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Kassie AM, Eakin E, Abate BB, Endalamaw A, Zewdie A, Wolka E, Assefa Y. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC Health Serv Res 2024; 24:438. [PMID: 38589897 PMCID: PMC11003118 DOI: 10.1186/s12913-024-10850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Ayelign Mengesha Kassie
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Elizabeth Eakin
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Biruk Beletew Abate
- School of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Aklilu Endalamaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care, Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Jones D, Gingrich M, Anstee C, Najmeh S, Safieddine N, Darling G, Malthaner R, Finley C, French DG, Ferri L, Seely A. Multicentre positive deviance seminar to generate best practice recommendations to reduce anastomotic leak and length of stay for patients undergoing oesophagectomy. BMJ Open Qual 2023; 12:e002458. [PMID: 38114245 DOI: 10.1136/bmjoq-2023-002458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/05/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND We describe a novel process using positive deviance (PD) with the Canadian Association of Thoracic Surgeons members, to identify perioperative best practice to minimise anastomotic leak (AL) and length of stay (LOS) following oesophagectomy. To our knowledge, this is the first National combination of level 1 evidence with expert opinion (ie, PD seminar) aimed at reducing AL and LOS in oesophageal surgery. Our primary hypothesis is that a multicentre National PD seminar is feasible, and could lead to the generation of best practices recommendations aimed at reducing AL and LOS in patients with oesophageal cancer. METHODS Adverse events, LOS and AL incidence/severity following oesophagectomy were prospectively collected from seven Canadian thoracic institutions using Thoracic Morbidity and Mortality classification system (2017-2020). Anonymised display of centre's data were presented, with identification of centres demonstrating PD. Surgeons from PD sites discussed principles of care, culminating in the consensus recommendations, anonymously rated by all (5-point Likert scale). RESULTS Data from 795 esophagectomies were included, with 25 surgeons participating. Two centres were identified as having the lowest AL rates 44/395 (11.1%) (vs five centres 71/400 (17.8%) (p<0.01)) and shortest LOS 8 days 45 (IQR: 6-14) (vs 10 days (IQR: 8-18) (p<0.001)). Recommendations included preoperative (prehabilitation, smoking cessation, chemotherapy for patients with dysphagia, minimise stents/feeding tubes), intraoperative (narrow gastric conduit, intrathoracic anastomosis, avoid routine jejunostomy, use small diameter closed-suction drains), postoperative day (POD) (early (POD 2-3) enteral feeding initiation, avoid routine barium swallow studies, early removal of tubes/drains (POD 2-3)). All ranked above 80% (4/5) in agreement to implement recommendations into their practice. CONCLUSION We report the feasibility of a National multicentre PD seminar with the generation of best practice recommendations aimed at reducing AL and LOS following oesophagectomy. Further research is required to demonstrate whether National PD seminars can be an effective quality improvement tool.
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Affiliation(s)
- Daniel Jones
- Surgery, Thoracic, University of Ottawa, Ottawa, Ontario, Canada
| | - Molly Gingrich
- Surgery, Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Caitlin Anstee
- Surgery, Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Sara Najmeh
- Thoracic and Upper GI, McGill University, Montreal, Quebec, Canada
| | - Najib Safieddine
- Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gail Darling
- Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Christian Finley
- Thoracic Surgery, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Daniel G French
- Thoracic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lorenzo Ferri
- Thoracic and Upper GI, McGill University, Montreal, Quebec, Canada
| | - Andrew Seely
- Surgery, Thoracic, University of Ottawa, Ottawa, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Meakins LT, Knox P, Legge L, Penner M, Wiebe P, Mackie AS. Interstage mortality among infants with hypoplastic left heart syndrome: Outcomes of a multicentre home monitoring program. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Foster BA, Seeley K, Davis M, Boone-Heinonen J. Positive deviance in health and medical research on individual level outcomes - a review of methodology. Ann Epidemiol 2022; 69:48-56. [PMID: 34915122 PMCID: PMC9081135 DOI: 10.1016/j.annepidem.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Positive deviance as a methodology is increasing in application yet there is high variability in how this approach is applied in health services research. METHODS We conducted a scoping review of the literature for positive deviance applied to health outcomes informed by PRISMA-ScR. We searched the literature from 1945 to 2020, including articles on positive deviance or positive outliers, and restricted to examining individual rather than organizational outcomes. We analyzed the methodology applied including the process of identifying deviants, the use of control groups, and the degree of community engagement. RESULTS Our initial search identified 1140 manuscripts; we included 104 papers describing 98 studies, 11 topical and one miscellaneous category. Most studies used objective measures of health or survey-based responses to identify deviants from a sub-set of the population at risk. The use of controls was less common in some topics (hospital infections), whereas controls were universally applied in other topics (malnutrition). The degree of community engagement varied widely. CONCLUSIONS Positive deviance would benefit from improvements in reporting and standardized approaches to defining deviance. Studies could be improved through clarified definitions of deviance/risk, explicit descriptions of community engagement, and more consistent use of controls.
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Affiliation(s)
- Byron A Foster
- Department of Pediatrics, Oregon Health & Science University, Portland, OR; School of Public Health, Portland State University and Oregon Health & Science University.
| | - Kylie Seeley
- Department of Pediatrics, Stanford University, Stanford School of Medicine, Palo Alto, CA
| | - Melinda Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Janne Boone-Heinonen
- School of Public Health, Portland State University and Oregon Health & Science University
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Rudd NA, Ghanayem NS, Hill GD, Lambert LM, Mussatto KA, Nieves JA, Robinson S, Shirali G, Steltzer MM, Uzark K, Pike NA. Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2020; 9:e014548. [PMID: 32777961 PMCID: PMC7660817 DOI: 10.1161/jaha.119.014548] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This scientific statement summarizes the current state of knowledge related to interstage home monitoring for infants with shunt-dependent single ventricle heart disease. Historically, the interstage period has been defined as the time of discharge from the initial palliative procedure to the time of second stage palliation. High mortality rates during the interstage period led to the implementation of in-home surveillance strategies to detect physiologic changes that may precede hemodynamic decompensation in interstage infants with single ventricle heart disease. Adoption of interstage home monitoring practices has been associated with significantly improved morbidity and mortality. This statement will review in-hospital readiness for discharge, caregiver support and education, healthcare teams and resources, surveillance strategies and practices, national quality improvement efforts, interstage outcomes, and future areas for research. The statement is directed toward pediatric cardiologists, primary care providers, subspecialists, advanced practice providers, nurses, and those caring for infants undergoing staged surgical palliation for single ventricle heart disease.
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Carrillo SA, Texter KM, Phelps C, Tan Y, McConnell PI, Galantowicz M. Tricuspid Valve and Right Ventricular Function Throughout the Hybrid Palliation Strategy for Hypoplastic Left Heart Syndrome and Variants. World J Pediatr Congenit Heart Surg 2020; 12:9-16. [PMID: 32783502 DOI: 10.1177/2150135120947692] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tricuspid valve (TV) and right ventricular (RV) function are major determinants of morbidity and mortality in patients with hypoplastic left heart syndrome (HLHS). We sought to retrospectively evaluate these parameters throughout the hybrid palliation strategy. METHODS From 2002 to 2018, 203 patients with HLHS and variants presented for hybrid stage I (HS1). Echocardiographic evaluation of tricuspid regurgitation (TR) and RV function was assessed at multiple time points. Clinical outcomes including tricuspid valvuloplasty, transplantation, and death were reviewed. RESULTS The most prevalent HLHS subtype was aortic atresia/mitral atresia. The presence of significant TR and/or RV dysfunction was 14.78% and 9.36%, respectively, at the time of initial HS1. There were 185 survivors following HS1 (91.13%, n = 185/203), while 147 patients underwent comprehensive stage II or bidirectional Glenn shunt (72.41%, n = 147/203). Tricuspid valvuloplasty was undertaken in nine patients (4.86%, n = 9/185). Ultimately, 100 patients underwent the Fontan procedure. The odds of development of significant TR and/or RV dysfunction were not statistically different throughout the stages of palliation (TR: odds ratio [OR] = 0.14-0.25, P = .5260; RV dysfunction: OR = 0.02-0.13, P = .3992). However, the risk of death and/or transplant was 2.5- to 3.8-fold when either were present alone or in combination (TR: OR = 2.58, P = .0356; RV dysfunction: OR = 3.84, P = .0262). Transplant-free survival at 15 years was 44.8%. CONCLUSION Following hybrid palliation for HLHS, the majority of survivors have normal RV and TV functions. Tricuspid valvuloplasty was required in few patients. Once significant TR and/or RV dysfunction ensues, there is a two- to three-fold risk of death and/or transplant.
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Affiliation(s)
- Sergio A Carrillo
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen M Texter
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina Phelps
- Division of Cardiology, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Yubo Tan
- Center for Biostatistics, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, The Ohio State University School of Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
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Barach P, Dadlani GH, Lipshultz SE. Evidence-based, safety management policies for pediatric cardiac care in New York State. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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