ArticleLiterature Review

A systematic review of the use of positive deviance approaches in primary care

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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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... In primary care, PD has been gaining momentum [20] and early applications have been promising, generating improvements in various healthcare-related outcomes [20][21][22][23]. A strength of this approach is its emphasis on uncovering both the concrete strategies used to perform exceptionally well, and the latent and abstract factors that support their delivery (e.g., organisational culture) [24]. ...
... In primary care, PD has been gaining momentum [20] and early applications have been promising, generating improvements in various healthcare-related outcomes [20][21][22][23]. A strength of this approach is its emphasis on uncovering both the concrete strategies used to perform exceptionally well, and the latent and abstract factors that support their delivery (e.g., organisational culture) [24]. ...
... A recent review [20] synthesised applications of the PD approach in primary care to develop a framework of factors associated with positively deviant care outcomes; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. More recently, this theoretical framework has undergone further qualitative refinement to examine its comprehensiveness, validity, and applicability in a novel context [25,29]. ...
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Background In 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. Methods This 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. Results In 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). Conclusion The 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.
... We found a number of crucial "Rebels are needed […] to spot what's wrong and champion what's right, and to push for greater openness, constructive discussion, and evidence-based change." (Godlee, 2021, p. 1) Rebel nurse leadership practices are important for sustainable innovation, which benefits the quality of care and the nurses' work environment (Clancy, 2010;Godlee, 2021;O'Malley et al., 2021;. Therefore, our study aimed to explore and understand the concept of rebel nurse leadership in daily nursing practices. ...
... We found rebel nurse leadership practices promising because in essence they are intended to change nursing practices for the benefit of the patient, quality of care, and the nurses work environment (Clancy, 2010;Godlee, 2021;O'Malley et al., 2021;. However, the LAP perspective allowed us to see that rebel nurse leadership practices are often not fully utilized. ...
Thesis
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Verpleegkundigen worden regelmatig uitgedaagd om af te wijken van organisatieregels en -voorschriften wanneer deze niet passen bij hun (professionele) normen en overtuigingen over goede kwaliteit van zorg. Door in suboptimale situaties te handelen in het belang van hun patiënten of een goede werkomgeving tonen verpleegkundigen leiderschap. In het proefschrift van Eline de Kok staat centraal hoe verpleegkundigen dit positief afwijkende gedrag en rebelse leiderschap in praktijk brengen. Rebelse verpleegkundigen slagen erin grenzen te verleggen, gevestigde ideeën uit te dagen en buiten de lijntjes te kleuren zonder de steun van collega's en management te verliezen. Ze gaan opzoek naar elegante en efficiënte oplossingen en veranderen daarmee uiteindelijk de praktijk. Vijf aspecten kenmerken en beïnvloeden de rebelse verpleegkundigen leiderschapspraktijken: 1) het interne conflict, 2) de kracht van reflectie, 3) kennis, ervaring en vaardigheden, 4) de invloed van netwerken, relaties en samenwerkingsverbanden, en 5) de impactvolle samenwerking tussen verpleegkundig en leidinggevenden. Dit proefschrift beschrijft het belang van rebels verpleegkundig leiderschap voor innovatie binnen de gezondheidszorg en voor verbetering van de kwaliteit van zorg en de verpleegkundige werkomgeving. Echter, laat het ook zien dat rebelse leiderschapspraktijken weerbarstig zijn, zich vaak buiten het zicht van anderen afspelen en zich regelmatig beperken tot quick fixes in het hier en nu. Dit bemoeilijkt duurzame verandering en het potentieel van deze leiderschapspraktijken blijft onbenut. Om het potentieel beter te benutten liggen er kansen in het gezamenlijk reflecteren, leren en acteren op de invloed van regels, zeggenschap, feedback, gewoonten en professionele spanningen binnen de verpleegkundige praktijk.
... Interviews identified the strategies these children's parents used to feed their children; researchers then created interventions to encourage other parents to change their practices, resulting in a significant reduction in malnutrition. The positive deviance approach has since been applied to improve pregnancy outcomes (Ahrari et al., 2002), myocardial infarction treatment (Bradley et al., 2009), and primary care (O'Malley et al., 2022). In this study, we interviewed leaders at high-performing VHA sites (i.e., those that improved most in increasing engagement and reducing burnout) to directly obtain insights and advice on how they were successful to share these strategies with all leaders across the health care system. ...
... We aimed, using a positive deviance approach, to develop hypotheses about how VHA leaders can address engagement and burnout (Bradley et al., 2009;O'Malley et al., 2022). This approach studies positive deviants (organizational components with exceptionally high performance identified quantitatively; Newton, 2016) by using qualitative methods to identify factors that enable these components to achieve top performance. ...
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In health care settings, employee engagement and burnout vary widely. Little is known, however, about how leadership actions may influence this variation. This study identified leadership behaviors that may increase employee engagement and decrease staff burnout in the Veterans Health Administration (VHA). Applying a positive deviance approach to examine organizational survey data across the entire administration, we first statistically identified VHA sites that, based on employee feedback, showed the greatest improvement in engagement or burnout from 2021 to 2022. We then interviewed these sites’ directors (N = 15) or primary care service chiefs (N = 13) about how they achieved this. Findings indicate commonalities across these leaders’ best practices. Interviewees emphasized creating community, making providers feel valued, including staff to assess and optimize organizational efficiency, and strategically communicating to obtain feedback and share updates. These findings highlight skills and attention foci of health care leaders relevant to increasing engagement and decreasing burnout.
... 14 A focus on positive culture, behaviors, and positive deviance can improve care quality and overall outcomes. 15 A positive and caring culture is built with intention, based on open communication and respect, and it is reinforced in the actions and behaviors of every team member in every interaction. ...
... PATIENT EXPERIENCE JOURNAL 2024;11(1):[14][15][16][17][18][19][20] ...
... The positive deviance approach has also been successfully implemented in healthcare settings to prevent healthcare-associated infections [8], reduce medication errors [9], and improve hand hygiene practices [10]. A systematic review that explored the positive deviance approaches within the primary care settings identified that positive deviants were more successful in improving disease management and health promotion, and positively influenced patients' health-related behaviors [11]. A review of nurses' role in positive deviance indicated that clinical settings, even in general circumstances, comprise uncertainties, and the decision-making often involves risks as the applicable professional standards may not always be readily available [12]. ...
... They also highlighted the value of teamwork as an important lesson they learned while finding solutions. Such traits are positively contagious and capable of inspiring and motivating others in a team in different healthcare settings [11]. A study on nurses described that the colleagues identified the positive deviant nurses as those who could bring everyone together as a team and were insightful and resourceful to bring positive changes [38]. ...
Article
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Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic.
... In addition, a combination of media influence and stakeholder recommendation [64], implementation-based [29], and experience-based criteria have also been used [31,91]. In six articles, the criteria for the selection of PDs were unclear or unspecified [39,47,50,76,143,145] and in the remaining papers, the selection of PDs does not apply as they are systematic reviews [20,57,59,63] and adoption program papers that are implemented based on best practices identified from other positive deviant practices [28,51,54,67,92,119]. However, performance-based criteria have been used to identify PDs at individual, health facility or health system levels in majority of the articles [11, 23, 24, 26, 27, 30, 32, 33, 35-38, 40-46, 48, 53, 55, 56, 60-62, 65, 66, 68-75, 77, 78, 80-88, 90, 93, 95-97, 99-105, 107-118, 121, 122, 124-142, 144]. ...
... [13][14][15] Furthermore, several studies have used the approach in different situations, including in nursing leadership, 16 in healthcare organisations, 17 patient safety, 18 healthcare equity in quality and obstetrical safety, 19 healthcare quality and safety, 20 in family planning and community-based health interventions 11 21 and for primary care. 22 However, the available evidence on PD is mixed and there are controversies on the effectiveness of the approach, particularly in complex and demanding settings including the healthcare system. This is due in large part to methodological limitations of the extant studies including inconsistencies in the quality of strategies employed to identify PDs or positive deviant practices. ...
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Introduction Healthcare systems are currently facing challenges in enhancing access and improving the quality of healthcare services around the world, and one of the innovative strategies that have been used to address such challenges is the positive deviance (PD) approach. The approach assumes that identifying, examining, understanding and disseminating solutions to problems that are already available within the community and organisations including the healthcare system can help in bringing improvements at scale. However, to the best of the researcher’s knowledge, there is no scoping review, that is, conducted to map and synthesise the available evidence on the use of the PD approach for healthcare system service improvements. Hence, this scoping review aims to map and synthesise resources on the methodologies and reported outcomes and identify gaps and potentials regarding the use of the PD approach in the healthcare system. Methods and analysis Articles will be searched and retrieved in research databases such as PubMed, Embase and Scopus. Retrieved articles will be screened independently for inclusion through a title and, or abstract review. Then, articles that passed the title and abstract review will be screened by reading the full texts. A descriptive mapping and synthesis of the literature will be employed to present data using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews checklist and data will be presented in text, figure and table formats. Ethics and dissemination The results of this scoping review will be published in peer-reviewed reputable international journals. Furthermore, it will also be disseminated through conference presentations, and popular press to the wider community. However, formal ethical approval is not required as primary data will not be collected.
... In more than 30 years of its history, the practice of positive deviance approach has been so far implemented in 65 countries at a different scale and has impacted more than 30 million people in the world as of May 2022 (Positive Deviance Collaborative, 2022). In one of the largest health-related database, PubMed, seven review articles are available on nutrition (Bisits Bullen PA, 2011, Machado et al., 2014, hand hygiene and infections (Alzunitan et al., 2022), healthcare (Baxter et al., 2016;Singh et al., 2019;O'Malley et al., 2022), and research methodology (Foster et al., 2022). These articles show both strengths and weaknesses of the positive deviance approach as a practice and as research. ...
... Furthermore, several studies have used the approach in different situations, including in nursing leadership (16), in healthcare organizations (17), patient safety (18), healthcare equity in quality, and obstetric safety (19), healthcare quality and safety (20), in family planning and community-based health interventions (11,21), and for primary care (22). ...
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Introduction: Healthcare systems are currently facing challenges in enhancing access and improving the quality of healthcare services around the world, and one of the innovative strategies that have been utilized to address such challenges is the positive deviance (PD) approach. The approach assumes that identifying, examining, understanding, and disseminating solutions to problems that are already available within the community and organizations including the healthcare system can help in bringing improvements at scale. However, to the best of the researcher's knowledge, there is no scoping review that is conducted to map and synthesize the available evidence on the use of the PD approach for healthcare system service improvements. Hence, this scoping review aims to map and synthesize resources on the methodologies and reported outcomes and identify gaps and potentials regarding the use of the PD approach in the healthcare system. Methods and analysis: Articles will be searched and retrieved in research databases such as PubMed, Embase, and Scopus. Retrieved articles will be screened independently for inclusion through a title and, or abstract review. Then, articles that passed the title and abstract review will be screened by reading the full texts. A descriptive mapping and synthesis of the literature will be employed to present data using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and data will be presented in text, figure, and table formats. Ethics and dissemination: The results of this scoping review will be published in peer-reviewed reputable international journals. Furthermore, it will also be disseminated through conference presentations, and popular press to the wider community. However, formal ethical approval is not required as primary data will not be collected.
Article
Aims: To (a) seek examples of nursing caring success stories and (b) identify the common contributors to these successes. By focusing on the successes of nursing care rather than critically examining failures, this research seeks to provide examples of proven and feasible approaches and processes for improving care. Design: This study used a narrative inquiry design. Methods: Data were collected through group interviews. Four interviews were conducted with a total of 20 nurse participants working in inpatient settings in South Australian hospitals. A thematic analysis approach was used to analyse the data. Results: Two dominant themes concerning the contributors to caring success were identified. These contributors were (1) the provision of holistic care and (2) the influence of the caring community, which includes family members and other patients. The findings also indicated that the definition of caring success according to nurses is not aligned with organisational performance indicators but is more closely represented by caring values. Conclusion: Success, according to nurses, is not exclusively defined by patient outcomes but includes the approach to, and process of, care delivery. Implications for the profession and/or patient care: Nurses value the caring process while working in an environment that primarily values clinical and systems-level outcomes. Nurses want patients and their families, allied health professionals and hospital executives to be involved and invested in the process of care. Impact: This study addressed a gap in the current literature to identify commonalities in nursing success stories, the contributors informing these successes and how these contributors can facilitate improved patient care. Understanding nursing definitions of caring success provides an opportunity to expand upon current accepted industry definitions and perspectives such as key performance indicators. Reporting method: Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Patient or public contribution: No direct patient or public contribution.
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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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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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Background Family-based ‘informal’ caregivers are critical to enable sustainable cancer care that produces optimal health outcomes but also gives rise to psychological burdens on caregivers. Evidence of psychosocial support for caregivers does not currently address the impacts of their role in providing clinical and health-related care for their loved ones. The present study sought to address this gap including with those from priority populations. Methods Qualitative data was collected using focus group and interview methods. We purposively sampled caregivers identified as having a high burden of responsibility for providing clinical care including those from ethnic minority backgrounds, parental caregivers and those living rurally. Transcripts were subject to thematic analysis utilising a team-based approach. Results Family-based caregivers included spouses (11), parents (7), children (1), siblings (1). Ten participants were from ethnic minority backgrounds and five participants were from regional or rural locations. Four resulting inter-related themes were; 1) Dual burden of providing clinical care and managing personal emotional distress; 2) Navigating healthcare partnership dynamics; 3) Developing a caregiving skillset, and 4) Unique supportive needs and barriers to access. These data provide evidence of the unique challenge of providing clinical care as part of family-based caregiving for a loved one with cancer, and the absence of support for caregivers to take up this role. Conclusion Our findings highlight the substantial contribution of family-based caregivers to the provision of cancer care in contemporary health systems. Inadequate support for caregivers is apparent with regard to their role in providing clinical aspects of care such as medication administration and management. Support programs to prepare caregivers to provide clinical care while building capacity to manage their stressors and emotions through this challenging period may be valuable towards sustainable, person-centred care.
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The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.
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Background The increasing prioritisation of healthcare quality across the six domains of efficiency, safety, patient-centredness, effectiveness, timeliness and accessibility has given rise to accelerated change both in the uptake of initiatives and the realisation of their outcomes to meet external targets. Whilst a multitude of change management methodologies exist, their application in complex healthcare contexts remains unclear. Our review sought to establish the methodologies applied, and the nature and effectiveness of their application in the context of healthcare. Methods A systematic review and narrative synthesis was undertaken. Two reviewers independently screened the titles and abstracts followed by the full-text articles that were potentially relevant against the inclusion criteria. An appraisal of methodological and reporting quality of the included studies was also conducted by two further reviewers. Results Thirty-eight studies were included that reported the use of 12 change management methodologies in healthcare contexts across 10 countries. The most commonly applied methodologies were Kotter’s Model (19 studies) and Lewin’s Model (11 studies). Change management methodologies were applied in projects at local ward or unit level (14), institutional level (12) and system or multi-system (6) levels. The remainder of the studies provided commentary on the success of change efforts that had not utilised a change methodology with reference to change management approaches. Conclusion Change management methodologies were often used as guiding principle to underpin a change in complex healthcare contexts. The lack of prescription application of the change management methodologies was identified. Change management methodologies were valued for providing guiding principles for change that are well suited to enable methodologies to be applied in the context of complex and unique healthcare contexts, and to be used in synergy with implementation and improvement methodologies.
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The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system–level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.
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Background The positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people. Methods A qualitative positive deviance study was conducted on four positively deviant and four slightly-above-average matched comparator wards, which had been identified using routinely collected NHS Safety Thermometer data. In total, 70 multidisciplinary staff participated in eight focus groups to explore staff perceptions about how their teams deliver safe patient care. A thematic analysis was conducted in two stages: first to identify the tools, processes, strategies, and cultural and social contexts that facilitated safety across all wards; and second to generate hypotheses about the characteristics that facilitated ‘positively deviant’ patient care. Results Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented. Conclusion This study exemplifies that there are no ‘silver bullets’ to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes.
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This article outlines recent developments in safety science. It describes the progression of three ‘ages’ of safety, namely the ‘age of technology’, the ‘age of human factors’ and the ‘age of safety management’. Safety science outside healthcare is moving from an approach focused on the analysis and management of error (‘Safety‐1’) to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring (‘Safety‐2’). A key factor in the understanding of safety within organisations relates to the distinction between ‘work as imagined’ and ‘work as done’. ‘Work as imagined’ assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the ‘sharp end’ of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include ‘appreciative inquiry’, ‘positive deviance’ and excellence reporting.
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Objective: We set out to investigate the behaviors of low-income African American women who successfully lost weight. Methods: From an urban, academic, family medicine practice, we used a mixed methods positive deviance approach to evaluate 35 low-income African American women who were obese and lost at least 10% of their maximum weight, and maintained this loss for 6 months, comparing them with 36 demographically similar control participants who had not lost weight. Survey outcomes included demographics and behaviors that were hypothesized to be related to successful weight loss. Interviews focused on motivations, barriers, and what made weight loss successful. Survey data were analyzed using t tests and linear regression for continuous outcomes and chi-square tests and logistic regression for categorical outcomes. Interviews were analyzed using a modified approach to grounded theory. Results: In adjusted analyses, women in the positive deviant group were more likely to be making diet changes compared with those women who did not lose at least 10% of their initial body weight. Major themes from qualitative analyses included ( a) motivations (of health, appearance, quality of life, family, and epiphanies), ( b) opportunity (including time and support), ( c) adaptability. Conclusions: The findings of this study may be useful in developing motivational interviewing strategies for primary care providers working with similar high-risk populations.
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Objective Solutions to quality and safety problems exist within healthcare organisations, but to maximise the learning from these positive deviants, we first need to identify them. This study explores using routinely collected, publicly available data in England to identify positively deviant services in one region of the country. Design A mixed methods study undertaken July 2014 to February 2015, employing expert discussion, consensus and statistical modelling to identify indicators of quality and safety, establish a set of criteria to inform decisions about which indicators were robust and useful measures, and whether these could be used to identify positive deviants. Setting Yorkshire and Humber, England. Participants None - analysis based on routinely collected, administrative English hospital data. Main outcome measures We identified 49 indicators of quality and safety from acute care settings across eight data sources. Twenty-six indicators did not allow comparison of quality at the sub-hospital level. Of the 23 remaining indicators, 12 met all criteria and were possible candidates for identifying positive deviants. Results Four indicators (readmission and patient reported outcomes for hip and knee surgery) offered indicators of the same service. These were selected by an expert group as the basis for statistical modelling, which supported identification of one service in Yorkshire and Humber showing a 50% positive deviation from the national average. Conclusion Relatively few indicators of quality and safety relate to a service level, making meaningful comparisons and local improvement based on the measures difficult. It was possible, however, to identify a set of indicators that provided robust measurement of the quality and safety of services providing hip and knee surgery.
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Background Despite health care access challenges among underserved populations, patients, providers, and staff at community health clinics (CHCs) have developed practices to overcome limited access. These “positive deviant” practices translate into organizational policies to improve health care access and patient experience. Objective To identify effective practices to improve access to health care for low-income, uninsured or underinsured, and minority adults and their families. Participants Seven CHC systems, involving over 40 clinics, distributed across one midwestern state in the United States. Methods Ninety-two key informants, comprised of CHC patients (42%) and clinic staff (53%), participated in semi-structured interviews. Interview transcripts were subjected to thematic analysis to identify patient-centered solutions for managing access challenges to primary care for underserved populations. Transcripts were coded using qualitative analytic software. Results Practices to improve access to care included addressing illiteracy and low health literacy, identifying cost-effective resources, expanding care offerings, enhancing the patient–provider relationship, and cultivating a culture of teamwork and customer service. Helping patients find the least expensive options for transportation, insurance, and medication was the most compelling patient-centered strategy. Appointment reminders and confirmation of patient plans for transportation to appointments reduced no-show rates. Conclusion We identified nearly 35 practices for improving health care access. These were all patient-centric, uncovered by both clinic staff and patients who had successfully navigated the health care system to improve access.
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Purpose Low-income, African American women are disproportionately impacted by obesity. Little is known about the interactions between low-income, African American women who successfully lost weight and their primary care physicians (PCPs). Design Mixed methods, positive deviance study. Setting Urban university-based family medicine practice. Participants The positive deviance group comprised low-income, African American women who were obese, lost 10% body weight, and maintained this loss for 6 months. Measures The PCP- and patient-reported weight-related variables collected through the electronic medical record (EMR), surveys, and interviews. Analysis Logistic regression of quantitative variables. Qualitative analysis using modified grounded theory. Results The EMR documentation by PCPs of dietary counseling and a weight-related medical problem were significant predictors of positive deviant group membership. Qualitative analyses of interviews revealed 5 major themes: framing obesity in the context of other health problems provided motivation; having a full discussion around weight management was important; an ongoing relationship with the physician was valuable; celebrating small successes was beneficial; and advice was helpful but self-motivation was necessary. Conclusion The PCP counseling may be an important factor in promoting weight loss in low-income, African American women. Patients may benefit from their PCPs drawing connections between obesity and weight-related medical conditions and enhancing intrinsic motivation for weight loss.
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Background Engaging health care staff in new quality improvement programs is challenging. Objective We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program. Methods Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation). Results A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%). Conclusions Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.
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Context and objective: Patient advisory councils (PACs) are a strategy for primary care clinics to engage patients in practice improvement. However, there is scant research on how PACs function. This study aimed to understand how PACs are organized and identify common challenges and perceived benefits of high-functioning PACs. Setting and population: Key informants identified 8 primary care clinics in California with high-functioning PACs. Leaders from each of the 8 clinics nominated 1 clinic staff member and 1 PAC patient member to be interviewed. Study design: Semistructured, one-on-one interviews were conducted at each clinic site or by phone. Interviews were dual-coded using modified grounded theory. Common themes were identified that would be pertinent to the development of future best practices for running PACs. Results: Common characteristics of high-functioning PACs included careful attention to participant recruitment, facilitation strategies guiding diverse personalities toward a common purpose, and assigning accountability for practice improvement projects. Interviewees identified a variety of positive outcomes that ranged from tangible improvements to the waiting area to a more patient-centered staff culture. Conclusions: PACs show potential for promoting patient-centered practice improvements in primary care. Lessons learned from high-functioning PACs can inform a common set of strategies to assist practices in creating and sustaining effective advisory councils.
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Background: It is an important goal to vaccinate a high proportion of health care providers (HCPs) against influenza, to prevent transmission to patients. Different aspects of how a HCP vaccination campaign is conducted may be linked to different vaccination rates. We sought to characterize organizational factors and practices that were associated with vaccination campaign success among six sites within the Veterans Health Administration, where receipt of flu-vaccination is voluntary. Method: We conducted a total of 31 telephone interviews with key informants who were involved with HCP flu vaccination campaigns at three sites with high-vaccination rates and three sites with low-vaccination rates. We compared the organization and management of the six sites' campaigns using constant comparison methods, characterzing themes and analyzing data iteratively. Results: Three factors distinguished sites with high flu vaccination rates from those with low vaccination rates. 1) High levels of executive leadership involvement: demonstrating visible support, fostering new ideas, facilitating resources, and empowering flu team members; 2) Positive flu team characteristics: high levels of collaboration, sense of campaign ownership, sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign; and 3) Several concrete strong practices emerged: advance planning, easy access to the vaccine, ability to track employee vaccination status, use of innovative methods to educate staff, and use of audit and feedback to promote targeted efforts to reach unvaccinated employees. Conclusion: Successful HCP flu campaigns shared several recognizable characteristics, many of which are amenable to adoption or emulation by programs hoping to improve their vaccination rates.
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Background Primary care nurses and allied health clinicians are potential providers of opportunistic preventive care. This systematic review aimed to summarise evidence for the effectiveness of practice change interventions in increasing nurse or allied health professional provision of any of five preventive care elements (ask, assess, advise, assist, and/or arrange) for any of four behavioural risks (smoking, inadequate nutrition, alcohol overconsumption, physical inactivity) within a primary care setting. Methods A search of Medline, Embase, PsycInfo, and CINAHL databases was undertaken to locate controlled intervention trials published between 1992 and May 2014 that provided practice change interventions to primary care nurses and/or allied health professionals to increase preventive care. The effect of interventions aimed at increasing the provision of any of the five care elements for any of the four behavioural risks was examined. A narrative synthesis was utilised. Results From 8109 articles, seven trials met the inclusion criteria. All trials bar one, assessed multi-strategic practice change interventions (three to five strategies) focused on care by nurses (six trials) or mixed nursing/allied health clinicians. One trial examined care provision for all four risks, five trials examined care for smoking only, and one trial examined care for alcohol consumption only. For the six trials reporting significance testing (excludes one smoking care trial), significant effects favouring the intervention group were reported in at least one trial for smoking risk assessment (2/4 trials reported an effect for at least one analysis of an assessment outcome), brief advice (2/3), assistance (2/2), and arranging referral (2/3); alcohol risk assessment (1/2) and brief advice (1/2); inadequate nutrition risk assessment (1/1); and physical inactivity risk assessment and brief advice (1/1). When the number of analyses undertaken within trials focusing on smoking care was considered, the results were less promising (e.g. of the 15 analyses conducted on brief advice variables across three trials, four showed a positive effect). Conclusions Evidence for the effect of practice change interventions on preventive care by primary care nurses or allied health providers is inconclusive given the small number of trials and inconsistency of results between and within trials. Systematic review registration number None Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0409-3) contains supplementary material, which is available to authorized users.
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Background: This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care. Design: This study is a systematic review of reviews. Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis. Results: Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term "cause" or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed "causes" in terms of "barriers and facilitators" to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders' buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the "fit" between the intervention and the context is critical in determining the success of implementation. Conclusions: This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here. Systematic review registration: PROSPERO CRD42014009410.
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Purpose: We aimed to identify the strategies used to support patient behavior change by clinicians whose patients had an increase in patient activation. Methods: This mixed methods study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization. We aggregated data on the change in patient activation measure (PAM) score for 7,144 patients to the primary care clinician level. We conducted in-depth interviews with 10 clinicians whose patients' score increases were among the highest and 10 whose patients' score changes were among the lowest. Transcripts of the interviews were analyzed to identify key strategies that differentiated the clinicians whose patients had top PAM change scores. Results: Clinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change (mean = 3.9 strategies): emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients. Clinicians whose patients had lesser change in activation were far less likely to describe using these approaches (mean = 1.3 strategies). Most clinicians, regardless of group, reported developing their own approach to support patient behavior change. Those whose patients showed high activation change reported spending more time with patients on counseling and education than did those whose patients showed less improvement in activation. Conclusions: Clinicians vary in the strategies they use to promote behavior change and in the time spent with patients on such activities. The 5 key strategies used by clinicians with high patient activation change are promising approaches to supporting patient behavior change that should be tested in a larger sample of clinicians to validate their effectiveness.
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The large-scale introduction of malaria rapid diagnostic tests (RDTs) promises to improve management of fever patients and the rational use of valuable anti-malarials. However, evidence on the impact of RDT introduction on the overprescription of anti-malarials has been mixed. This study explored determinants of provider decision-making to prescribe anti-malarials following a negative RDT result. A qualitative study was conducted in a rural district in mid-western Uganda in 2011, ten months after RDT introduction. Prescriptions for all patients with negative RDT results were first audited from outpatient registers for a two month period at all facilities using RDTs (n = 30). Facilities were then ranked according to overall prescribing performance, defined as the proportion of patients with a negative RDT result prescribed any anti-malarial. Positive and negative deviant facilities were sampled for qualitative investigation; positive deviants (n = 5) were defined ex post facto as <0.75 % and negative deviants (n = 7) as >5 %. All prescribing clinicians were targeted for qualitative observation and in-depth interview; 55 fever cases were observed and 22 providers interviewed. Thematic analysis followed the ‘framework’ approach. 8344 RDT-negative patients were recorded at the 30 facilities (prescription audit); 339 (4.06 %) were prescribed an anti-malarial. Of the 55 observed patients, 38 tested negative; one of these was prescribed an anti-malarial. Treatment decision-making was influenced by providers’ clinical beliefs, capacity constraints, and perception of patient demands. Although providers generally trusted the accuracy of RDTs, anti-malarial prescription was driven by perceptions of treatment failure or undetectable malaria in patients who had already taken artemisinin-based combination therapy prior to facility arrival. Patient assessment and other diagnostic practices were minimal and providers demonstrated limited ability to identify alternative causes of fever. Provider perceptions of patient expectations sometimes appeared to influence treatment decisions. The study found high provider adherence to RDT results, but that providers believed in certain clinical exceptions and felt they lacked alternative options. Guidance on how the RDT works and testing following partial treatment, better methods for assisting providers in diagnostic decision-making, and a context-appropriate provider behaviour change intervention package are needed.
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Importance Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. Objective We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. Evidence review We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. Findings Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2–3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. Conclusions and relevance Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. Systematic review registration This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).
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Objective To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. Design Systematic review of reviews. Data sources MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. Eligibility criteria for selecting studies Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. Data synthesis Extracted data were synthesised using a narrative approach. Results 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2–9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. Conclusions There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO registration number CRD42014009410.
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Introduction: Positive deviance is an asset-based approach to improvement which has recently been adopted to improve quality and safety within healthcare. The approach assumes that solutions to problems already exist within communities. Certain groups or individuals identify these solutions and succeed despite having the same resources as others. Within healthcare, positive deviance has previously been applied at individual or organisational levels to improve specific clinical outcomes or processes of care. This study explores whether the positive deviance approach can be applied to multidisciplinary ward teams to address the broad issue of patient safety among elderly patients. Methods and analysis: Preliminary work analysed National Health Service (NHS) Safety Thermometer data from 34 elderly medical wards to identify 5 'positively deviant' and 5 matched 'comparison' wards. Researchers are blinded to ward status. This protocol describes a multimethod, observational study which will (1) assess the concurrent validity of identifying positively deviant elderly medical wards using NHS Safety Thermometer data and (2) generate hypotheses about how positively deviant wards succeed. Patient and staff perceptions of safety will be assessed on each ward using validated surveys. Correlation and ranking analyses will explore whether this survey data aligns with the routinely collected NHS Safety Thermometer data. Staff focus groups and researcher fieldwork diaries will be completed and qualitative thematic content analysis will be used to generate hypotheses about the strategies, behaviours, team cultures and dynamics that facilitate the delivery of safe patient care. The acceptability and sustainability of strategies identified will also be explored. Ethics and dissemination: The South East Scotland Research Ethics Committee 01 approved this study (reference: 14/SS/1085) and NHS Permissions were granted from all trusts. Findings will be published in peer-reviewed, scientific journals, and presented at academic conferences. Trial registration number: This study is registered on the UK Clinical Research Network Study Portfolio (reference number-18050).
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Background The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. ‘Positive deviants’ are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved. Methods Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed. Results 37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources. Conclusion Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches. PROSPERO registration number CRD42014009365.
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The current approach to patient safety, labelled Safety I, is predicated on a 'find and fix' model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. We need to switch the focus to what we have come to call Safety II: a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails. Clinicians constantly adjust what they do to match the conditions. Facilitating work flexibility, and actively trying to increase the capacity of clinicians to deliver more care more effectively, is key to this new paradigm. At its heart, proactive safety management focuses on how everyday performance usually succeeds rather than on why it occasionally fails, and actively strives to improve the former rather than simply preventing the latter. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
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To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes. Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices. Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems. In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities. Copyright © 2015 by the American Academy of Pediatrics.
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Objectives: To identify elements that are integral to high-quality practice and determine considerations relating to high-quality practice organisation in primary care. Study design: A narrative systematic review of published and grey literature. Data sources: Electronic databases (PubMed, CINAHL, the Cochrane Library, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service website, Google Scholar) were searched in November 2013 and used to identify articles published in English from 2002 to 2013. Reference lists of included articles were searched for relevant unpublished articles and reports. Data synthesis: Data were configured at the study level to allow for the inclusion of findings from a broad range of study types. Ten elements were most often included in the existing organisational assessment tools. A further three elements were identified from an inductive thematic analysis of descriptive articles, and were noted as important considerations in effective quality improvement in primary care settings. Conclusion: Although there are some validated tools available to primary care that identify and build quality, most are single-strategy approaches developed outside health care settings. There are currently no validated organisational improvement tools, designed specifically for primary health care, which combine all elements of practice improvement and whose use does not require extensive external facilitation.
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In 2008, the Sunshine Coast Division of General Practice (SCDGP) in Queensland, Australia initiated a highly successful Improved Diabetes Management (IDM) program with general practices in a regional area. The IDM program was evaluated against the 10 elements of a high functioning clinical microsystem framework as identified by Nelson et al. (2007) in order to determine key factors contributing to the successful adoption and uptake of the program in participating general practices. The evaluation focussed on in-depth key informant interviews with 10 SCDGP staff and general practitioners (GPs) involved in the IDM program. A thematic analysis was undertaken and common emergent themes were reviewed against the 10 elements of high performing clinical microsystem. While all aspects of the clinical microsystem approach appeared effective in the design, implementation and adoption of the IDM program, several characteristics were crucial. The identification of champions of change in both the division and participating practices, the celebration of positive achievements and the use 'real data' from practices to demonstrate improved health outcomes for patients from the practice were instrumental in motivating participating GPs to both implement and sustain changes in their diabetes care delivery. In designing and redesigning health care, the clinical microsystems approach offers a pathway for the effective uptake of innovation in Australian primary health care; a means of integrating structure, process and outcomes of a care framework for reviewing improvements in the health care delivery process and could lead to improvements in patient health outcomes.
Article
Background: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. Objective: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. Design: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). Participants: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. Interventions: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). Main measures: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. Key results: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). Conclusions: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.
Article
Background Healthcare-associated infections (HAIs) remain a major challenge. Various strategies have been tried to prevent or control HAIs. Positive deviance, a strategy that has been used in the last decade, is based on the observation that a few at-risk individuals follow uncommon, useful practices and that, consequently, they experience better outcomes than their peers who share similar risks. We performed a systematic literature review to measure the impact of positive deviance in controlling HAIs. Methods A systematic search strategy was used to search PubMed, CINAHL, Scopus, and Embase through May 2020 for studies evaluating positive deviance as a single intervention or as part of an initiative to prevent or control healthcare-associated infections. The risk of bias was evaluated using the Downs and Black score. Results Of 542 articles potentially eligible for review, 14 articles were included for further analysis. All studies were observational, quasi-experimental (before-and-after intervention) studies. Hand hygiene was the outcome in 8 studies (57%), and an improvement was observed in association with implementation of positive deviance as a single intervention in all of them. Overall HAI rates were measured in 5 studies (36%), and positive deviance was associated with an observed reduction in 4 (80%) of them. Methicillin-resistant Staphylococcus aureus infections were evaluated in 5 studies (36%), and positive deviance containing bundles were successful in all of them. Conclusions Positive deviance may be an effective strategy to improve hand hygiene and control HAIs. Further studies are needed to confirm this effect.
Article
Research Objective Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. Understanding the context within which testosterone prescribing occurs is key to planning successful interventions to improve guideline‐concordant prescribing. We examined system‐ and clinician‐level factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. Study Design We conducted a qualitative study using a positive deviance approach to understand practice variation in high‐ and low‐testosterone prescribing sites. Semi‐structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross‐case matrix was created to evaluate variation across high‐ and low‐prescribing sites. Population Studied Twenty‐two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high‐ and 3 low‐testosterone prescribing sites. These high‐ and low‐testosterone‐prescribing sites were located in six states and all four regions of the United States. Principal Findings We identified four system‐level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well‐defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician‐level domains were also identified: structured initial testosterone prescribing process and well‐specified follow‐up protocols following testosterone prescription. The four system‐level domains were related systematically to level of testosterone prescribing whereas the clinician level domains were similar across all sites. At all sites, most testosterone prescriptions were initiated by patient request and clinicians varied in their adherence to guideline‐concordant prescribing. The third high‐prescribing site was unusual in that, at the time of our visit, it exhibited system‐level domain characteristics similar to the 3 low‐prescribing sites. This outlier had recognized its status as a high‐prescribing site and implemented several improvement strategies in the year between selection and interviews, resulting in greatly reduced rates of testosterone prescribing. Conclusions In this study, we found that low‐prescribing sites shared some common features, including easier access to specialty care expertise, existence of an electronic health record‐based system to facilitate guideline‐concordant prescribing, well‐defined dissemination processes for information, availability of guidance from multiple sources, and clarity regarding what constitutes best practices for prescribing. Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record‐based system to facilitate guideline‐concordant prescribing, well‐defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing. Implications for Policy or Practice The use of these system‐level factors to change medication prescribing can also be extrapolated to improving other prescribing behavior, including safer prescribing of high‐risk drugs and facilitating deprescribing of unnecessary and/or harmful medications. Lessons learned from this study will serve as an exemplar for any site aiming to improve its testosterone‐prescribing practices and prescribing in general beyond testosterone. Primary Funding Source Department of Veterans Affairs.
Article
Introduction Despite the safety and efficacy of the human papillomavirus vaccine, thousands are impacted by human papillomavirus and its related cancers. Rural regions have disproportionately low rates of human papillomavirus vaccination. Primary care clinics play an important role in delivering the human papillomavirus vaccine. A positive deviance approach is used to identify workflows, organizational factors, and communication strategies in rural clinics with higher human papillomavirus vaccine up-to-date rates. Positive deviance is a process by which exceptional behaviors and strategies are identified to understand factors that enable success. Methods Rural primary care clinics were rank ordered by human papillomavirus vaccine up-to-date rates using 2018 Oregon Immunization Program data, then recruited via purposive sampling of clinics in the top and bottom quartiles. Two study team members conducted previsit interviews, intake surveys, and 2-day observation visits with 12 clinics and prepared detailed field notes. Data were collected October–December 2018 and analyzed using a thematic approach January–April 2019. Results Four themes distinguished rural clinics with higher human papillomavirus vaccine up-to-date rates from those with lower rates. First, they implemented standardized workflows to identify patients due for the vaccine and had vaccine administration protocols. Second, they designated and supported a vaccine champion. Third, clinical staff in higher performing sites were comfortable providing immunizations regardless of visit type. Finally, they used clear, persuasive language to recommend or educate parents and patients about the vaccine's importance. Conclusions Positive deviance identified characteristics associated with higher human papillomavirus vaccine up-to-date rates in rural primary care clinics. These findings provide guidance for rural clinics to inform human papillomavirus vaccination quality improvement interventions.
Article
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.
Article
The revised edition of the Handbook offers the only guide on how to conduct, report and maintain a Cochrane Review ? The second edition of The Cochrane Handbook for Systematic Reviews of Interventions contains essential guidance for preparing and maintaining Cochrane Reviews of the effects of health interventions. Designed to be an accessible resource, the Handbook will also be of interest to anyone undertaking systematic reviews of interventions outside Cochrane, and many of the principles and methods presented are appropriate for systematic reviews addressing research questions other than effects of interventions. This fully updated edition contains extensive new material on systematic review methods addressing a wide-range of topics including network meta-analysis, equity, complex interventions, narrative synthesis, and automation. Also new to this edition, integrated throughout the Handbook, is the set of standards Cochrane expects its reviews to meet. Written for review authors, editors, trainers and others with an interest in Cochrane Reviews, the second edition of The Cochrane Handbook for Systematic Reviews of Interventions continues to offer an invaluable resource for understanding the role of systematic reviews, critically appraising health research studies and conducting reviews.
Article
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.
Article
Background: Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. Purpose: To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. Methodology: A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. Results: Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion (p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice (p = .04), believing that patients and families feel respected (p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance (p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership (p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. Conclusions: Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. Practice implications: Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.
Article
Objective: Performance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures. Methods: Using a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods. Results: We identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices. Conclusions: This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.
Article
CONTEXT Historically, primary care (community and family) medicine has often been viewed as lower status than secondary care (hospital) practice. Current evidence suggests this pattern continues to impact medical practice and education. Medical education has however, yet to fully reflect this power dynamic, with undergraduate training in many institutions maintaining the hegemonic position of secondary care as the prime context for learning. METHODS In this paper, we present primary and secondary care as conflicting paradigms of medical practice. Using a sociocultural lens drawing on Figured Worlds theory, implications for medical education are explored. CONCLUSIONS We outline the two paradigms as having distinct epistemologies, identities and practices. Tensions at the primary–secondary care interface can, from a sociocultural perspective, be seen to impact developing identity and day-to-day clinical practice issues such as patient safety. We offer possibilities for engaging with paradigm conflict in meaningful ways and suggest potential changes for future educational policy and practice.
Article
Background: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. Objectives: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. Research design: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. Sampling: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. Results: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices. Conclusions: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.
Article
The term “positive deviance” has become increasingly popular in recent years, resulting in the co-existence of multiple definitions and applications scattered among diverse sources of academic literature. The aim of this paper is to bring conceptual clarity to the term by providing a comprehensive synthesis and review of the positive deviance literature. Analysis reveals conceptual and thematic differences in the language employed by authors applying positive deviance in a practical context compared with articles of a more theoretical nature. New directions are proposed for exploring the use and merit of the positive deviance concept into new areas of research.
Article
Background: Primary care provider (PCP) support of patient self-management may be important mechanism to improving patient health outcomes. In this paper we develop a PCP-reported measure of clinician strategies for supporting patient self-management, and we psychometrically test and validate the measure. Methods: We developed survey items based upon effective self-management support strategies identified in a prior mixed methods study. We fielded a survey in the fall of 2014 with 139 Fairview Health Services PCPs, and conducted exploratory factor analysis and Cronbach's Alpha to test for scale reliability. To validate the measure, we examined the Self-Management Support (SMS) scale's relationship to survey items on self-management support, as well as clinicians' patient panel rates of smoking cessation and weight loss. Results: Nine survey items clustered reliably to create a single factor (Cronbach's Alpha=0.73). SMS scores ranged from 2.1 to 4.9. The SMS was related to each of the validation variables. PCPs who reported spending 60% percent or more of their time counseling, educating, and coaching patients had a mean SMS score of 4.0, while those who reported spending less than 30% of their time doing so had mean SMS scores 15% lower. PCPs' SMS scores exhibited significant but modest associations with their patients' smoking cessation and weight loss (among obese patients) (r=0.21 and r=0.13 respectively). Conclusions: This study develops and tests a promising measure of PCPs' strategies to support patient self-management. It highlights variation across PCPs. Future work should examine whether increasing scores of PCPs low on the SMS improves chronic care quality outcomes.
Article
Purpose: To explore how converging fields of co-creation and positive deviance may increase value in healthcare. Methods: Informed by research in positive deviance, patient engagement, value co-creation, and quality improvement, we propose a positive deviance approach to co-creation of health. Results: Co-creation has shown to improve health outcomes with regard to multiple health conditions. Positive deviance has also shown to improve outcomes in multiple healthcare and patient community environments. Conclusion: A positive deviance co-creation framework may aid in achieving improved outcomes for patients, care teams and their respective healthcare organizations.
Article
Tell me how you measure me, and I will tell you how I will behave.Eliyahu Moshe Goldratt1 The pursuit of patient safety is a key component of the wider endeavour to improve quality of healthcare delivery. In its contemporary form, safety is characterised as a condition where the occurrence of adverse outcomes is minimised. Our efforts to improve safety are therefore almost entirely focused on identifying adverse incidents and errors, and implementing adaptations to avoid their recurrence. This reactive approach to safety (‘Safety-I’) advocates incident reporting and root-cause analysis in order to identify adverse incidents and their causes.2 Following major reports emphasising the significant role of human error3 and the need for organisational learning from adverse incidents,4 incident reporting has become well established in the National Health Service (NHS). Trends of monitoring and reporting of adverse events are increasing.5 ,6 While this approach may achieve good results, with higher levels of adverse incident reporting correlating with a more positive safety culture,5 some studies of healthcare safety interventions suggest that the benefits of this approach are limited.7 ,8 Adverse incident reporting is widely encouraged in the NHS, but reporting rates and methods for investigating incidents vary widely between organisations. Staff and patients may not always receive feedback about incidents in which they have been involved, and there is often inadequate evidence of lessons learned or effective change implemented following incidents.9 An important consideration of Safety-I practice is the potential negative impact on healthcare workers. Staff involved in incidents may often experience the second-victim phenomenon.10 Effects on second victims may include detachment, anxiety and depression, as well as reduced clinical confidence and cognitive functioning, potentially impairing that individual's clinical performance. Some may go on to suffer long-standing issues, similar to …
Article
Background: Influenza (flu) is an acute viral infection of the respiratory tract, which can lead to serious complications for individuals within at-risk groups. Evidence indicates that aspects of organization and delivery within GP practices can have an influence on the rates of flu vaccination uptake. Positive deviance is a methodological approach that facilitates identification of factors associated with high performance. Objective: To use positive deviance to isolate factors associated with high performance by comparing GP practices achieving high and low flu vaccination uptake. Methods: This was a qualitative study. A total of 18 practice managers and 2 GPs from 20 GP practices participated, 10 with high and low vaccination rates, respectively. Telephone interviews were conducted, audio recorded and fully transcribed. Framework Analysis was used to analyse the data. Results: High uptake practices were more likely than low uptake practices to have a lead member of staff who demonstrated tenacity, have aspirational uptake targets, have developed and used additional prompts within their IT systems to identify eligible patients, have GPs who were opportunistically vaccinating and use phone calls as a first-line strategy to invite patients for vaccination. Conclusions: This is the first known qualitative study to identify strategies used by UK GP practices to deliver seasonal flu vaccination programmes. It is one of few studies using the robust and novel approach of positive deviance to inform health care recommendations. This approach has offered new and more nuanced insights into GP practice factors associated high flu vaccination uptake beyond those captured through large-scale survey research.
Article
... microsystems , which comprise a unified health system. EMT, emergency medical technician; Cath, catheterization; Rehab, rehabilitation. Dan Vitale&apos;s Acute Myocardial Infarction (AMI) Journey in Health Care Copyright 2008 Joint Commission on Accreditation of Healthcare ...
Article
Background: Prescription drugs are a central component of healthcare worldwide. We investigated changes in drug-prescribing patterns over time in the general population. Methods: Secular trends were analyzed using 1999-2012 prescription data from The Health Improvement Network. Prevalence of receipt of medication prescriptions was computed by age, sex, and therapeutic category for each calendar year. Spearman correlations were computed to assess change over time. Results: Between 1999 and 2012, the percentage of the population that received at least one medication prescription increased from 64.5% to 69.2% (rho = 0.96, p < 0.001). The percentage of patients receiving prescriptions for one to four unique agents declined from 45.6% to 42.1% (Spearman's rho = -0.98, p < 0.001). Meanwhile, the percentage receiving five to nine and 10 or more unique agents increased from 14.1% to 17.5% (rho = 0.996, p < 0.001) and 4.7% to 9.6% (rho = 1.000, p < 0.001) respectively. Largest increases were seen in use of drugs for gastrointestinal disease among women and cardiovascular disease among men. In 2012, the most commonly used agents were for infection or nervous system drugs, with 32.0% and 28.9% of patients receiving at least one prescription, respectively. Conclusions: Nearly 70% of the United Kingdom population has received prescriptions for one or more medication with increasing proportions receiving prescriptions for five or more. The high rates of medication use increase the complexity and cost of healthcare. These data can be used for public health planning and to design pharmacoepidemiology and comparative effectiveness studies. Copyright © 2015 John Wiley & Sons, Ltd.
Article
Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.
Article
Background: There is growing evidence that practice-based care management can improve clinical quality and reduce costly healthcare utilization. Objectives: To explore how a disparate group of patient-centered medical homes (PCMHs) embedded care management in their team care environment to identify best practices. Study design: A positive deviance approach was used to contrast care management implementation in practices having the greatest and least improvement on clinical measures of diabetes, the initial target disease for a multipayer-supported statewide initiative involving 25 National Committee on Quality Assurance-recognized PCMH practices participating in a regional learning collaborative. Methods: Practices were ranked according to their average absolute percentage point increase from baseline to 18 months on 3 diabetes quality measures. Semistructured interviews were conducted with 136 individuals in 21 of the 25 practices. Interview data were analyzed using grounded theory with NVivo 9.0 software. To develop hypotheses related to care management best practices, we compared and contrasted emerging themes across clinical performance tertiles. Results: Practices with the greatest diabetes improvement described (1) more patient-centered care manager duties, (2) better use of the electronic medical record (EMR) for messaging and patient tracking, and (3) stronger integration of the care manager into the care team compared with practices with the least diabetes improvement. Conclusions: PCMHs may want to ensure that care managers are available to meet with patients during visits, support patient self-management, fully leverage the EMR for team messaging and patient tracking, and ensure integration into the care team with office huddles and ongoing communication.
Article
There is ongoing interest in including grey literature in systematic reviews. Including grey literature can broaden the scope to more relevant studies, thereby providing a more complete view of available evidence. Searching for grey literature can be challenging despite greater access through the Internet, search engines and online bibliographic databases. There are a number of publications that list sources for finding grey literature in systematic reviews. However, there is scant information about how searches for grey literature are executed and how it is included in the review process. This level of detail is important to ensure that reviews follow explicit methodology to be systematic, transparent and reproducible. The purpose of this paper is to provide a detailed account of one systematic review team's experience in searching for grey literature and including it throughout the review. We provide a brief overview of grey literature before describing our search and review approach. We also discuss the benefits and challenges of including grey literature in our systematic review, as well as the strengths and limitations to our approach. Detailed information about incorporating grey literature in reviews is important in advancing methodology as review teams adapt and build upon the approaches described. Copyright © 2013 John Wiley & Sons, Ltd. Copyright © 2013 John Wiley & Sons, Ltd.
Article
Importance Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment.Objective To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia.Design, Setting, and Participants Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.Main Outcomes and Measures Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks.Results There were 652 378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205 857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430 178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.Conclusions and Relevance Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.