Positive Deviance in Health Care: Beware of Pseudo-Equifinality
Objective Identification of best practices constitutes an important strategy for organizational improvement. We compared different criteria (different measurement thresholds, different comparators, and performance consistency over time) on identification of high-performing facilities, especially positive deviants.
Methods The design was serial cross-sectional, using yearly VHA administrative data (2009–2013). Our primary outcome measure was facility-level rate of HbA1c overtreatment of diabetes in patients at risk for hypoglycemia. Outlier status was assessed by three methods.
Results From 2009 to 2013, the rate of overtreatment overall based on a threshold of 6.5% decreased from 28.6% in 2009 to 22.7% in 2013; the rate of undertreatment increased from 7 to 10.3%. Fourteen facilities were identified in the lowest decile of overtreatment. Undertreatment rates among these facilities were compared to the mean overall undertreatment rate; several facilities identified as positive deviants based on overtreatment rates had exceptionally high rates of undertreatment.
Conclusion Because two facilities may arrive at the same results via very different pathways, it is important to consider that a best practice may actually reflect a separate worst practice.
Funding. The work was supported by grants from the Veterans Health Administration (VHA) Health Services Research & Development Service and its Quality Enhancement Research Initiative (QUERI) to Dr. Aron (SCE 12-181), to Dr. Pogach (RRP-12-492), and to Dr. Tseng (IIR 11-077).
Disclaimer. The opinions expressed are solely those of the authors and do not represent the views of the Department of Veterans Affairs.
- 5.A systematic review of outliers detection techniques in medical data: preliminary study. 11 Jan 26; Rome, Italy: HEALTHINF 2011, 2011.Google Scholar
- 15.Singhal A, Greiner K. Using the Positive Deviance approach to reduce hospital-acquired infections at the Veterans Administration Healthcare System in Pittsburgh. In: Suchman A, Sluyter D, Williamson P, editors. Leading change in healthcare: transforming organizations using complexity, positive psychology, and relationship-centered care. New York: Radcliffe Publishing; 2011. p. 177–209.Google Scholar
- 17.Sternin J. Practice positive deviance for extraordinary social and organizational change. In: The change champion’s field guide: strategies and tools for leading change in your organization. Hoboken, NJ: Wiley; 2013. p. 20–37.Google Scholar
- 18.Zeitlin M, Ghassemi H, Mansour M. Positive deviance in child nutrition - with emphasis on psychosocial and behavioural aspects and implications for development. New York: United Nations University Press; 1991.Google Scholar
- 19.Selby L. Public health project taps into superstar patients’ expertise. http://thedo.osteopathic.org/2015/04/public-health-project-taps-into-superstar-patients-expertise/ (2017). Accessed 5 Jan 2017.
- 21.Spreitzer G, Sonenshein S. Positive deviance and extraordinary organizing. In: Cameron K, Dutton J, editors. Positive organizational scholarship: foundations of a new discipline. Oakland, CA: Berrett-Koehler Publishers; 2003. p. 207–24.Google Scholar
- 23.Vadera A, Pratt M, Mishra P. Constructive deviance in organizations: integrating and moving forward. J Manag. 2013;39:1221–76.Google Scholar
- 24.Warren D. Constructive and destructive deviance in organizations. Acad Manag Rev. 2003;28:622–32.Google Scholar
- 26.Spindler M, Wagenheim G. Positive deviance: sparks that ignite systems change. Chall Organ Soc. 2015;4:647–9.Google Scholar
- 27.Richardson KA, Mathieson G, Cilliers P. The theory and practice of complexity science: epistemological considerations for military operational analysis. SysteMexico 2000;1:25–66.Google Scholar
- 28.Richardson KA. Complex systems thinking and its implications for policy analysis. In: Handbook of decision making. Boca Raton, FL: CRC Press; 2007. p. 189–122.Google Scholar
- 29.Pascale R, Sternin J, Sternin M. The power of positive deviance: how unlikely innovators solve the world’s toughest problems. Boston, MA: Harvard Business Press; 2010.Google Scholar
- 36.National action plan for adverse drug event prevention. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion; 2014. https://health.gov/hcq/pdfs/ade-action-plan-508c.pdf. Accessed 5 Jan 2017.
- 37.Trucil D. AGS unveils revised list of topics to talk about with older adults as part of choosing wisely®campaign. http://www.choosingwisely.org/ags-unveils-revised-list-of-topics-to-talk-about-with-older-adults-as-part-of-choosing-wisely-campaign/. Accessed 5 Jan 2017.