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.
Commentaire du Dr Marius Laurent (PAQS)
- L’approche par déviance positive comprend une série d’étapes : la phase initiale consiste à exploiter les données recueillies systématiquement afin d’identifier les organisations qui présentent des performances exceptionnelles. Elles font ensuite l’objet d’un examen qualitatif afin de formuler des hypothèses expliquant leurs résultats supérieurs. Les étapes suivantes impliquent la confirmation expérimentale de ces hypothèses par le biais d’une analyse statistique sur des échantillons organisationnels plus larges et la diffusion des résultats afin de promouvoir la reproduction de ces meilleures pratiques dans des contextes analogues. On retrouve une culture proche des « pratiques exemplaires », sinon que la logique est inverse : le point de départ est bien d’identifier une organisation qui réussit mieux que ses voisines et identifier ce qui la différencie des autres, et non de bâtir une procédure « up-to-date » et de la tester. Les obstacles apparaissent à toutes les étapes décrites et expliquent que la plupart des articles soient des études qualitatives et narratives. On attendrait une diffusion dans les pays économiquement peu favorisés, mais ce sont des États-Unis, de la Grande-Bretagne et du Canada que viennent la plupart des publications. Fort peu d’études convaincantes sur les 125 retenues, sinon dans le domaine de l’hygiène des mains, la gestion des erreurs médicamenteuses et la réalisation d’économies dans les soins. Peu de certitudes « evidence based », mais l’amélioration de la qualité et de la sécurité nous a appris à être moins exigeants vis-à-vis de ces prescriptions si on veut sortir de l’immobilisme.
Kassie AM, Eakin E, Abate BB, et al. The use of positive deviance approach to improve health service delivery and quality of care: A scoping review. BMC Health Serv Res. 2024;24(1):438. Doi : 10.1186/s12913-024-10850-2.