Learning from positive deviants to improve the quality and safety of healthcare.

Every day around the globe, patients are harmed within healthcare organisations. Attempts to improve the quality and safety of healthcare traditionally focus on past errors and harm, yet there is little evidence of widespread improvement. In contrast, the positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance despite facing the same constraints as others. Bradley et al. (2009) have proposed a four stage process to apply positive deviance within healthcare organisations: 1) positive deviants are identified using routinely collected data; 2) hypotheses are generated about how they succeed; 3) these are tested within representative samples; and 4)the successful strategies are disseminated. Despite this, limited guidance exists to support applications. This thesis sought to test a robust and pragmatic method for applying the positive deviance approach within multidisciplinary healthcare teams. Study 1 systematically reviewed the methods used to apply positive deviance within healthcare. Previous applications identified positively deviant organisations or individuals and focused on narrow outcomes or processes of care. Applications lacked quality and used extensive resources. Study 2 analysed NHS Safety Thermometer data to identify five positively deviant and five matched comparison elderly medical wards. In the main, staff and patient perceptions of safety on these wards supported their identification. During study 3, multidisciplinary staff focus groups were conducted to explore how these wards delivered exceptionally safe care. In total, 14 behaviours and cultures were hypothesised to facilitate positive deviance at ward level. Study 4 assessed the feasibility of applying positive deviance within a general practice setting. Findings highlighted challenges of selecting data to identify positive deviants, recruiting general practices to participate, and generating hypotheses about success strategies that were unique to positive deviants yet common among them. In combination, these studies generated guidance to support rigorous applications of the positive deviance approach within healthcare organisations. The evidence suggested that, in the future, it may be possible to improve the quality and safety of care by focusing on those that demonstrate exceptional rather than poor outcomes of care.