Introduction

Positive deviance (PD) is based on the observation that in every community there are certain individuals or groups whose uncommon practices enable them to find better solutions to problems than their neighbors or colleagues despite having access to the same resources. These individuals are known as positive deviants [1, 2].

History

PD, pioneered by Jerry and Monique Sternin of the Positive Deviance Initiative (PDI), has been used worldwide to combat such intractable problems as childhood malnutrition, sex trafficking of girls, and poor infant health [2]. PD has also been used to control MRSA in the healthcare setting [3••, 4, 5•].

A New Form of Management

The PD approach is totally different from the traditional approach for stimulating performance improvement in any area. In PD the healthcare workers decide how the work should be done and they promote discovery among their peers. The leadership and managers support frontline workers in implementing new ideas into their routine [5•, 6••, 7]. The positive deviants discuss problems that they have noticed (e.g., Dr. X did not wash his hands before a patient examination; Dr. Y did not perform hand hygiene even after examining a patient in contact precautions). Participants discuss ways to stimulate a discussion with noncompliant individuals in a positive manner. No embarrassment is permitted.

A core principle of PD is the belief that solutions to seemingly intractable problems already exist [1, 2]. Another important concept is that problems are discovered by members of the community, and the positive deviants with a spirit of creativity and innovation will share experiences, discuss these problems, and remove the barriers to find the solutions [2, 4, 8].

Different Initiatives

There are a number of successful interventions that have applied a PD approach. These successes have been observed in more than 41 countries in different fields such as education, healthcare, nutrition, public health, protecting vulnerable groups and for some other social problems [2].

The PDI’s web site (www.positivedeviance.org) [9] shares a network organization which is dedicated to amplifying the use of the PD approach in all those concepts mentioned above.

There are some examples from around the world that are important to mention:

  1. (a)

    A sustained 65 % to 80 % reduction in childhood malnutrition in Vietnamese communities, reaching a population of 2.2 million people [2, 9]

  2. (b)

    A significant reduction in childhood malnutrition in communities in 41 different countries around the world [2, 9]

  3. (c)

    A reduction in neonatal mortality in Pakistan, along with a blurring of defined gender roles and an increased voice for women [2, 9]

  4. (d)

    A reduction of 60 % in transmission of methicillin-resistant Staphylococcus aureus (MRSA) in American hospitals [3••, 4]

  5. (e)

    An increase of 50 % in primary school student retention in ten participating schools in Argentina [2, 9]

  6. (f)

    Thousands of female circumcisions averted in Egypt and the formation of dozens of female genital mutilation-free communities [2, 9]

  7. (g)

    A documented reduction in trafficking of girls in impoverished communities in East Java, Indonesia [2, 9]

There are other significant initiatives using PD that can be viewed at www.positivedeviance.org [9].

By sharing experiences it is possible to find solutions and to apply simple measures that can have a tremendous impact on society [8]. Positive deviants are reflective about their practices [10] and give thought to ways to improve their work. They are stimulated to find information through the internet or books or discussions with others [8]. At first glance the strategies employed by the deviants may not seem to be very unusual or innovative; in fact some of them appear to be common sense. The PD challenge is to disseminate these strategies to others. The leaders need to believe that PD can advance engagement of frontline workers in prevention efforts and implementation of all interventions.

Changing Behavior

In our experience, using PD to improve hand hygiene compliance, nurse managers facilitate the discussions among frontline workers and give the positive deviants opportunities to express their feelings about the best practices for hand hygiene to be implemented and to discuss what needs to be changed, what needs to be improved, what is wrong and what is right. One of the strategies from the PD project for improving hand hygiene compliance was to show the number of alcohol gel handrub aliquots dispensed per unit and to compare data and the impressions of healthcare workers [6••, 11].

Participants in PD meetings include, in addition to the nursing staff, physical therapists, pharmacists, dietitians, physicians, and cleaning and food service staff. During one of these meetings, the idea of using an indirect metric to assess staff adherence to hand hygiene practices emerged, i.e. the ratio between the number of alcohol gel handrub aliquots dispensed (registered on electronic counters) and the number of nurse visits to patients’ rooms (obtained from the nurse call system reports). The proposal was brought up during a discussion about the value of the month-by-month comparison of alcohol gel handrub use, where there was concern regarding variation in product use due to changes in occupancy rates and workload in the hospital unit [12].

Positive deviants are multipliers, and this contributes to the success of the PD program in the different initiatives [2, 6••, 8, 9].

Infection Prevention

The infection control unit was created to prevent healthcare-associated infections in the hospital by focusing on surveillance, organizational processes, and standardization of procedures and routines. A major objective of infection control is the creation of a proactive process and a structure for systematic data collection, interpretation and dissemination of information. Some hospital settings such as the intensive care unit, the oncology unit, the bone marrow transplantation unit and the dialysis unit require more attention [13]. Our infection control unit is staffed by infectious diseases physicians and nurses (infection preventionists). These individuals are responsible for infection control across hundreds of beds. However, it is unfair to assign all of these responsibilities to only one department.

All hospital personnel (doctors, nurses, physical therapists, speech pathologists, nutritionists and pharmacists) need to act as infection preventionists. Moreover, all hospital quality indicators need to be discussed at group meetings [14]. Priorities need to be analyzed and strategies need to be defined. Everyone should understand that the knowledge of some specific processes, such as central venous catheter insertion and hand hygiene compliance, and bring valuable information that could be addressed during PD meetings or case discussions [6••, 15]. The PD strategy worked because it had the accountability of the multidisciplinary team in the planning and implementation of different measures for improving infection control and prevention in the unit [6••, 7, 16, 17]. The hospital leadership needs to be involved. There are no leaders without followers [18].

Many solutions have been suggested by positive deviants in hospital settings. Some examples include: changing the position of the alcohol gel handrub dispensers to allow easier access and use; putting alcohol gel handrub dispensers on mobile x-ray machines [19]; changing the procedure for monitoring the consumption of alcohol gel handrub, which was initially performed by one single staff member each 48 h, and gradually evolved to become the responsibility of every professional involved with patient care at the end of their shift [6••]. Other solutions using the PD process were discovery and action dialogues (DADs) with colleagues on how to make the time around change of shift safer for patients [20•]. The outcome of one DAD was an agreement that the entire dialysis unit should be cleaned and disinfected by the prior shift before allowing patients on the next dialysis shift to enter the treatment area [20•].

Infection control personnel know that such improvement processes have a tremendous impact on the quality of care, but the question remains as to how to initiate and sustain this improvement.

The first step is to decrease the distance between the infection control unit personnel and the healthcare workers. PD promotes ownership of problems by frontline workers, and empowers the positive deviants to implement the infection control prevention processes. The next step is to accept and support ideas that arise during the team observations in their daily practice.

Recently, the number of nurse visits to patient rooms was measured by a nurse call system, which was installed in two step-down units [12]. The additional metric of compliance with the use of alcohol gel handrub by the nursing staff allowed calculation of the number of alcohol gel handrub aliquots dispensed/number of nurse visits to patient rooms [12].

Patient Safety

Patient safety is the cornerstone of a high-quality healthcare system [21]. Many quality indicators have been developed to quantify the best measures for taking care of patients [18, 21]. These quality indicators are also valuable tools for guiding and evaluating the interventions that are developed in response to adverse events [21, 22].

The 100,000 Lives Campaign and the subsequent 5 Million Lives Campaign promoted by the Institute for Healthcare Improvement (IHI) were important early steps in the patient safety movement [23]. These IHI campaigns supported the improvement of medical care and encouraged hospitals to follow 12 steps to reduce harm and deaths. Four of these steps are related to infection prevention (prevention of central line infections, prevention of ventilator-associated pneumonia, prevention of surgical site infections and reducing MRSA infection). This initiative inspired other nationwide patient safety and quality improvement efforts around the world [22].

In parallel there was a need to help organize and strengthen patient safety efforts standardizing hospitals with accreditation [23]. The National Patient Safety Goals developed by the Joint Commission [24], include improving hand hygiene compliance, preventing infections that are difficult to treat (such as MRSA), preventing bloodstream infection from central lines, preventing infection after surgery, and preventing catheter-associated urinary tract infections [25, 26, 27••, 28–30].

In most settings there are numerous violations of standard procedures that can put patients at risk, and yet comparatively few lead to harm or real danger [31]. They are therefore tolerated and even viewed as normal occurrences in routine work. Furthermore, they are influenced by a range of personal, social and organizational factors and their occurrence may also have a distinct time-course as a system migrates to the boundaries of safety or recalibrates following an adverse incident [31, 32].

PD tries to improve processes every single day by analyzing work flow, questioning possible errors, and promoting the view that all tasks are as insignificant as they are important for the final result. And the improvement continues, learning together, sharing tasks, sharing knowledge and ideas, and analyzing all tasks and actions.

Social Networks

Networks that have a large core of overlapping clusters of individuals from different units or organizations and a sizeable periphery of loose connections that bring in new ideas and resources are particularly effective in generating and diffusing innovations [33••].

Recent studies using social network analysis confirm that we are influenced not only by people close to us (parents, siblings, friends), but also friends of friends [20•, 33••]. Thus, the impact of the PD approach is propagated in a social network much greater than the network of its participants [10, 20•]. In this sense, we can understand it as a complex system in which different parts of the system interact, influencing and being influenced in this regard.

PD seeks to engage all those whose behavior affects the problem and has facilitators skilled in fostering open discussion as well as in encouraging the participation of smaller groups. PD seeks those with a differential efficacy, but also involves people in their discussions that despite being part of the process are not usually involved. For example, in the case of infection prevention, human resources and transportation personnel are invited to contribute their knowledge and insights [5•]. Leaders encourage everyone to participate actively in decisions of change or who wish to try a change in their units in order to achieve better results. They also need to respond quickly when the team identifies barriers to best practices in infection prevention. The goal is for the team to be responsible for identifying opportunities for improvement, and to propose solutions and to follow the proceedings.

The structure and the PD process offer a space for discussion of experiences, ideas and plans that emerge from team participation. This requires that those managers who are experts learn to tolerate a certain amount of uncertainty in this process.

The exercise to practice thinking can lead to high-impact actions. An example is the idea to place alcohol gel handrub on portable x-ray machines that traverse the hospital, so that radiologic technicians have alcohol gel handrub available to use at any time [19].

Another study used network mapping as part of the PD strategy to prevent MRSA transmission and infection in hospitals. This mapping process revealed that network health, as measured by a set of social network analysis metrics, corresponds to low MRSA transmission rates. The analysis process also showed steps that could be taken—using a combination the interest of staff in working with others and some additional strategic linkages to connect individuals across units—that would be likely to further lower MRSA rates throughout the hospital [33••].

Most important is that all the changes that have occurred or are occurring are developed by people performing the tasks. The socialization of thought and attitude become the main role of PD.

Conclusions

The PD approach is particularly appropriate in situations where organizations can track the results with valid performance measures and where there is substantial natural variation in performance. Thus emerges a favorable environment for the discussion of practices and interventions to achieve improvements in patient safety.