Abstract
BackgroundDespite 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.MethodsWe 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.ResultsThe 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.ConclusionThe identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.
Highlights
Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care
Despite enormous national investment in biomedical research, less than 1% of this is directed at research on improving health care delivery [7], and when innovations in clinical care are discovered, the uptake of these improvements into practice is often delayed and incomplete [8,9,10,11]
We conclude with an illustrative example of the positive deviance approach applied to improving hospital care nationally for patients with myocardial infarction
Summary
Elizabeth H Bradley*1, Leslie A Curry, Shoba Ramanadhan, Laura Rowe, Ingrid M Nembhard and Harlan M Krumholz. Address: 1Division of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT, USA, 2Yale School of Management, New Haven, CT, USA and 3Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA. Published: 8 May 2009 Implementation Science 2009, 4:25 doi:10.1186/1748-5908-4-25.
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