Frugal improvement and how we can make the most of positive deviants in health care

Suppose someone told you that they could improve your outcomes without you having to invest anymore than you are doing so currently? Having spent two days at a positive deviance workshop in April, I was left with the feeling that this much under-utilised technique offers that very possibility.

Positive deviance is the term given for the process of studying 'positive deviants': those individuals, teams, families, organisations that - despite being faced with exactly the same challenges of context and resourcing as others - are still managing to achieve results at the top of the Gaussian distribution. Through studying such positive deviants across a range of sectors, it’s been possible to uncover 'micro-behaviours' that stack the cards in favour of the desired outcomes and enable better results to be delivered within largely the same resources.

Taking a positive deviance approach starts with the way you frame the question. Our general approach to inquiry is to try to understand why something doesn't happen - or why something fails. Why don't people take up offers for screening? Why do we have high levels of particular harms? Why do we have high absenteeism? Why don't people adhere to their medicine? We try to get deeper and deeper understanding of the problems and then design solutions for which we often have no prior evidence that they will be successful.

But in studying positive deviants you flip it round and ask the question: why, in the same challenging circumstances, do some people/teams/families manage to get good results? Every system has a natural distribution so, in every system, there will be some people achieving the desired outcome against the odds. For instance, some prisons have lower reoffending and staff absenteeism despite the same case mix of offenders. Some schools have higher attainment for migrant children despite the same socio-economic catchment as other schools. Some clinicians have much higher patient satisfaction ratings despite providing the ‘same’ care.

Having identified the positive deviants, the next step is to carry out a 'discovery and action dialogue' to get under the surface of what is actually different about how the positive deviants are acting. These 'micro-behaviours' may be very small but profound differences in behaviour.

For instance, in a project in Danish prisons, it was found that the positive deviant wardens would knock on the doors of cells before they entered (despite having the key and, in reality, the prisoner not even being able to open the door to them). In a positive deviant Dutch school, they found that teachers would greet each student every morning with a handshake. In a US hospital with low MRSA rates, a porter was found to use an innovative and effective method for gown removal to reduce cross contamination. In a Tokyo ward where cancer screening uptake was higher, it was because of the role the wider family played in supporting attendance…

And the examples go on. And the fascinating factor in all of these things is that, on the whole, they require no extra resource. They are simply about a different set of behaviours generating a different set of values that, in turn, inculcate a different response.

These micro behaviours can then shared and spread around the community and results follow. Because they are already 'homegrown' in a similar context, you reduce the risk of the 'not invented here' syndrome. Because the process of sharing and spreading allows for dialogue, there is both a give and a take which creates a shared commitment to the improvements. And because the solutions come from within the community, they are often sustainable even when structural elements change.

Positive deviance isn't new. Nor is it new to health care - Helen Bevan and others have advocated the principles for some time. So, why hasn't it been more widely adopted into the improvement toolbox?

Perhaps in what is often a highly technical setting, social interventions are considered less valuable. Perhaps the philosophy of looking to the 'front line' for the solutions is counter-cultural in what remains a very top-down system.

However, at a time when we need to find ways of improving our care with less and less resource available to do so, I feel this is an approach that we cannot overlook.