Identifying positive deviants in healthcare quality and safety: a mixed methods study

Abstract

Objective Solutions to quality and safety problems exist within healthcare organisations, but to maximise the learning from these positive deviants, we first need to identify them. This study explores using routinely collected, publicly available data in England to identify positively deviant services in one region of the country. Design A mixed methods study undertaken July 2014 to February 2015, employing expert discussion, consensus and statistical modelling to identify indicators of quality and safety, establish a set of criteria to inform decisions about which indicators were robust and useful measures, and whether these could be used to identify positive deviants. Setting Yorkshire and Humber, England. Participants None - analysis based on routinely collected, administrative English hospital data. Main outcome measures We identified 49 indicators of quality and safety from acute care settings across eight data sources. Twenty-six indicators did not allow comparison of quality at the sub-hospital level. Of the 23 remaining indicators, 12 met all criteria and were possible candidates for identifying positive deviants. Results Four indicators (readmission and patient reported outcomes for hip and knee surgery) offered indicators of the same service. These were selected by an expert group as the basis for statistical modelling, which supported identification of one service in Yorkshire and Humber showing a 50% positive deviation from the national average. Conclusion Relatively few indicators of quality and safety relate to a service level, making meaningful comparisons and local improvement based on the measures difficult. It was possible, however, to identify a set of indicators that provided robust measurement of the quality and safety of services providing hip and knee surgery.

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people

“…In addition to the limitations outlined above, our findings may have been influenced by identifying positively deviant wards using ST data. Although our previous research supported using ST data as a proxy measure for ‘safe’ care,26 there are challenges to identifying positive deviants,72 and the wards’ performances on other aspects of safety (eg, medication safety) remain unknown. Furthermore, the relative importance of each positively deviant characteristic can only be inferred, and the extent to which they actually facilitate exceptionally safe care remains unknown.…”

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

“…A four staged framework has been proposed to apply positive deviance within healthcare organisations [32]. Exceptional performers are identified using routine data (stage 1) [34], and then qualitatively studied to explore how they succeed (stage 2) [35][36][37]. The success strategies are tested in larger more representative samples (stage 3) before being disseminated to others (stage 4).…”

Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation

“…18 The search for the features of exceptionally high-performing settings is now a uniting trait of several literatures, including those on high reliability organisations, [19][20][21] safety engineering, safety II and resilient healthcare, [22][23][24][25] and positive deviance approaches. [26][27][28] Although they Original research have emerged from somewhat different theoretical perspectives and have varying emphases, these literatures share several conceptual similarities. 26 A consistent finding is the forces that create positive conditions for safety may be at least partially invisible to those who create them because they remain tacit or habitualised: they require structured study to surface them.…”

“…Indeed, a key principle emerging from the literature on positive deviance is that the ability to solve a problem may already exist within the community experiencing the problem, and the challenge is to find and share particular practices or solutions already in use that may be of benefit to all. [27][28][29] A further growing insight of recent work, particularly in the area of positive deviance, is that, to provide useful and actionable guidance for clinicians and managers, it may be especially important to produce descriptions of 'what good looks like' that are specific to their particular areas of care, rather than operating at the level of generality. [26][27][28][29] An explicit, empirically based account is therefore likely to be valuable in identifying features of safety that are important for maternity units.…”

“…[27][28][29] A further growing insight of recent work, particularly in the area of positive deviance, is that, to provide useful and actionable guidance for clinicians and managers, it may be especially important to produce descriptions of 'what good looks like' that are specific to their particular areas of care, rather than operating at the level of generality. [26][27][28][29] An explicit, empirically based account is therefore likely to be valuable in identifying features of safety that are important for maternity units. Also important is ensuring that the findings are available, useful and accessible for those who might seek to use them as a basis for reflection and action.…”