Positive Deviance Research Articles

Leadership best practices for improving engagement and burnout in health facilities: A positive deviance approach from the Veterans Health Administration.

Leadership best practices for improving engagement and burnout in health facilities: A positive deviance approach from the Veterans Health Administration.

Barriers and facilitators to remote healthcare services use: perspectives of women and providers

Abstract Background The remote health services (RHS) proliferation raises concerns regarding relatively low use among minorities. Arab women in Israel belong to a minority that experiences health disparities, stigmatization, social and economic marginalization. This study aimed to identify barriers and facilitating means to RHS use relevant to Arab women in Israel from the perspective of women, primary care physicians (PCPs), and nurses. Methods Semi-structured interviews were conducted with 25 Arab women, 18 PCPs, and 4 nurses from different parts in Israel between December 2023-March 2024. We used a positive deviance approach by interviewing 14 women who succeeded in using RHS and 11 who did not. Interviews were audiotaped, transcribed, and thematically analyzed using Atlas qualitative analysis software. Findings The data distilled three main barriers to RHS use: sociocultural- importance of close relations with PCPs, privacy concerns of revealing the body or conversing with unfamiliar physicians, strict supervision by the family (Bedouin society); logistical-limited internet access and infrastructure, personal- unawareness to RHS, digital literacy, normative conceptions of limited quality of care and believing that only some health conditions are suitable for RHS. Facilitating means to RHS use: gender roles-women’s role as family health caretakers, mothers maintaining work-family balance and younger women generation feeling responsible for the older generation RHS adoption, accessibility- wider access to care due to limited transportation. Conclusions It is important to identify facilitating conditions (e.g., training opportunities, social, technological support), cultured elements (gender roles, limited mobility), and trust to adopting RHS by minority populations. The study provide data for developing requirements to ensure more equitable access to RHS to Arab women including addressing privacy concerns, guidelines for RHS-related information dissemination, and for RHS providers. Key messages • The findings help develop approaches and means to improve RHS use for Arab women from diverse backgrounds by identifying barriers associated with access, culture, and normative conceptions. • Developing RHS systems into routine care must ensure equitable use across social groups and address economic, logistical, and sociocultural barriers and guidelines for RHS information dissemination.

Positive Deviance in Nutritional Practices for Two-Year-Olds in Poor Fisherman Families in the Belawan Health Center Area, 2022

The problem of malnutrition is still the main problem faced in human resource development. The problem of growth and development of Baduta is a serious problem because at this age the process of physical and intellectual growth and development is critical. Malnutrition problems mostly occur in poor families but are not caused by poor families who have well-nourished children. The Belawan Community Health Center working area is one of the community health centers with the highest number of cases of malnutrition in Medan City. To overcome this, a program is needed that is believed to be effective and sustainable. One of the existing programs to overcome the problem of malnutrition and malnutrition is positive deviation. This research aims to identify positive behavior in feeding (type of food, processing of food ingredients, mealtimes and method of feeding) of toddlers who are well-nourished in poor fishing families in the Belawan Community Health Center Working Area in 2022. This research method is qualitative research with a narrative approach. Researchers studied individual lives by asking one or several individuals to tell stories about their lives related to positive behavior in feeding well-nourished animals. This information is then retold by the researcher in a narrative chronology. The findings of this research indicate that addressing nutritional challenges in children can be effectively achieved by leveraging the potential and resources within the community. This is done through the identification of positive deviant behaviors, particularly those related to beneficial feeding practices. These practices encompass aspects such as the types of food provided, the methods of food preparation, the timing of meals, and the approach to food administration. Keep up the great work! The way you’re thinking about integrating community strengths is spot-on for creating sustainable solutions.

Strategies of positive deviants in fodder conservation among smallholder dairy farming systems in highlands and midlands of Kenya.

Fodder scarcity and low quality affect the productivity of dairy cattle in Kenya yet only few smallholder dairy farmers show positive deviance in fodder conservation. Information on the strategies of such positive deviant (PD) farmers is scanty. The objective of this study was to determine strategies that distinguish PDs from peers (non-PDs) in fodder conservation among smallholder dairy farmers in highlands and midlands of Kenya. A cross-sectional survey was conducted among farms producing and conserving fodder in Tharaka Nithi County. Multistage sampling procedures was used; purposive sampling of the Sub-counties and locations, random selection of villages and proportional selection of 246 farms through snowball chain referral. Data were collected on demographic, socio-economic, farm characteristics and fodder conservation. Farms were categorized as PDs (n = 24) or non-PDs (n = 97). The PDs conserved fodder adequate to last dry season (about 3 months) and had milk yield 15kg/cow/day and above, while non-PDs do not qualify for both criteria. Chi-square and T-test were used to analyze categorical and continuous variables respectively. Logit regression was used to examine independent variables that influence probability of PDs. Farmers with high school and tertiary education who accessed extension services were PDs while non-PDs had non-formal and primary education and access extension less. Farms conserving hay and silage dominated PDs. Land in hectare (ha) and herd sizes in Tropical Livestock Unit (TLU) distinguished PDs (1.7ha and 9.0 TLU) from non-PDs (0.7ha and 3.3 TLU). The strategies that distinguished PDs from non-PDs were allocating land to fodder production, high milk yield kg/cow/day, large herd size and access to extension services. Increasing access to extension and resources (land) raised chances of PDs in fodder conservation. Knowledge of PDs strategies is important for fodder conservation, improve productivity and inform direction of future research.

Positive Deviance Theory: Leveraging Compliments Data to Guide Strategic Planning for Patient Experience Improvement in a Large Rural Health Care System.

Patient-centered care (PCC) has been called for as a solution to improving care quality and patient outcomes. Patient experience, termed care experience, is a measurable aspect of PCC and aligns with coproduction. Identifying patterns of positivity and high performers is a Positive Deviance approach that can inform strategic improvement of the care experience. To identify the characteristics of positive deviances from voluntary, unsolicited compliments from patients and family members about their care experiences. The authors conducted a mixed-method analysis, including content and a thematic analysis of unsolicited comments from patients and families, submitted between January 2021 and January 2022. After removing duplicates and miscategorized comments, 213 compliments were included in the analysis using a single, blinded inductive coding to synthesize thematic statements. The main campus received the most compliments by location (89%); the most widely used patient sentiment was thankful (36.8%). Compassionate (26.8%), together with six others: competent (11.6%), communication (10.6%), cared for (8.5%), care team (8.0%), and supportive (8.0%), made up approximately 80% of drivers of care quality. Physicians (37.3%) and nurses (34.2%) were the most complimented personnel, although surgery (17.0%) were the most complimented services team. Similar characteristics were reported for exemplary individuals and their associated care teams. The results align with previously reported work by the Beryl Institute and CMS 5-star rating on key drivers of patient experience. This approach provides a method by which exemplars can be identified within health systems, and that information is used to guide improvement and organizational planning.

Validity and reliability of the Checklist for Habitual Physical Activity for people 75 years and older in Japan.

Despite health benefits, many older adults struggle to meet physical activity guidelines, leading to stagnant activity levels. While integrating physical activity into daily routines has been proposed as a promising strategy for older adults, fit-for-purpose measurement tools to assess such routines are lacking. The Checklist for Habitual Physical Activity (CHaPA) was developed based on the positive deviance approach and socio-ecological model to assess daily behaviours encouraging physical activity among adults aged 75 and older. It has been confirmed for its content and face validity. However, to ensure its broader applicability and usefulness, assessing its construct validity and reliability is necessary. Therefore, this study aims to assess the construct validity and reliability of the CHaPA and accordingly update the tool. To validate the construct validity of the CHaPA 22-item version, we conducted item analysis and exploratory and confirmatory factor analyses. We removed inappropriate items based on predefined criteria. Then, we assessed the reliability, internal consistency, test-retest reliability, and measurement errors of the CHaPA final version. Item analyses and factor analyses resulted in the deletion of 11 items. The results of confirmatory factor analysis validated the CHaPA 11-item version with the three-factor structure based on model fit index with χ2/degree of freedom = 1.25, comparative fit index = 0.965, Tucker-Lewis index = 0.952, and root-mean-square error of approximation = 0.038. Omega coefficient (0.90) showed excellent internal consistency. Intraclass correlation coefficient (ICC) demonstrated good test-retest reliability (ICC (1, 2) = 0.77, 95% CI = 0.34-0.89, standard error of measurement = 1.75). We finalised the CHaPA 11-item version as a valid and reliable instrument for assessing daily behaviours conducive to physical activity among individuals aged 75 years and older. We need to examine the methods and effectiveness of disseminating this checklist to ensure its utilisation as a resource for promoting healthy ageing and aiding older adults in maintaining active lifestyles.

Clues to fostering a program culture of academic integrity: findings from a multidimensional regression model

Using multivariate regression, we identified situational, personal and contextual variables correlated with business students’ self-reported rates of academic misconduct. The most influential predictors of increasing academic misconduct were: higher estimates of peers’ academic misconduct, increasingly negative perceptions of the program’s academic integrity culture, and rating questionable academic behaviours less seriously. Individual priorities, personal characteristics and social support were less influential. We then analyzed our quantitative results in light of our deep understanding of the broader context to derive richer insights from the interplay of our independent variables. Importantly, our results indicate that program-led proactive messaging designed to foster a culture of academic integrity can effectively buffer tendencies towards academic dishonesty. Absent ongoing messaging, however, increasing academic pressures may erode those initial benefits. Moreover, repercussions of major academic integrity breaches can be long lasting, suggesting an even greater need for fostering a culture of academic integrity a priori. Finally, we recommend a public health practice of identifying positive deviants – individuals who thrive in challenging environments – and then in an effort to change a peer support system that fosters academic misconduct into one that discourages it, engaging with those individuals to understand why and how they resist the status quo.

The Positive Deviance Concept: Pro and Con

ABSTRACT Multiple sociologists use the term, “positive deviance,” to refer to a sociologically meaningful category of behavior. Earlier, the author questioned the concept’s utility on the basis of its grab-bag, miscellaneous character – and hence, the inability of any known sociological theory to explain or account for it – as well as the fact that its components, “positive” and “deviance” are based on qualities lodged in distinctly separate dimensions. Still, curious about how sociologists of deviance regard the concept, the author contacted more than 200 instructors of the course and asked them how they feel about its coherence and utility; out of the 50 replies, only a quarter (N = 12) of the respondents rejected the meaningfulness of the concept out of hand, while two-thirds (N = 33) accepted it; the remaining one out of ten (N = 5) weren’t sure or reacted non-judgmentally. Though not rigorous or consistent, the concept seems to have achieved a secure place in the sociology of deviance literature; perhaps, on that basis, the nay-sayers should re-think their opposition to the concept.

Rethinking leadership approaches for community-wide opioid crisis intervention: harnessing positive inquiry to unearth front-line insight

Background/AimThe opioid crisis presents a complex and widespread health challenge for communities, necessitating a deeper exploration beyond simple solutions. To address this crisis, it is crucial to identify and disseminate...

Effectiveness of Rumoh Gizi Gampong and positive deviance in improving the nutritional status of toddlers in Aceh

Stunting is a chronic nutritional problem that is a priority to address because it can affect the quality of children. Fulfilling the nutritional needs of children under five through positive family habits, including through family improvement and Rumoh Gizi Gampong (RGG), can significantly reduce stunting rates. The purpose of the study was to identify the effectiveness of Rumoh Gampong Nutrition and positive deviance in efforts to improve the nutritional status of toddlers in Aceh, with a quasi experimental design conducted in Merduati village, Kutaradja sub-district, Banda Aceh with 50 samples (25 intervention groups and 25 controls) using purposive sampling technique carried out on October 15, 2020-15 January 2021. Data collection using questionnaires with interview techniques, food record documentation studies and weight measurements using Dacin and height using microtoise. Data processing with paired T test, the results showed a significant difference in the intervention group on how to fulfill toddler food (p = 0.000), food intake (p = 0.000), and nutritional status (p = 0.000), there were differences in how to fulfill food in the intervention and control groups (p = 0.00), there were differences in food intake in the intervention and control groups (p = 0.001) and there were differences in body weight in the intervention and control groups (p = 0.001). It is recommended to support the positive deviance program and Rumoh Gampong Nutrition for all posyandu in their working area.

Long-term retention and positive deviant practices in Uganda’s community client-led antiretroviral distribution groups (CCLADs): a mixed-methods study

BackgroundHIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community...

Injectable Contraceptives as an Underutilized Option for Women's Reproductive Health: An Exploratory Qualitative Study.

Injectable contraceptives (IC) provide a highly effective, reversible method of preventing conception, yet discontinuation rates are high. Health workers play a crucial role in the successful implementation of family welfare services. Adding up the basket of choices without knowing the community's needs can lead to poor utilization of services. To explore the facilitators and barriers to the utility of injectable contraceptives among reproductive women from the user's point of view and to understand solutions from the key informants. The study was conducted in the field practice areas among reproductive women attending a primary health center in Puducherry. It was an exploratory qualitative study in which in-depth interviews were conducted among 19 IC users using an interview guide. This was followed by a key informant interview with seven service providers, including doctors, staff nurses, auxiliary nurse midwives, and Anganwadi workers, to explore the solutions for the identified barriers. Purposive, convenient sampling was adopted for the selection of study participants, and the sample size was chosen until the point of saturation. Two investigators trained in qualitative research have performed a manual content analysis of transcripts to ensure credibility. Descriptive codes were derived, and similar codes were merged into categories and themes. The most common facilitators were awareness from service providers and dissatisfaction with previous methods. Fear of side effects, inadequate information, out-of-pocket expenditure, lack of family support, and sociocultural myths were the most common barriers. Key informants suggested counseling on side effects, incentive-based follow-up, universal health insurance, couple-based counseling, training of service providers, and a positive deviance approach. Health workers are pivotal in the successful delivery of family welfare services. The acceptability of IC could be improved by addressing concerns about side effects and its effective management through various targeted interventions.

Improving access to buprenorphine for rural veterans in a learning health care system.

To describe a learning health care system research process designed to increase buprenorphine prescribing for the treatment of opioid use disorder (OUD) in rural primary care settings within U.S. Department of Veterans Affairs (VA) treatment facilities. Using national administrative data from the VA Corporate Data Warehouse, we identified six rural VA health care systems that had improved their rate of buprenorphine prescribing within primary care from 2015 to 2020 (positive deviants). We conducted qualitative interviews with leaders, clinicians, and staff involved in buprenorphine prescribing within primary care from these sites to inform the design of an implementation strategy. Qualitative interviews to inform implementation strategy development. Interviews were audio-recorded, transcribed verbatim, and coded by a primary coder and secondary reviewer. Analysis utilized a mixed inductive/deductive approach. To develop an implementation strategy, we matched clinical needs identified within interviews with resources and strategies participants had utilized to address these needs in their own sites. Interview participants (n = 30) identified key clinical needs and strategies for implementing buprenorphine in rural, primary care settings. Common suggestions included the need for clinical mentorship or a consult service, buprenorphine training, and educational resources. Building upon interview findings and in partnership with a clinical team, we developed an implementation strategy composed of an engaging case-based training, an audit and feedback process, and educational resources (e.g., Buprenorphine Frequently Asked Questions, Rural Care Model Infographic). We describe a learning health care system research process that leveraged national administrative data, health care provider interviews, and clinical partnership to develop an implementation strategy to encourage buprenorphine prescribing in rural primary care settings.

Food interventions and nutritional status of undernourished children ages 0-5 years old in southern Philippines: a systematic review and meta-analysis

Abstract This review aims to provide a comprehensive synthesis and determine pooled effectiveness of food interventions on the nutritional status of undernourished children ages 0-5 years old in low- and middle-income countries. Specific objectives include identification, selection, and appraisal of interventions that target undernourished children ages 0-5 years old. This study included Randomized Controlled Trials, Pre-post Interventional, Case-Control, and Cohort Studies that were conducted from 2016-2019 that target Undernourished children, 0-5 years old. The outcome is improvement in Nutritional Status: Weight-for-age, Length-for-age, Weight-for-length, Weight Gain, Mean Weight, Mid-Upper Arm Circumference, Length (cm). The search and identification of studies, supplemented with the inclusion and exclusion criteria, was done through an online database (Pubmed, Ebscohost, ScienceDirect, and Google Scholar) and in the Department of Agriculture Library. The study used four (4) tools in appraising the studies. The four tools differed in terms of their indication of use by study design: Risk of Bias-2 for Randomized Controlled Trials (RCTs), Risk of Bias in Non-Randomized Studies- of Interventions for Non-Randomized Studies (NRSI), and Heller’s Public Health Checklist for quasi-experimental (within-group) designs. Out of thirty-one (31) studies, this paper compiled seven (7) interventions. The interventions are local and homemade food, nutritional education, food production, milk-based formula, reduced dose of RUTF, rehabilitation programs, and positive deviance approach. Risk of Bias: (ROB-2) 100% of the studies have low risk in random sequence generation, blinding of outcome assessment, and selective reporting domains. Only 10% of the studies demonstrated unclear or moderate risk under attrition bias due to incomplete outcome data. Roughly 20% of the studies also showed unclear or moderate risk under selection and performance bias. (ROBINS-I) 67% (6/9) of the included studies are low risk for overall bias. (Heller) Studies were appraised by Heller’s checklist where identification of strengths and weaknesses were identified. This review found that local and homemade food improves the nutritional status of undernourished children below five years old. Findings show that nutrition education has little to no effect, while food production needs more studies to increase its certainty. Other interventions mentioned need more similar studies to obtain a pooled effectiveness. This review has excluded studies that are of high risk of bias to minimize low certainty of evidence. However, this review was unable to examine adverse effects of the interventions. This review has some studies not pooled due to missing values such as standard deviations and confidence interval.

Study protocol: Examining sexual and reproductive health literacy in Mexican American young women using a positive deviance approach.

Health literacy is generally low in marginalized groups, leading to delays in accessing care, poor health outcomes, and health disparities. Yet, some individuals in these groups demonstrate higher health literacy and better health outcomes. These exceptional cases exemplify 'positive deviance' because they have found ways to be successful where others have not. Identifying the methods, practices, and resources that these individuals have used to gain health literacy and healthcare access may have generalized application to improve health literacy, access to care, and health outcomes. Using the Integrated Model of Health Literacy, the main objectives of this study are to (1) identify facilitators, barriers, and strategies to gain sexual and reproductive health literacy and healthcare access and (2) to explore each of the core domains of health literacy as they relate to successful access of sexual and reproductive healthcare services among individuals identified as positive deviants. For the purposes of this mixed methods community engaged study, positive deviants are defined as Mexican American young women aged 18-29 years old living in Rural Western New York who have accessed sexual and reproductive healthcare within the past year. A community advisory committee will be formed to provide community-engaged guidance and support for the recruitment of participants. Positive deviants will participate in a survey and semi-structured interview. Data collection and analysis will be simultaneous and iterative. Results will provide evidence of positive deviant methods, practices, and strategies to gain health literacy and access to sexual and reproductive healthcare. Findings may reveal characteristics and patterns in the relationship of health literacy and healthcare access that can inform interventions to improve health literacy and make healthcare more accessible for this demographic group and context.

“She takes rest as seriously as working:” Communicative resilience and professional caregivers’ meanings of rest

ABSTRACT Are resilient employees so tough that they neglect to rest? To answer this question, eleven extraordinarily resilient professional caregivers (positive deviants [PD]) were interviewed about their meanings and practices of rest. Additionally, five professionals who scored extremely low in resilience and four who were average were also interviewed. Analysis of interviews revealed that PD caregivers held multifaceted interpretive schema of rest. Namely, they embraced bounded physicality, the limited ability to engage in space and time. In turn, they viewed rest as a (a) strategic defense and (b) normal indispensable joy, and practiced rest through (c) multimodal care. Thus, findings implied that resilient employees make rest a priority. The paper contributes to the communicative theory of resilience and the meanings of work literatures.

Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health.

Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT. This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition. A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group. The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT. Diagnostic study-retrospective cohort study.

Predictive Analysis of the Principal Components that Configure Autistic Spectrum Disorder

At currently, developments regarding to autism spectrum disorder have enabled its diagnostic group to be defined as a multilateral neurodevelopmental disorder characterised by peculiarities in the procedural functioning of perceptual-cognitive parameters, derived from a characteristic connexional form in the pathway of interconnection between intrinsic information and contextual stimuli. In this characteristic process, neuronal networks are involved a fundamental processing task for working memory to be able to perform the set of executive functions with a certain degree of stability, which is severely limited in people diagnosed with this disorder. In this study, the reports of 403 participants diagnosed with the disorder were analysed with the following basic goals: 1) to analyse the relationship between relational deficits and the elaboration of semantic content, 2) to analyse the etiological attribution of the GABAergic pathway responsible for the limitations in these connections and, consequently, 3) to conclude the main predictive-explanatory level of this disorder. The data have been found by means of different statistical tests, both initial correlational tests, statistical calculation processes, univariate one-factor ANOVA tests and final consequential ordinal multinomial logit regression tests. Data found allow us to delimit that the regression equation of the model fitting information explaining the disorder shows a final logit model chi-square: 217.23, with a significant associated critical level (sig: .00), which are complemented by the significantly positive Pearson and Deviance data significantly related to the logit level (sig: .00), which confirms the importance of the predictive-explicative level of the neuronal and semantic variables derived from the GABAergic limitations in order to be able to be converted into the main propositional components of autism as a highly related neurocognitive systemic process.

Health Motivation in the Influencer Era: Analyzing Entertainment, Personal, and Social Media Role Models

ABSTRACT This research explored how personal and entertainment role models motivate an individual’s health goals, and how following a role model on social media affects this process. A survey of 404 adults revealed that identifying a personal role model, such as a family member, friend, or healthcare professional, had a stronger influence on health motivation in comparison to identifying an entertainment role model. Additionally, our findings indicated that following any role model on social media, whether a personal acquaintance or a celebrity, enhanced motivation. Role model attributes that mediated these relationships included perceived similarity, and in some instances, positive and negative norm deviance. This study highlights the importance of leveraging role model relationships in health communication campaigns and developing authentic influencer-driven health initiatives that feature relatable entertainment figures. Additionally, this research supports the need for further examination of how a role model’s perceived positive or negative norm deviance influences motivational capability. We discuss implications for the motivational theory of role modeling, health promotion, and entertainment education.

Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals

BackgroundIn recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework.MethodsThis study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework.ResultsIn total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member).ConclusionThe addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.