Research in action: using positive deviance to improve quality of health care

Elizabeth H Bradley, Leslie A Curry, Shoba Ramanadhan, Laura Rowe, Ingrid M Nembhard, Harlan M Krumholz, Elizabeth H Bradley, Leslie A Curry, Shoba Ramanadhan, Laura Rowe, Ingrid M Nembhard, Harlan M Krumholz

Abstract

Background: Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality.

Methods: We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction.

Results: The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices.

Conclusion: The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.

Figures

Figure 1
Figure 1
Steps in the positive deviance approach.
Figure 2
Figure 2
Key drivers of the diffusion process.

References

    1. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006;354:1147–1156. doi: 10.1056/NEJMsa044464.
    1. Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams JL, Schuster MA, McGlynn EA. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523. doi: 10.1056/NEJMsa064637.
    1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–2645. doi: 10.1056/NEJMsa022615.
    1. Krumholz HM, Normand SL, Spertus JA, Shahian DM, Bradley EH. Measuring performance for treating heart attacks and heart failure: the case for outcomes measurement. Health Aff (Project Hope) 2007;26:75–85. doi: 10.1377/hlthaff.26.1.75.
    1. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–298.
    1. Krumholz HM, Chen J, Rathore SS, Wang Y, Radford MJ. Regional variation in the treatment and outcomes of myocardial infarction: investigating New England's advantage. Am Heart J. 2003;146:242–249. doi: 10.1016/S0002-8703(03)00237-0.
    1. Moses H, 3rd, Dorsey ER, Matheson DH, Thier SO. Financial anatomy of biomedical research. JAMA. 2005;294:1333–1342. doi: 10.1001/jama.294.11.1333.
    1. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ. 1998;317:465–468.
    1. Farquhar CM, Stryer D, Slutsky J. Translating research into practice: the future ahead. Int J Qual Health Care. 2002;14:233–249.
    1. Institute of Medicine . Performance Measurement: Accelerating Improvement. Washington: D.C.: National Academy of Sciences; 2006.
    1. Lenfant C. Shattuck lecture – clinical research to clinical practice – lost in translation? N Engl J Med. 2003;349:868–874. doi: 10.1056/NEJMsa035507.
    1. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004;329:1177–1179. doi: 10.1136/bmj.329.7475.1177.
    1. Sternin J, Choo R. The power of positive deviancy. An effort to reduce malnutrition in Vietnam offers an important lesson about managing change. Harv Bus Rev. 2000;78:14–15.
    1. Walker LO, Sterling BS, Hoke MM, Dearden KA. Applying the concept of positive deviance to public health data: a tool for reducing health disparities. Public Health Nurs. 2007;24:571–576. doi: 10.1111/j.1525-1446.2007.00670.x.
    1. Ahrari M, Kuttab A, Khamis S, Farahat AA, Darmstadt GL, Marsh DR, Levinson FJ. Factors associated with successful pregnancy outcomes in upper Egypt: a positive deviance inquiry. Food Nutr Bull. 2002;23:83–88.
    1. Positive Deviance Initiative: Projects
    1. Marsh DR, Pachon H, Schroeder DG, Ha TT, Dearden K, Lang TT, Hien ND, Tuan DA, Thach TD, Claussenius DR. Design of a prospective, randomized evaluation of an integrated nutrition program in rural Viet Nam. Food Nutr Bull. 2002;23:36–47.
    1. Sternin M, Sternin J, Marsh D. Scaling up a poverty alleviation and nutrition progran in Viet Nam. In: Marchione T, editor. Scaling up, scaling down: Capacities for overcoming malnutrition in developing countries. Amsterdam: Gordon and Beach; 1999.
    1. Schroeder DG, Pachon H, Dearden KA, Kwon CB, Ha TT, Lang TT, Marsh DR. An integrated child nutrition intervention improved growth of younger, more malnourished children in northern Viet Nam. Food Nutr Bull. 2002;23:53–61.
    1. Mackintosh UAT, Marsh DT, Schroeder DG. Sustained positive deviant child care practices and their effects on child growth in Viet Nam. Food Nutr Bull. 2002;23:18–27.
    1. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76:593–624. doi: 10.1111/1468-0009.00107. 510.
    1. Lagoe RJ, Aspling DL. Enlisting physician support for practice guidelines in hospitals. Health Care Manage Rev. 1996;21:61–67.
    1. Patton MQ. Qualitative Research and Evaluation Methods. Thousand Oaks: Sage Publications; 2002.
    1. Glaser B, Strauss A. The discovery of grounded research: Strategies for qualitative research. Chicago: Aldine; 1967.
    1. Britten N. Qualitative interviews in medical research. BMJ. 1995;311:251–253.
    1. Creswell JR. Research Design: Qualitative, Quantitative, and Mixed Method Approaches. 2. Thousand Oaks: Sage Publications; 2003.
    1. Ragin CC. The Comparative Method: Moving Beyond Qualitative and Quantitative Strategies. Berkley: University of California Press; 1987.
    1. Berwick DM, Godfrey AB, Roessner J. Curing health care: new strategies for quality improvement. San Francisco, California: Jossey-Bass; 1990.
    1. Langley GJ, Nolan KM, Norman CL, Provost LP, Nolan TW. The improvement guide: a practical approach to enhancing organizational performance. San Francisco, California: Jossey-Bass; 1997.
    1. Passmore W. Action research in the workplace: the socio-technical perspective. In: Reason P, Bradbury H, editor. Handbook of Action Research. Thousand Oaks, California: Sage; 2001.
    1. Schein EH. Clinical inquiry/research. In: Reason P, Bradbury H, editor. Handbook of Action Research. Thousand Oaks, California: Sage; 2001.
    1. Cassell C, Johnson P. Action research: explaining the diversity. Hum Relat. 2006;59
    1. Emery FE, Trist EL. The causal texture of organizational environments. Hum Relat. 1965;18:21–32. doi: 10.1177/001872676501800103.
    1. Susman GI. Action research: sociotechnical systems perspective. London: Sage Publications; 1983.
    1. Leyland AH, Goldstein H. Multilevel modelling of health statistics. Chichester, NY: Wiley; 2001.
    1. Bryk AS, Raudenbush SW. Hierarchical linear models: applications and data analysis. Newbury Park, California: Sage; 1992.
    1. Berwick DM. The science of improvement. JAMA. 2008;299:1182–1184. doi: 10.1001/jama.299.10.1182.
    1. Fixen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: a synthesis of the literature. Tampa, Florida: University of South Florida, Louis de la Parta Florida Mental Health Institute, The National Implementation Research Network; 2005.
    1. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357:608–613. doi: 10.1056/NEJMsb070738.
    1. Hackman JR, Wageman R. Total quality management: empirical, conceptual and practical issues. Admin Sci Q. 1995;40:309–342. doi: 10.2307/2393640.
    1. French WI, Bell C. Organization development behavioral science interventions for organization improvement. Englewood Cliffs, New Jersey: Prentice-Hall; 1973.
    1. Stetler CB, Mittman BS, Francis J. Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implement Sci. 2008;3:8. doi: 10.1186/1748-5908-3-8.
    1. Stacey RD. Strategic management and organizational dynamics: the challenge of complexity. 4. New York: Prentice-Hall; 2003.
    1. Berta WB, Baker R. Factors that impact the transfer and retention of best practices for reducing error in hospitals. Health Care Manage Rev. 2004;29:90–97.
    1. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581–629. doi: 10.1111/j.0887-378X.2004.00325.x.
    1. Ven AH Van de. Explaining development and change in organizations. Acad Manage Rev. 1995;20:510–540. doi: 10.2307/258786.
    1. Aday L. Designing and conducting health surveys: a comprehensive guide. 3. San Francisco: Jossey-Bass; 2006.
    1. Krause N. A comprehensive strategy for developing closed-ended survey items for use in studies of older adults. J Gerontol B Psychol Sci Soc Sci. 2002;57:S263–S274.
    1. Rossi PH, Wright JD, Anderson AB, Eds Handbook of Survey Research. New York. 1983.
    1. Tucker AL, Nembhard IM, Edmondson AC. Implementing new practices: an empirical study of organizational learning in hospital intensive care units. Manage Sci. 2007;53:894–907. doi: 10.1287/mnsc.1060.0692.
    1. Bradley EH, Webster TR, Baker D, Schlesinger M, Inouye SK, Barth MC, Lapane KL, Lipson D, Stone R, Koren MJ. Translating research into practice: speeding the adoption of innovative health care programs. Issue brief (Commonwealth Fund) 2004:1–12.
    1. Rogers EM. Diffusion of Innovations. 4. New York: Free Press; 1995.
    1. Mumford MD, Gustafson SB. Creativity syndrome: integration, application, and innovation. Psychol Bull. 1988;103:27–43. doi: 10.1037/0033-2909.103.1.27.
    1. Wilson-Evered E, Hartel CEH, Neale M. Leadership and innovation surfacing synergies among theories and constructs. In: Ghobadian A, O'Regan N, Gallear D, Viney H, editor. Strategy and Performance: Achieving Competitive Advantage in the Global Market Place. Basingstoke: Palgrave MacMillan; 2004.
    1. Amabile T, Conti R, Coon H, Lazenby J, Herron M. Assessing the work environment for creativity. Acad Manage J. 1996;39:1154–1184. doi: 10.2307/256995.
    1. West E, Barron DN, Dowsett J, Newton JN. Hierarchies and cliques in the social networks of health care professionals: implications for the design of dissemination strategies. Soc Sci Med. 1999;48:633–646. doi: 10.1016/S0277-9536(98)00361-X.
    1. Stetler CB, McQueen L, Demakis J, Mittman BS. An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series. Implement Sci. 2008;3:30. doi: 10.1186/1748-5908-3-30.
    1. Berger PB, Ellis SG, Holmes DR, Jr, Granger CB, Criger DA, Betriu A, Topol EJ, Califf RM. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999;100:14–20.
    1. Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, Gore JM, Weaver WD, Rogers WJ, Tiefenbrunn AJ. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA. 2000;283:2941–2947. doi: 10.1001/jama.283.22.2941.
    1. McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, Peterson ED, Blaney M, Frederick PD, Krumholz HM. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006;47:2180–2186. doi: 10.1016/j.jacc.2005.12.072.
    1. De Luca G, Suryapranata H, Zijlstra F, van't Hof AW, Hoorntje JC, Gosselink AT, Dambrink JH, de Boer MJ. Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol. 2003;42:991–997. doi: 10.1016/S0735-1097(03)00919-7.
    1. McNamara RL, Herrin J, Bradley EH, Portnay EL, Curtis JP, Wang Y, Magid DJ, Blaney M, Krumholz HM. Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002. J Am Coll Cardiol. 2006;47:45–51. doi: 10.1016/j.jacc.2005.04.071.
    1. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002–2004. N Engl J Med. 2005;353:255–264. doi: 10.1056/NEJMsa043778.
    1. Bradley EH, Nallamothu BK, Curtis JP, Webster TR, Magid DJ, Granger CB, Moscucci M, Krumholz HM. Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Crit Pathw Cardiol. 2007;6:91–97.
    1. French WJ. Trends in acute myocardial infarction management: use of the National Registry ofMyocardial Infarction in quality improvement. Am J Cardiol. 2000;85:5B–9B. doi: 10.1016/S0002-9149(00)00752-9. discussion 10B–12B.
    1. Bradley EH, Roumanis SA, Radford MJ, Webster TR, McNamara RL, Mattera JA, Barton BA, Berg DN, Portnay EL, Moscovitz H, et al. Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it? J Am Coll Cardiol. 2005;46:1236–1241. doi: 10.1016/j.jacc.2005.07.009.
    1. Bradley EH, Curry LA, Webster TR, Mattera JA, Roumanis SA, Radford MJ, McNamara RL, Barton BA, Berg DN, Krumholz HM. Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. Circulation. 2006;113:1079–1085. doi: 10.1161/CIRCULATIONAHA.105.590133.
    1. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Hawthorne, NY: Aldine Publishing Company; 1980.
    1. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2. Thousand Oaks, California: Sage Publications; 1994.
    1. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42:1758–1772. doi: 10.1111/j.1475-6773.2006.00684.x.
    1. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308–2320. doi: 10.1056/NEJMsa063117.
    1. Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline-Rogers E, Stern AF, Byrd JR, Brush JE. A campaign to improve the timeliness of primary percutaneous coronary intervention, door-to-balloon time: an alliance for quality. JACC: Cardiovascular Interventions. 2008;1:97–104. doi: 10.1016/j.jcin.2007.10.006.
    1. Mehta RH, Bufalino VJ, Pan W, Hernandez AF, Cannon CP, Fonarow GC, Peterson ED. Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program. Am Heart J. 2008;155:1059–1067. doi: 10.1016/j.ahj.2008.01.010.
    1. Pfeffer J, Sutton RI. The Knowing-Doing Gap. Boston, MA: Harvard Business School Press; 2000.
    1. McCannon CJ, Berwick DM, Massoud MR. The science of large-scale change in global health. JAMA. 2007;298:1937–1939. doi: 10.1001/jama.298.16.1937.

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