Despite the potential of the positive deviance approach to improve quality and promote continuous learning, some caveats should be noted. First, the approach depends on the ability to clearly identify leading organizations on key performance measures, which requires rankings and applies only to processes that can be measured quantitatively. In addition, the approach requires that leading organizations be willing to share their methods and be open about their work, which may not always be the case (Bradley et al., 2009). Moreover, using positive deviance may have the unintended consequence of organizations adopting individual innovations in a piecemeal fashion instead of developing sustainable strategies for continuous learning and improvement. For this reason, de novo quality improvement research may better drive an institution toward continuous learning and improvement. Finally, undertaking large-scale quality-improvement projects under a positive deviance framework requires resources that many organizations cannot commit. In the case study in Box 9-5, for example, a grant
Positive Deviance Approach to Improvement at Cincinnati
Children’s Hospital Medical Center’s Cystic Fibrosis Center
As part of a Robert Wood Johnson Foundation/Institute for Healthcare Improvement (IHI) Pursuing Perfection grant, Cincinnati Children’s Hospital Medical Center undertook a project to improve the performance of its Cystic Fibrosis Center. The Medical Center worked with the Cystic Fibrosis Foundation to analyze the Cystic Fibrosis Center’s performance. The evaluation results were surprising to the Medical Center, because it ranked in the 20th percentile for cystic fibrosis patient outcomes for lung function. In response to these findings, the organization formed a multidisciplinary group of parents and clinicians who decided to take a positive deviance approach to improving the Cystic Fibrosis Center’s performance. They studied the top five cystic fibrosis centers, identified by the Cystic Fibrosis Foundation, and worked with those centers to learn how they were able to achieve consistently high performance. As a result, a number of process changes were made. To improve patients’ lung function, the Cystic Fibrosis Center focused on daily airway clearance, teaching parents and patients more effective clearance techniques. To ensure that patients saw the appropriate caregivers and received well-coordinated care, the Center reviewed patients’ charts before they came to clinic, developed coordinated care plans for each patient, determined which specialists should see the patients during each visit, and created a caregiver visit checklist. As a result of these efforts, by 2008 the Center’s lung function outcomes had moved from the 20th to the 95th percentile.
SOURCE: Tucker and Edmondson, 2010.