Deconstruction of central line insertion guidelines based on the positive deviance approach-Reducing gaps between guidelines and implementation: A qualitative ethnographic research

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

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.

Advanced theoretical-applied model based on the PD approach in the light of healthcare-associated infections: what have we achieved so far?

Healthcare-associated infections remain a persistent concern despite decades of research and intervention efforts. Adherence to infection prevention and control guidelines by health professionals remains a challenge, necessitating innovative strategies. The Positive Deviance (PD) approach, rooted in harnessing localized solutions, holds promise but lacks comprehensive frameworks and empirical validation to bolster its theoretical underpinnings. This perspective article serves a dual purpose: first, to examine the unique challenges of applying the PD approach in the context of HAIs; and second, to introduce a robust theoretical-applied model developed in response to these challenges. This article addresses these gaps through a multi-faceted model developed in a mixed-methods study across three Israeli governmental hospitals and comprises four essential components that address the identified gaps in existing research. This article enriches the dialog on PD's applicability in HAIs by providing a robust model that not only offers solutions but reshapes the approach to healthcare hygiene and safety. It responds to critical gaps highlighted in the literature, offering tailored interventions by practical, context-specific solutions to improve adherence to IPC guidelines in the long term. Methodological clarity is also a key focus, offering a toolkit for practical implementation. This bottom-up approach empowers HPs to drive change, fostering a culture of innovation and improvement in healthcare settings.

An Asset-Based Quality Improvement Tool for Health Care Organizations: Cultivating Organizationwide Quality Improvement and Health Care Professional Engagement

In the United States, health care organizations are often biased toward deficit-based quality and safety improvement techniques, such as incident reporting and peer review. However, deficit-based techniques may elicit negative sentiments from frontline health care professionals, causing disengagement and adverse event underreporting. To complement deficit-based quality improvement, our institution developed an organizationwide asset-based quality improvement tool. Inspired by asset-based quality improvement methodologies such as appreciative inquiry, Safety-II, and positive deviance, this tool facilitates the identification and analysis of clinical excellence. Resultant best practices and quality improvement projects are then propagated throughout our organization. Ultimately, asset-based quality improvement tools are logistically and technologically feasible for organizationwide deployment, and they potentially improve care quality and team culture. Health care organizations should consider adding these tools to their quality and safety improvement initiatives.

Reduction of Central-line-Associated Bloodstream Infections in a Tertiary Neonatal Intensive Care Unit through Simulation Education

Introduction

Critically ill neonates and those with complex medical conditions frequently require the use of central venous lines. Unfortunately, central line-associated bloodstream infections (CLABSIs) result in significant morbidity and mortality, and the cost and increased length of stay burden the healthcare system. Previous studies have demonstrated that standardized care bundles can decrease CLABSI rates, but achieving sustained improvement has proven difficult.

Methods

All patients admitted to the Neonatal Intensive Care Unit between 2014 and 2020 who had a CVL were included in this study. First, we recorded all CLABSI events and total CVL days according to defined criteria. Then, in late 2016, we instituted simulation-based nursing training for CVL care.

Results

Job Instruction Sheets were initially introduced to Neonatal Intensive Care Unit nursing staff simultaneously with one-on-one teaching sessions between instructors and bedside nurses. Intermittent performance audits and re-education for identified deficiencies did not improve the CLABSI rate per 1000 line days. After instituting simulation-based CVL training in 2016, there was a decreased rate of CLABSI events per 1000 line days sustained over time (x = 0.692).

Conclusions

Standardized care bundles and Hospital-acquired Condition interactor audits were insufficient to reduce the CLABSI rate. However, combining care bundles and education with simulation-based training significantly decreased CLABSI rates. One-on-one intensive training and continued ongoing monitoring were critical to producing a sustained reduction. This experience demonstrates that supervised, interactive education combined with simulation can significantly impact patient outcomes.

Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines

Background

Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.

Objectives

This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.

Methods

A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).

Results

The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.

Conclusion

Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.

Positive deviance in health and medical research on individual level outcomes - a review of methodology

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.

Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms

Background

The literature examining healthcare-associated infections (HAI) points to two main problems in conforming to infection prevention and control (IPC) guidelines among healthcare professionals (HP). One is the discrepancy between HPs’ behavioral intentions and their implementation in practice. The other refers to how HPs maintain these practices after the intervention stage ends. The method proposed in this study seeks to address both these issues by using the Positive Peviance (PD) approach to focus on the dissemination stage of interventions. The study seeks to offer a method for disseminating 27 PD practices to 135 HPs, among them nurses, nurse assistants and physicians, so as to help them maintain IPC guidelines, offer feedback on the dissemination process and examine the impact of the dissemination stage on changes in their behavior.

Methods

The theoretical model underlying this qualitative research was the Recognition-Primed dDecision (RPD) model, which we implemented in the field of healthcare-associated infections (HAIs). Moreover, we used the Discovery & Action Dialogue (DAD) and Think Aloud (TA) techniques to describe the methodological development of simulations for HPs. Feedback from the HP demonstrators underwent content analysis, while descriptive statistics were used to characterize behavioral changes.

Results

HPs’ information processing regarding infection prevention shifts from peripheral/automatic processing to intuition and analytical/central processing, turning PD practices into positive norms. The HPs personally experienced finding a solution and made repeated corrections until they overcame the barriers. Most of the HPs (69.4%) reported that the practices were fully implemented, together with additional practices.

Conclusions

Implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, merely observing simulations is not sufficient. Rather, each staff member must personally carry out the procedures.

What is new in catheter use and catheter infection prevention in the ICU

PURPOSE OF REVIEW

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

RECENT FINDINGS

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

SUMMARY

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.

What distinguishes positive deviance (PD) health professionals from their peers and what impact does a PD intervention have on behaviour change: a cross-sectional study of infection control and prevention in three Israeli hospitals

Past studies using the positive deviance (PD) approach in the field of infection prevention and control (IPC) have primarily focused on impacts on healthcare-associated infection rates. This research aimed to determine if health professionals who exhibit PD behaviours have distinctive socio-cognitive profiles compared to non-PD professionals, and to examine the impact of a PD intervention on healthcare professionals’ (HPs) behavioural changes in maintaining IPC guidelines. In a cross-sectional study among 135 HPs, respondents first filled out a socio-cognitive characteristics questionnaire, and after 5 months were requested to complete a self-reported behavioural change questionnaire. The main findings indicate that socio-cognitive variables such as external locus of control, perceived threat and social learning were significant predictors of a person exhibiting PD behaviours. Almost 70% of HPs reported behavioural change and creating social networks as a result of the PD intervention in maintaining IPC guidelines, 16.9% of them are a ‘PD boosters’ (a new group of HPs who have adopted the positive practices of PDs that were originally identified, and also added additional practices of their own). Social networks can contribute to internalizing and raising personal accountability even among non-PD professionals, by creating a mind map that makes each person believe they are an important node in the network, regardless of their status and role. Health intervention programmes should purposely make visible and prominent social network connections in the hospital system.

A mixed-methods sequential explanatory design comparison between COVID-19 infection control guidelines' applicability and their protective value as perceived by Israeli healthcare workers, and healthcare executives' response

Background

Healthcare workers (HCWs) are on the front line of the COVID-19 outbreak, and their constant exposure to infected patients and contaminated surfaces puts them at risk of acquiring and transmitting the infection. Therefore, they must employ protective measures. In practice, HCWs in Israel were not fully prepared for this sudden COVID-19 outbreak. This research aimed to identify and compare: (1) Israeli HCWs’ perceptions regarding the official COVID-19 guidelines’ applicability and their protective value, and (2) HCWs executives’ response to HWCs’ concern regarding personal protective equipment (PPE) shortage.

Methods

A mixed-methods sequential explanatory design consists of: (1) An online survey of 242 HCWs about the application of the guidelines and PPE, and (2) Personal interviews of 15 HCWs executives regarding PPE shortage and the measures they are taking to address it.

Results

A significant difference between the perceived applicability and protective value was found for most of the guidelines. Some of the guidelines were perceived as more applicable than protective (hand hygiene, signage at entrance, alcohol rub sanitizers at entrance, and mask for contact with symptomatic patients). Other were perceived as less applicable than protective (prohibited gathering of over 10 people, maintaining a distance of 2 m’, and remote services).

Conclusions

HCWs need the support of the healthcare authorities not only to provide missing equipment, but also to communicate the risk to them. Conveying the information with full transparency, while addressing the uncertainty element and engaging the HCWs in evaluating the guidelines, are critical for establishing trust.