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The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

The positive deviance approach has gained traction within healthcare organizations, yet there remains a scarcity of comprehensive guidance, resulting in the utilization of disparate methods of varying quality.

Published in Healthcare & Nursing

Go to the profile of Ayelign Mengesha Kassie
Ayelign Mengesha Kassie
Doctoral Student , The University of Queensland
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The use of positive deviance approach to improve health service delivery and quality of care: a scoping review - BMC Health Services Research

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.

Healthcare systems worldwide are faced with a myriad of challenges in enhancing accessibility and delivering top-notch healthcare services on a global scale. These hurdles encompass deficiencies in data collection and monitoring systems, subpar organizational team culture and limited capacity, ineffective leadership, a lack of incentivization for outstanding performance, and a scarcity of evidence-based health policies to bolster implementation and enhance the proficiency of healthcare professionals. Consequently, there is an increasing imperative to explore and adopt innovative approaches to enhance and provide safe, effective, and high-quality healthcare services within the healthcare system.

The positive deviance approach emerges as an innovative strategy aimed at identifying exemplary practices existing within a given community. This community, within the healthcare context, encompasses various entities including teams, groups, departments, and organizations. For example, regional/provincial, zonal, and district-based administrative health offices, local health facilities, and their respective units can be considered as departments and organizations within this community. Notably, social service agencies, healthcare organization representatives, and local government bodies have been regarded as integral components of communities in studies employing the positive deviance approach to understand collaboration among social service and healthcare providers in communities achieving relatively low levels of healthcare utilization and expenses among senior citizens.

This approach acknowledges the intrinsic value of existing expertise and operates under the premise that solutions to problems already exist within the community. By identifying and disseminating these solutions, others can effectively address existing complex and intractable challenges. It further underscores that despite facing similar resource constraints, there are individuals who excel in their performance within organizations, and when given the opportunity, these positive deviants are eager to share their experiences, particularly when leaders facilitate the process.

Go to the profile of Ayelign Mengesha Kassie
Ayelign Mengesha Kassie
Doctoral Student , The University of Queensland

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