare professionals (table 1).For example, the negative deviance approach, during

the aftermath of an adverse event, typically mobilisesinstantaneous attention, managerial resources, and asense of urgency. The combination of these factors islikely to generate engagement from healthcare profes-sionals to find and fix the problem. For positive devi-ance, a cohesive and well-performing team is unlikely

to create managerial attention, as the positive practicesmay have simply evolved over time. Harnessing strat-egies from the negative deviance approach applied topositive deviance might involve: allocating resourcesusually focussed on reporting and reducing error tospreading positive behaviours, recognising positivelydeviant teams, and creating a sense of urgency aboutspreading positive exemplars of practice.

CONCLUSIONThe myopic focus on errors, harm and near misseshas been sending negative messages for a long time.Politicians, bureaucrats, managers, the media andthose leading enquiries as far back as Bristol RoyalInfirmary and earlier, and more recentlyMid-Staffordshire in the UK, have essentially indicatedto clinicians: you are prone to making mistakes, andwe must insist that you reduce the harm or potentialharm you cause; and if you do not, we will regulateyour activities, tightening the rules over time. Whileno one would argue against the need to identify thosepeople and organisations whose performance is con-sistently or deliberately negatively deviant,21 there is aclear obligation to recognise that healthcare is deliv-ered in complex, uncertain settings, and although clin-icians are time-pressured and resource-constrained,things go right very often, even in times of austerity.Now is the time to send more optimistic signals toclinicians, focusing on the behaviours, processes andsystems contributing to resilient, safe care. Healthcareprofessionals surely need more sincere and

Table 1 Positive and negative deviance: characteristics and learning opportunities

Negative deviancecharacteristics Positive deviance characteristics What can positive deviance learn from negative deviance?

Focus on what goes wrong andpreventing harm

Focus on what goes right and spreadingpositive behaviours

Use the same mediums of dissemination about adverse events to encourageteams to vocalise their efforts and successes

Reactive Proactive Be responsive to positively deviant practice by encouraging the spread ofsuccessful behaviours identified using the positive deviance approach

Easily attracts attention Does not naturally attract attention Market positively deviant teams. Money is often spent campaigning toavoid adverse events—redirect resources to spreading positive practice

Sense of urgency to find andfix problems

Solutions evolve over time Create a sense of urgency about spreading positively deviant practice

Backward-looking, retrospectivethinking

Forward-looking, prospective thinking Highlight the time it takes to analyse an adverse event, identify the cause,and implement the solution—and acknowledge that often the solution maynot be evident from analysing the adverse event. Compare this to the timeit takes for local teams to spend time looking at their own practice, anddeveloping context-specific solutions currently available in the system

Managerial pressure Cohesive well-performing team withoutreason for managerial intervention

Use managerial support to promote positive deviance; actively recognising(and rewarding) teams that have initiated change and found improvement—highlight the need to learn how it was achieved and to spread the goodpractice

Targeted success A philosophy Rather than single instances of find and fix, use a longer-term approach tobuild a philosophy of positive deviance across a system

Reduce variability Promote effectiveness Accept that variability is a recurring feature of all systems and can never becompletely eradicated—even when evidence-based care is applied. This canbe a sign of resilience

Measures change followingharm

Good practice is a longitudinalphenomenon

Continuously measure practice to demonstrate improvement and sustainedperformance over time

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constructive praise, and a positive message to balancethe extensive criticism they receive.Contributors All authors contributed equally to this manuscriptin line with the four criteria recommend by ICMJE (http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html).

Funding This article presents independent research fundedpartly by the Australian National Health and Medical ResearchCouncil (NHMRC) (program Grant APP1054146), and theNational Institute for Health Research Collaboration forLeadership in Applied Health Research and Care Yorkshire andHumber (NIHR CLAHRC YH). The views and opinionsexpressed are those of the authors, and not necessarily those ofthe UK NHS, the NIHR the Department of Health, or theAustralian NHMRC.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially, and license their derivative works on differentterms, provided the original work is properly cited and the useis non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

REFERENCES1 Shojania KG, Thomas EJ. Trends in adverse events over time:

why are we not improving? BMJ Qual Saf 2013;22:273–7.2 Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in

rates of patient harm resulting from medical care. N Engl J Med2010;363:2124–34.

3 Hollnagel E, Braithwaite J, Wears RL, eds. Resilient health care.Ashgate, 2013.

4 Hollnagel E, Braithwaite J, Wears RL. Epilogue: how to makehealth care resilient. In: Hollnagel E, Braithwaite J, Wears R, eds.Resilient health care. Surrey, UK: Ashgate Publishing Limited,2013:227–38.

5 Wishik SM, Van der Vynckt S. The use of nutritional “positivedeviants” to identify approaches for modification of dietarypractices. Am J Public Health 1976;66:38–42.

6 Marra AR, Luciana RG, de Araujo CMP, et al. Positivedeviance: a new strategy for improving hand hygienecompliance. Infect Control Hosp Epidemiol 2010;31:12–20.

7 Bradley EH, Curry LA, Ramanadhan S, et al. Research inaction: using positive deviance to improve quality of healthcare. Implement Sci 2009;4:25.

8 Marsh DR, Schroeder DG, Dearden KA, et al. The power ofpositive deviance. BMJ 2004;329:1177–9.

9 Mesman J. Resources of strength: an exnovation of hiddencompetences to preserve patient safety. In: Rowley E, Waring J,eds. A sociocultural perspective on patient safety. Surry, UK:Ashgate Publishing Ltd., 2011:71–92.

10 Gabbay RA, Friedberg MW, Miller-Day M, et al. A positivedeviance approach to understanding key features to improvingdiabetes care in the medical home. Ann Fam Med 2013;11(Suppl 1):S99–107.

11 Appleby J, Bell A. Reporting NHS performance: how did themedia perform? BMJ 2000;321:248.

12 Zhan C, Miller M. Administrative data based patient safetyresearch: a critical review. Qual Saf Health Care 2003;12(Suppl2):ii58–63.

13 Berg M, Meijerink Y, Gras M, et al. Feasibility first: developingpublic performance indicators on patient safety and clinicaleffectiveness for Dutch hospitals. Health Policy2005;75:59–73.

14 Lilford R, Mohammed MA, Spiegelhalter D, et al. Use andmisuse of process and outcome data in managing performanceof acute medical care: avoiding institutional stigma. Lancet2004;363:1147–54.

15 Hutchinson A, Young T, Cooper K, et al. Trends in healthcareincident reporting and relationship to safety and quality data inacute hospitals: results from the National Reporting andLearning System. Qual Saf Health Care 2009;18:5–10.

16 Benn J, Burnett S, Parand A, et al. Studying large-scaleprogrammes to improve patient safety in whole care systems:challenges for research. Soc Sci Med 2009;69:1767–76.

17 Newell A, Simon HA. Human problem solving. EnglewoodCliffs, NJ: Prentice-Hall, 1972.

18 Nicolini D, Waring J, Mengis J. Policy and practice in the useof root cause analysis to investigate clinical adverse events:Mind the gap. Soc Sci Med 2011;73:217–25.

19 Currie G, Suhomlinova O. The impact of institutional forcesupon knowledge sharing in the UK NHS: the triumph ofprofessional power and the inconsistency of policy. Public Adm2006;84:1–30.

20 Currie G, Brown A. Narratological approach to understandingprocesses of organizing in a UK NHS hospital. Hum Relations2003;56:563–86.

21 Walshe K, Shortell SM. When things go wrong: how healthcare organizations deal with major failures. Health Aff2004;23:103–11.

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