National Alliance for Physician Competence Discovery Workshop

Context

Positive Deviance

Curt Lindberg

I will have a few opening comments, and then you will be given an opportunity to spend some time reading. We have selected several articles for you about a new trend called positive deviance. This technique has been used to address very difficult challenges from female excision in Egypt to AIDS mitigation among sex workers in Indonesia. The Plexus Institute has been using this technique to deal with MRSA transmissions in hospitals. The results have been very exciting.

In social systems, there are individuals and groups who are performing much better than the system in general. The positive deviance process helps a community to find its top performers, learn the traits that make them successful, and then transmit those traits to the rest of the community to improve performance.

Discussion
This reminded me of memes – memes are ideas that behave like genes, and they try to replicate themselves. Positive Deviance seems like a technique for trying to identify the positive memes in the community, rather than imposing foreign memes. The National Alliance could become a positive meme engine – you will identify and promote positive ideas and methods for the behaviors that we want to promote.

Curt Lindberg
It seemed helpful that in many of the examples the outcomes were easily measurable. In the world of physician competence, we will be measuring some things, but there are also a number of factors that are much more difficult to measure. I like that this technique is very positive in nature – you focus on existing strengths in the organization.

PD is very dependent on having good data – it is essential to help identify the positive deviants within the community. You can find interesting ways to measure some behaviors – for example, medication reconciliation can be a great measurement for the communication practices of a physician. There might be other patterns in the data that help us understand how different data trends reflect behaviors and competencies of physicians – we look at the “digital footprint” of academic researchers and we can tell a lot about what kind of researcher they are and how they will progress in their careers.

Grass-roots initiatives tend to be more effective than top-down initiatives. People trust people they know and other physicians that they work with. We need to find local people to exemplify and promote these qualities of competency. The key is finding people who are “similar to us” – to the people we are targeting.

Often the PD process identifies ideas and techniques that experts would never dream of. In Brazil, uneducated parents were invited into the schools to help teach the students – this helped address the challenge of retention.

How would regulatory bodies encourage this kind of process? It seems difficult to mandate the use of PD, but we should find ways to encourage this kind of grass-roots innovation. This is a very time- and people-intensive process. The topic must be something that people are passionate about, because it requires a lot of their time.

The PD process also requires that leaders and experts change their roles. They are used to knowing all of the answers, and they can feel very challenged by having their “subordinates” coming up with ideas and innovations.

The regulatory body could provide a lot of data to the healthcare system. Some med schools and residency programs are already very thirsty for data on their own performance, and they proactively make changes to improve quality.

The danger with improvement programs is that improvements that work in one setting are suddenly expected to be used everywhere. How can we foster experimentation and innovation through a regulatory body? People can get focused on individual techniques and not the outcomes that those techniques are intended to achieve. This is one of the flaws of the “best practices” approach.

PD is very good at making the practices accessible to everyone that make the positive deviants successful. Everyone wants to learn from their peers.