President’s Column: Designing Practice Change

Aug 01, 2018

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I introduced the idea of positive deviance at NTI this May. Positive deviance is an approach that focuses on those who demonstrate exceptional performance despite facing the same constraints as others. It is the recognition of small differences in behavior within a group or community that yield significantly different results from others despite the appearance of similar circumstances.

Let’s look at an example of positive deviance in healthcare. In 2006, a large hospital in Pittsburgh had a problem with hospital-acquired MRSA. The hospital had been working to reduce MRSA transmission for some time when they realized that two units had eliminated it, while other units continued to have a high rate. Specifically, the two positive deviant units had a different culture for the practice of hand-washing. Those units were diligent — almost obsessive — about hand hygiene.

Some leaders thought this meant that the solution was a no-brainer: Simply share the positive results from the two units with all departments and couple this with reeducation on proper hand-washing. The results realized by the two units would then be repeated all over the hospital when everyone followed the example, right? Unfortunately, that was not the case. The MRSA infection rate did not decrease, and proper hand hygiene did not increase.

So, what happened?

In their attempt to find a quick and logical solution, leaders had focused on the “what” instead of the “how.” The two positive deviant units had spent time planning and working together on an improvement project to address MRSA transmission. The “what” of hand-washing was not the catalyst for the reduction in the MRSA infection rate. The “how” of the units designing the practice change was the true and lasting solution. The power of positive deviance does not come from just knowing the final solution. It comes from the collaborative journey and discoveries. As many of us know too well, the uptake of a new practice is limited when it is imposed by others and not self-discovered.

The example illustrated by this story is all too common in our hospitals and health systems. So often, education and translation of a discovered best practice have mixed results in terms of implementation. Does this mean that we should not seek to implement best practices? Absolutely not! But it certainly means that we can’t underestimate the value of the community driving the way in which that practice change is approached and implemented.

This is why social innovation experts say that we must ACT our way into a new way of THINKING instead of THINKING our way into a new way of ACTING. We become stronger advocates for our patients and ourselves when WE own the improvements we wish to see.

Tell me how you are acting your way into a new way of thinking at