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Kassie AM, Eakin E, Abate BB, Endalamaw A, Zewdie A, Wolka E, Assefa Y. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC Health Serv Res 2024; 24:438. [PMID: 38589897 PMCID: PMC11003118 DOI: 10.1186/s12913-024-10850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs. METHODS Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats. RESULTS A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections. CONCLUSION The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.
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Affiliation(s)
- Ayelign Mengesha Kassie
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Elizabeth Eakin
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Biruk Beletew Abate
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Aklilu Endalamaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Sofaer S, Glazer KB, Balbierz A, Kheyfets A, Zeitlin J, Howell EA. Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality. THE JOURNAL OF PEDIATRICS: X 2023; 10:100094. [PMID: 38186750 PMCID: PMC10769867 DOI: 10.1016/j.ympdx.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024] Open
Abstract
Objective To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM). Methods Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters. Results The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics. Conclusions and relevance Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.
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Affiliation(s)
| | - Kimberly B. Glazer
- Department of Population Health Science and Policy, Blavatnik Family Women's Health Research Institute, The Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amy Balbierz
- New York University Grossman School of Medicine, New York, NY
| | - Anna Kheyfets
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA
| | - Jennifer Zeitlin
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Inserm, Inrae, Paris, France
| | - Elizabeth A. Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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O’Malley R, Lydon S, Faherty A, O’Connor P. Identifying Factors that Support the Delivery of Exceptional Care in General Practice and Development of the IDEAL Framework: A Qualitative Study. QUALITATIVE HEALTH RESEARCH 2023; 33:1232-1248. [PMID: 37694934 PMCID: PMC10626987 DOI: 10.1177/10497323231197387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
The positive deviance approach seeks to identify and learn from those that perform exceptionally well. Positive deviance as an approach to quality improvement is gaining traction in general practice. This study aimed to explore and compare stakeholders' perceptions of the factors that support the delivery of exceptional care in general practice and to refine a previously developed theoretical framework of factors associated with positively deviant care in general practice: the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Semi-structured interviews were conducted with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers in Irish general practice. Subsequently, a directed content analysis approach was employed to deductively analyse interview data using the IDEAL framework, and newly emerging factors were inductively analysed and abstracted into the framework. Several distinct strategies (e.g. patient activation and team collaboration), structures (e.g. facilities and staffing), and contextual factors (e.g. communication and rapport, and culture) were found to support the delivery of exceptional care, and differences in perceptions, values, and expectations emerged between patients and practice staff. Interview data largely supported the pre-determined factors posited by the IDEAL framework, and new factors were abstracted into the framework (e.g. facilities and infrastructure). Stakeholder engagement regarding the factors supporting exceptional care in general practice supported and extended the IDEAL framework, contributing to a more comprehensive understanding of how exceptional care is delivered in general practice. The refined framework will support researchers, policymakers, and teams looking to support, measure, and achieve exceptionally good patient care in general practice.
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Affiliation(s)
- Roisin O’Malley
- Discipline of General Practice, University of Galway, Galway, Ireland
| | - Sinéad Lydon
- School of Medicine, Clinical Science Institute, University of Galway, Galway, Ireland
| | - Aileen Faherty
- Discipline of General Practice, University of Galway, Galway, Ireland
| | - Paul O’Connor
- Discipline of General Practice, University of Galway, Galway, Ireland
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López-Zambrano MA, Pita CC, Escribano MF, Galán Meléndez IM, Cebrián MG, Arroyo JJG, Huerta C, Cuadrado LM, Ruiperez CM, Núñez C, Zapata AP, de la Pinta MLR, Uriz MAS, Conejo ISA, Gomila CM, Carbajo MDL, Gómez AS. Factors associated to influenza vaccination among hospital's healthcare workers in the Autonomous Community of Madrid, Spain 2021-2022. Vaccine 2023; 41:6719-6726. [PMID: 37806803 DOI: 10.1016/j.vaccine.2023.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/12/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023]
Abstract
Influenza vaccination (IV) aims primarily to protect high-risk groups against severe influenza-associated disease and death. It is recommended in Spain for high-risk groups, including Healthcare workers (HCWs). However, vaccination uptake has been consistently below desirable levels. The objective of this study were to evaluate influenza vaccination coverage using data from the regional vaccination registry, during 2021-2022 season, among HCWs in public hospitals in Autonomous Community of Madrid (CAM) and to explore factors associated with influenza vaccination. We conducted a cross-sectional study using administrative data retrieved from the Regional Department of Health data repositories. A multilevel logistic regression model was designed to estimate Level 1 (individual) and Level 2 (contextual) variables that are associated with HCẂs vaccination. The study population was HCWs from 25 public hospitals in CAM who were active during the period of the influenza 2021-2022 vaccination campaign. The global influenza vaccination coverage (IVC) was 52.1 %. All study Level 1 variables were significantly associated with vaccine uptake. Greater IVC is associated with individual characteristics: female (OR1.14; 95 %CI 1.09-1.19), older age 59-69 years old (OR1.72; 95 %CI 1.60-1.84), born in Spain, medical staff, more than one high-risk condition (OR1.24; 95 %CI 1.10-1.40; respectively) and vaccinated in two previous campaigns (OR25.64; 95 %CI 24.27-27.09). IVC was highest among HCWs celiac disease (65.5 %) followed by diabetes mellitus (65.1 %) and chronic inflammatory disease (64.3 %). The hospital where the study subject worked also showed an effect on the vaccination uptake, although Level 2 variable (hospital complexity) was not positively associated. IVC in HCWs remains suboptimal. These findings may prove useful to tailor strategies to reach specific groups. It is recommended to delve into the identification of factors associated with the HCWs workplace that may have a positive impact on IV.
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Affiliation(s)
- María Alejandra López-Zambrano
- Subdirección General de Prevención y Promoción de la Salud, Consejería de Sanidad de la Comunidad Autónoma de Madrid, Spain.
| | - Covadonga Caso Pita
- Servicio de Prevención de Riesgos Laborales, Hospital Clínico San Carlos, Madrid, Spain.
| | | | - Isabel Mª Galán Meléndez
- Servicio de Prevención y Salud Laboral, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
| | - Manuela García Cebrián
- Servicio de Prevención de Riesgos Laborales, Hospital Universitario de La Princesa, Hospital Infantil Universitario Niño Jesús, Hospital Universitario Santa Cristina, Madrid, Spain.
| | | | - Carmen Huerta
- Servicio de Prevención Riesgos Laborales, Hospital Universitario de Móstoles, Madrid, Spain.
| | - Luis Mazón Cuadrado
- Servicio de Prevención de Riesgos Laborales, Hospital Universitario de Fuenlabrada, Madrid, Spain.
| | - Carmen Muñoz Ruiperez
- Servicio de Medicina del Trabajo y Prevención de Riesgos Laborales, Hospital Universitario 12 de octubre, Madrid, Spain.
| | - Concha Núñez
- Servicio de Prevención Riesgos Laborales, Hospital U. La Paz-Carlos III-Cantoblanco, Madrid, Spain.
| | - Aurora Pérez Zapata
- Servicio de Prevención de Riesgos Laborales - Salud Laboral, Hospital Universitario Príncipe de Asturias, Madrid, Spain.
| | | | - Mª Angeles Sánchez Uriz
- Servicio de Prevención Mancomunado de Grupo, Hospital Universitario Infanta Leonor, Madrid, Spain.
| | | | | | - Mª Dolores Lasheras Carbajo
- Subdirección General de Prevención y Promoción de la Salud, Consejería de Sanidad de la Comunidad Autónoma de Madrid, Spain.
| | - Amaya Sánchez Gómez
- Subdirección General de Prevención y Promoción de la Salud, Consejería de Sanidad de la Comunidad Autónoma de Madrid, Spain.
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Distinguishing High-Performing From Low-Performing Hospitals for Severe Maternal Morbidity. Obstet Gynecol 2022; 139:1061-1069. [DOI: 10.1097/aog.0000000000004806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/10/2022] [Indexed: 11/26/2022]
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O'Malley R, O'Connor P, Madden C, Lydon S. A systematic review of the use of positive deviance approaches in primary care. Fam Pract 2022; 39:493-503. [PMID: 34849733 DOI: 10.1093/fampra/cmab152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care. OBJECTIVE(S) This review aimed to synthesize the extant research on applications of the PD approach in primary care. METHODS Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS). RESULTS In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels. CONCLUSION Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.
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Affiliation(s)
- Roisin O'Malley
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Paul O'Connor
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Caoimhe Madden
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Sinéad Lydon
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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Singh S, Mazor KM, Fisher KA. Positive deviance approaches to improving vaccination coverage rates within healthcare systems: a systematic review. J Comp Eff Res 2019; 8:1055-1065. [PMID: 31580161 DOI: 10.2217/cer-2019-0056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Our objective was to systematically review the use of the positive deviance approach to identify strategies to improve vaccination coverage rates. Materials & methods: We searched English language articles in Medline, Embase, Cochrane Library, CINAHL and PsycINFO without any date restrictions on 4 October 2017. We compiled a list of all strategies and evaluated the quality of these studies using the QATSDD tool. Results: After a review of 241 citations, we included eight studies. These studies focused on a wide variety of vaccines and settings. Core strategies that support vaccine uptake include the importance of tailoring and targeting in both messaging and delivery of vaccines and tracking delivery of vaccines. Patient and provider education, reminders, feedback loops, community collaborations, immunization registries and use of a medical home were also identified as other strategies. Conclusion: Our findings highlight several useful core strategies, which can be used to promote vaccination coverage. PROSPERO: CRD42017078221.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine & Community Health, University of Massachusetts School of Medicine, Worcester, MA 01655, USA.,Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group & Fallon Health, Worcester, MA 01605, USA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group & Fallon Health, Worcester, MA 01605, USA.,Department of Medicine, Pulmonary & Critical Care Medicine, University of Massachusetts School of Medicine, Worcester, MA 01655, USA
| | - Kimberly A Fisher
- Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group & Fallon Health, Worcester, MA 01605, USA.,Department of Medicine, Division of Geriatrics, University of Massachusetts School of Medicine, Worcester, MA 01655, USA
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Howell EA, Ahmed ZN, Sofaer S, Zeitlin J. Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics. Clin Obstet Gynecol 2019; 62:560-571. [PMID: 31206366 PMCID: PMC6988184 DOI: 10.1097/grf.0000000000000472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.
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Affiliation(s)
- Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute
- Departments of Population Health Science & Policy
- Obstetrics, Gynecology, and Reproductive Science
| | - Zainab N Ahmed
- Departments of Population Health Science & Policy
- Obstetrics, Gynecology, and Reproductive Science
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shoshanna Sofaer
- American Institutes for Research, Washington, District of Columbia
| | - Jennifer Zeitlin
- Departments of Population Health Science & Policy
- Icahn School of Medicine at Mount Sinai, New York, New York
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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Atkins D, Kilbourne AM, Shulkin D. Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration. Annu Rev Public Health 2017; 38:467-487. [DOI: 10.1146/annurev-publhealth-031816-044255] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.
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Affiliation(s)
- David Atkins
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
| | - Amy M. Kilbourne
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48109-5624
| | - David Shulkin
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
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Rose AJ, McCullough MB. A Practical Guide to Using the Positive Deviance Method in Health Services Research. Health Serv Res 2016; 52:1207-1222. [PMID: 27349472 DOI: 10.1111/1475-6773.12524] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To provide practical tips for health services researchers considering the use of positive deviance (PD) methods to help explain variations in quality of care or other meaningful parameters. DATA SOURCES Published literature and personal experience. STUDY DESIGN Narrative review. PRINCIPAL FINDINGS This review includes a discussion of possible applications of PD to health services research, some methodological choices applicable to PD, and some brief tips regarding publishing the results and incorporating them into future interventions. CONCLUSIONS It is hoped that this article will help health services researchers to use this valuable research method more effectively, especially those who have not done so before.
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Affiliation(s)
- Adam J Rose
- Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118.,Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA.,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA
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