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{{SI}}
{{SI}}


In [[quality improvement]], '''{{PAGENAME}}''' is a "bottom-up" approach to quality improvement. An description of this method was:
In [[quality improvement]], '''{{PAGENAME}}''' is a "bottom-up" approach to quality improvement<ref name="pmid26590198">{{cite journal| author=Baxter R, Taylor N, Kellar I, Lawton R| title=What methods are used to apply positive deviance within healthcare organisations? A systematic review. | journal=BMJ Qual Saf | year= 2016 | volume= 25 | issue= 3 | pages= 190-201 | pmid=26590198 | doi=10.1136/bmjqs-2015-004386 | pmc=4789698 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26590198  }} </ref>. An description of this method was<ref name="pmid15539680">{{cite journal| author=Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M| title=The power of positive deviance. | journal=BMJ | year= 2004 | volume= 329 | issue= 7475 | pages= 1177-9 | pmid=15539680 | doi=10.1136/bmj.329.7475.1177 | pmc=527707 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15539680  }} </ref>:


* "Develop case definitions"
* "Develop case definitions"
Line 10: Line 10:
* "Monitor implementation and evaluate the results"
* "Monitor implementation and evaluate the results"


A more recent listing of the steps is:
A more recent listing of the steps is<ref name="pmid19426507">{{cite journal| author=Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM| title=Research in action: using positive deviance to improve quality of health care. | journal=Implement Sci | year= 2009 | volume= 4 | issue=  | pages= 25 | pmid=19426507 | doi=10.1186/1748-5908-4-25 | pmc=2690576 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19426507  }} </ref>:
* Identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care)
* Identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care)
* Study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance
* Study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance
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* Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practice
* Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practice


Positive deviance is consistent with complexity leadership and [[learning health system]]s
Positive deviance is consistent with complexity leadership<ref name="pmid30709082">{{cite journal| author=Belrhiti Z, Nebot Giralt A, Marchal B| title=Complex Leadership in Healthcare: A Scoping Review. | journal=Int J Health Policy Manag | year= 2018 | volume= 7 | issue= 12 | pages= 1073-1084 | pmid=30709082 | doi=10.15171/ijhpm.2018.75 | pmc=6358662 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30709082  }} </ref><ref name="LindbergClancy2010">{{cite journal|last1=Lindberg|first1=Curt|last2=Clancy|first2=Thomas R.|title=Positive Deviance|journal=JONA: The Journal of Nursing Administration|volume=40|issue=4|year=2010|pages=150–153|issn=0002-0443|doi=10.1097/NNA.0b013e3181d40e39}}</ref><ref name="LindbergSchneider2013">{{cite journal|last1=Lindberg|first1=Curt|last2=Schneider|first2=Marguerite|title=Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance|journal=Leadership|volume=9|issue=2|year=2013|pages=229–253|issn=1742-7150|doi=10.1177/1742715012468784}}</ref> and [[learning health system]]s<ref name="pmid30398449">{{cite journal| author=McLachlan S, Potts HWW, Dube K, Buchanan D, Lean S, Gallagher T | display-authors=etal| title=The Heimdall Framework for Supporting Characterisation of Learning Health Systems. | journal=J Innov Health Inform | year= 2018 | volume= 25 | issue= 2 | pages= 77-87 | pmid=30398449 | doi=10.14236/jhi.v25i2.996 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30398449  }} </ref>


Positive deviance may include grounded theory, ethnography methods, guided conversations/interviews, and focus groups.
Positive deviance may include grounded theory, ethnography methods, guided conversations/interviews, and focus groups<ref name="pmid19289649">{{cite journal| author=Curry LA, Nembhard IM, Bradley EH| title=Qualitative and mixed methods provide unique contributions to outcomes research. | journal=Circulation | year= 2009 | volume= 119 | issue= 10 | pages= 1442-52 | pmid=19289649 | doi=10.1161/CIRCULATIONAHA.107.742775 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19289649  }} </ref>.


Not all QI measures may be appropriate.
Not all QI measures may be appropriate<ref name="pmid29749286">{{cite journal| author=O'Hara JK, Grasic K, Gutacker N, Street A, Foy R, Thompson C et al.| title=Identifying positive deviants in healthcare quality and safety: a mixed methods study. | journal=J R Soc Med | year= 2018 | volume= 111 | issue= 8 | pages= 276-291 | pmid=29749286 | doi=10.1177/0141076818772230 | pmc=6100151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29749286 }} </ref>.
 
Positive deviance can provide structure to [[Quality circles]] (QCs). Quality circles are "small groups of 6 to 12 professionals from a similar background who meet at regular intervals to discuss and review their clinical practice...QCs select the issues they want to deal with themselves, decide on their method of gathering data, and determine a way of finding solutions to prioritized problems. Facilitators observe and lead the group through the circle of quality improvement"<ref name="pmid24321626">{{cite journal| author=Rohrbasser A, Mickan S, Harris J| title=Exploring why quality circles work in primary health care: a realist review protocol. | journal=Syst Rev | year= 2013 | volume= 2 | issue= | pages= 110 | pmid=24321626 | doi=10.1186/2046-4053-2-110 | pmc=4029275 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24321626 }} </ref>.




==Methods==
==Methods==
Overviews of methods are available.
Overviews of methods are available<ref name="pmid19426507">{{cite journal| author=Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM| title=Research in action: using positive deviance to improve quality of health care. | journal=Implement Sci | year= 2009 | volume= 4 | issue=  | pages= 25 | pmid=19426507 | doi=10.1186/1748-5908-4-25 | pmc=2690576 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19426507  }} </ref><ref name="pmid27349472">{{cite journal| author=Rose AJ, McCullough MB| title=A Practical Guide to Using the Positive Deviance Method in Health Services Research. | journal=Health Serv Res | year= 2017 | volume= 52 | issue= 3 | pages= 1207-1222 | pmid=27349472 | doi=10.1111/1475-6773.12524 | pmc=5441507 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27349472  }} </ref>.


Positive deviance is a viable strategy with variation in performance is present. Variation in performance has been measured with the coefficient of variation.
Positive deviance is a viable strategy with variation in performance is present. Variation in performance has been measured with the coefficient of variation<ref name="pmid27623461">{{cite journal| author=Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C et al.| title=Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. | journal=JAMA | year= 2016 | volume= 316 | issue= 10 | pages= 1061-72 | pmid=27623461 | doi=10.1001/jama.2016.12226 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27623461  }} </ref>.


===1. Identifying deviants===
===1. Identifying deviants===


Ideally, positive deviants should be identified by blinded comparison to control groups, yet this is infrequently done and instead deviants are informally identified by reputation.
Ideally, positive deviants should be identified by blinded comparison to control groups<ref name="bock">Bock, L. (2015). The Two Tail. In: Work rules!: Insights from inside Google that will transform how you live and lead. Twelve.</ref>, yet this is infrequently done<ref name="pmid26590198">{{cite journal| author=Baxter R, Taylor N, Kellar I, Lawton R| title=What methods are used to apply positive deviance within healthcare organisations? A systematic review. | journal=BMJ Qual Saf | year= 2016 | volume= 25 | issue= 3 | pages= 190-201 | pmid=26590198 | doi=10.1136/bmjqs-2015-004386 | pmc=4789698 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26590198  }} </ref> and instead deviants are informally identified by reputation<ref name="pmid21646881">{{cite journal| author=McAlearney AS, Garman AN, Song PH, McHugh M, Robbins J, Harrison MI| title=High-performance work systems in health care management, part 2: qualitative evidence from five case studies. | journal=Health Care Manage Rev | year= 2011 | volume= 36 | issue= 3 | pages= 214-26 | pmid=21646881 | doi=10.1097/HMR.0b013e318201d1bf | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21646881  }} </ref><ref name="pmid23690328">{{cite journal| author=Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T| title=In search of joy in practice: a report of 23 high-functioning primary care practices. | journal=Ann Fam Med | year= 2013 | volume= 11 | issue= 3 | pages= 272-8 | pmid=23690328 | doi=10.1370/afm.1531 | pmc=3659145 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23690328  }} </ref>.


Various statistical approaches are used to identify the true deviants.  
Various statistical approaches are used to identify the true deviants<ref name="pmid28384376">{{cite journal| author=Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM| title=A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems. | journal=Health Serv Res | year= 2018 | volume= 53 | issue= 3 | pages= 1851-1869 | pmid=28384376 | doi=10.1111/1475-6773.12693 | pmc=5980166 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384376  }} </ref><ref name="pmid12110077">{{cite journal| author=Berlowitz DR, Christiansen CL, Brandeis GH, Ash AS, Kader B, Morris JN et al.| title=Profiling nursing homes using Bayesian hierarchical modeling. | journal=J Am Geriatr Soc | year= 2002 | volume= 50 | issue= 6 | pages= 1126-30 | pmid=12110077 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12110077  }} </ref><ref name="RubensChen2018">{{cite journal|last1=Rubens|first1=Fraser|last2=Chen|first2=Li|last3=Ramsay|first3=Tim|last4=Forster|first4=Alan|last5=Wells|first5=George|last6=Sundaresan|first6=Sudhir|title=The development of a positive deviancy strategy to identify excellence in patient experience|journal=European Journal for Person Centered Healthcare|volume=6|issue=4|year=2018|pages=540|issn=2052-5656|doi=10.5750/ejpch.v6i4.1542}}</ref><ref name="pmid29749286">{{cite journal| author=O'Hara JK, Grasic K, Gutacker N, Street A, Foy R, Thompson C et al.| title=Identifying positive deviants in healthcare quality and safety: a mixed methods study. | journal=J R Soc Med | year= 2018 | volume= 111 | issue= 8 | pages= 276-291 | pmid=29749286 | doi=10.1177/0141076818772230 | pmc=6100151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29749286  }} </ref>.  


Performance rates may need adjustment before comparison.
Performance rates may need adjustment before comparison<ref name="pmid29298402">{{cite journal| author=Wholey DR, Finch M, Kreiger R, Reeves D| title=Public Reporting of Primary Care Clinic Quality: Accounting for Sociodemographic Factors in Risk Adjustment and Performance Comparison. | journal=Popul Health Manag | year= 2018 | volume= 21 | issue= 5 | pages= 378-386 | pmid=29298402 | doi=10.1089/pop.2017.0137 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29298402  }} </ref>.


Inadequate sample may hinder identifying deviants. Regression to the mean may confound identifying postive deviances and the assessment of improvement.
Inadequate sample may hinder identifying deviants<ref name="pmid31108502">{{cite journal| author=Singh S, Goodwin JS, Zhou J, Kuo YF, Nattinger AB| title=Variation Among Primary Care Physicians in 30-Day Readmissions. | journal=Ann Intern Med | year= 2019 | volume= 170 | issue= 11 | pages= 749-755 | pmid=31108502 | doi=10.7326/M18-2526 | pmc=6743324 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31108502  }} </ref>. Regression to the mean may confound identifying postive deviances and the assessment of improvement<ref name="pmid31242277">{{cite journal| author=Joshi S, Nuckols T, Escarce J, Huckfeldt P, Popescu I, Sood N| title=Regression to the Mean in the Medicare Hospital Readmissions Reduction Program. | journal=JAMA Intern Med | year= 2019 | volume=  | issue=  | pages=  | pmid=31242277 | doi=10.1001/jamainternmed.2019.1004 | pmc=6596330 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31242277  }} </ref>.


== Psychology, barriers and promoters of shared learning==
== Psychology, barriers and promoters of shared learning==
{{main|https://www.wikidoc.org/index.php/Industrial_and_organizational_psychology#Personality_traits}}
{{main|https://www.wikidoc.org/index.php/Industrial_and_organizational_psychology#Personality_traits}}


Learning of success can inspire others to perform. On the other hand, "Individuals with higher levels of [Performance‐prove goal orientation] PPGO have decreased self-efficacy and performance when observing higher performing coworkers" Coworker envy make occur depending on relationships between colleagues and managers.
Learning of success can inspire others<ref name="QuinnMyers2020">{{cite journal|last1=Quinn|first1=Ryan W|last2=Myers|first2=Christopher|last3=Kopelman|first3=Shirli|last4=Simmons|first4=Stefanie A.|title=How Did You Do That? Exploring the Motivation to Learn from Others' Exceptional Success|journal=Academy of Management Discoveries|year=2020|issn=2168-1007|doi=10.5465/amd.2018.0217}}</ref> to perform. On the other hand, "Individuals with higher levels of [Performance‐prove goal orientation] PPGO have decreased self-efficacy and performance when observing higher performing coworkers"<ref name="pmid32463258">{{cite journal| author=Downes PE, Crawford ER, Seibert SE, Stoverink AC, Campbell EM| title=Referents or role models? The self-efficacy and job performance effects of perceiving higher performing peers. | journal=J Appl Psychol | year= 2020 | volume=  | issue=  | pages=  | pmid=32463258 | doi=10.1037/apl0000519 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32463258  }} </ref> Coworker envy make occur depending on relationships between colleagues and managers<ref name="BreidenthalLiu2020">{{cite journal|last1=Breidenthal|first1=Amy P.|last2=Liu|first2=Dong|last3=Bai|first3=Yuntao|last4=Mao|first4=Yina|title=The dark side of creativity: Coworker envy and ostracism as a response to employee creativity|journal=Organizational Behavior and Human Decision Processes|volume=161|year=2020|pages=242–254|issn=07495978|doi=10.1016/j.obhdp.2020.08.001}}</ref>.


==Interventions and assessments using positive deviants==
==Interventions and assessments using positive deviants==
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! Organizational issues among causes found
! Organizational issues among causes found
|-
|-
| Acute myocardial infarction
| Acute myocardial infarction<ref name="pmid22547471">{{cite journal| author=Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP et al.| title=Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. | journal=Ann Intern Med | year= 2012 | volume= 156 | issue= 9 | pages= 618-26 | pmid=22547471 | doi=10.7326/0003-4819-156-9-201205010-00003 | pmc=3386642 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22547471  }} </ref>
| Adjusted mortality: mean 15.4% (SD, 1.5%; range, 11.5% to 21.7%)
| Adjusted mortality: mean 15.4% (SD, 1.5%; range, 11.5% to 21.7%)
| Fostering an organizational environment in which clinicians are encouraged to solve problems creativelyHaving physician and nurse champions rather than nurse champions alone
| Fostering an organizational environment in which clinicians are encouraged to solve problems creatively<br />Having physician and nurse champions rather than nurse champions alone
|-
|-
| Sepsis
| Sepsis<ref name="pmid27623461">{{cite journal| author=Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C et al.| title=Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. | journal=JAMA | year= 2016 | volume= 316 | issue= 10 | pages= 1061-72 | pmid=27623461 | doi=10.1001/jama.2016.12226 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27623461  }} </ref>
| Length of stay: median (IQR) 4.9 (3.0-7.9)
| Length of stay: median (IQR) 4.9 (3.0-7.9)
| Not queried
| Not queried
|-
|-
| Beta-blockers after myocardial infarction
| Beta-blockers after myocardial infarction<ref name="pmid11368734">{{cite journal| author=Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM| title=A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed? | journal=JAMA | year= 2001 | volume= 285 | issue= 20 | pages= 2604-11 | pmid=11368734 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368734  }} </ref>
| Rates not reported
| Rates not reported
| shared goals for improvementsubstantial administrative supportstrong physician leadership advocating beta-blocker useuse of credible data feedback
| shared goals for improvement<br />substantial administrative support<br />strong physician leadership advocating beta-blocker use<br />use of credible data feedback
|-
|-
| Dabigatran adherence
| Dabigatran adherence<ref name="pmid25871670">{{cite journal| author=Shore S, Ho PM, Lambert-Kerzner A, Glorioso TJ, Carey EP, Cunningham F et al.| title=Site-level variation in and practices associated with dabigatran adherence. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1443-50 | pmid=25871670 | doi=10.1001/jama.2015.2761 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871670  }} </ref>
| 74% (IQR: 66%-80%)
| 74% (IQR: 66%-80%)
| Organizational strategies not assessed
| Organizational strategies not assessed
Line 71: Line 69:


Reports of using positive deviance to assess the tactics behind successful performance have been published:
Reports of using positive deviance to assess the tactics behind successful performance have been published:
* In ital cardiac arrest
* In hospital cardiac arrest<ref name="pmid29986959">{{cite journal| author=Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL | display-authors=etal| title=How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. | journal=Circulation | year= 2018 | volume= 138 | issue= 2 | pages= 154-163 | pmid=29986959 | doi=10.1161/CIRCULATIONAHA.118.033674 | pmc=6245659 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29986959  }} </ref>
* Hypertension
* Hypertension<ref name="pmid32078589">{{cite journal| author=Ritchey MD, Hannan J, Wall HK, George MG, Sperling LS| title=Notes from the Field: Characteristics of Million Hearts Hypertension Control Champions, 2012-2019. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 7 | pages= 196-197 | pmid=32078589 | doi=10.15585/mmwr.mm6907a5 | pmc=7043391 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32078589  }} </ref><ref name="pmid26590198">{{cite journal| author=Baxter R, Taylor N, Kellar I, Lawton R| title=What methods are used to apply positive deviance within healthcare organisations? A systematic review. | journal=BMJ Qual Saf | year= 2016 | volume= 25 | issue= 3 | pages= 190-201 | pmid=26590198 | doi=10.1136/bmjqs-2015-004386 | pmc=4789698 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26590198  }} </ref>


Reports of using positive deviance to assess ''and improve performance'' have been published Specific examples include:
Reports of using positive deviance to assess ''and improve performance'' have been published<ref name="pmid27349472">{{cite journal| author=Rose AJ, McCullough MB| title=A Practical Guide to Using the Positive Deviance Method in Health Services Research. | journal=Health Serv Res | year= 2017 | volume= 52 | issue= 3 | pages= 1207-1222 | pmid=27349472 | doi=10.1111/1475-6773.12524 | pmc=5441507 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27349472  }} </ref> Specific examples include:
* Ambulatory Care-Sensitive italizations
* Ambulatory Care-Sensitive Hospitalizations<ref name="pmid29401005">{{cite journal| author=Tanenbaum J, Cebul RD, Votruba M, Einstadter D| title=Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations. | journal=Health Aff (Millwood) | year= 2018 | volume= 37 | issue= 2 | pages= 266-274 | pmid=29401005 | doi=10.1377/hlthaff.2017.1209 | pmc=7003658 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29401005  }} </ref>
* Myocardial infarction treatment including:
* Myocardial infarction treatment<ref name="pmid19426507">{{cite journal| author=Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM| title=Research in action: using positive deviance to improve quality of health care. | journal=Implement Sci | year= 2009 | volume= 4 | issue=  | pages= 25 | pmid=19426507 | doi=10.1186/1748-5908-4-25 | pmc=2690576 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19426507  }} </ref><ref name="pmid22547471">{{cite journal| author=Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP et al.| title=Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. | journal=Ann Intern Med | year= 2012 | volume= 156 | issue= 9 | pages= 618-26 | pmid=22547471 | doi=10.7326/0003-4819-156-9-201205010-00003 | pmc=3386642 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22547471  }} </ref> including:
** [[beta-blockers]]
** [[beta-blockers]]<ref name="pmid11368734">{{cite journal| author=Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM| title=A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed? | journal=JAMA | year= 2001 | volume= 285 | issue= 20 | pages= 2604-11 | pmid=11368734 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368734  }} </ref>
** [[Percutaneous coronary intervention]] door to balloon time
** [[Percutaneous coronary intervention]] door to balloon time<ref name="pmid19426507">{{cite journal| author=Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM| title=Research in action: using positive deviance to improve quality of health care. | journal=Implement Sci | year= 2009 | volume= 4 | issue=  | pages= 25 | pmid=19426507 | doi=10.1186/1748-5908-4-25 | pmc=2690576 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19426507  }} </ref>
* Patient activation
* Patient activation<ref name="pmid26951590">{{cite journal| author=Greene J, Hibbard JH, Alvarez C, Overton V| title=Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels. | journal=Ann Fam Med | year= 2016 | volume= 14 | issue= 2 | pages= 148-54 | pmid=26951590 | doi=10.1370/afm.1904 | pmc=4781518 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26951590  }} </ref>
* Reduction in ital readmission.
* Reduction in hospital readmission<ref name="pmid29401005">{{cite journal| author=Tanenbaum J, Cebul RD, Votruba M, Einstadter D| title=Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations. | journal=Health Aff (Millwood) | year= 2018 | volume= 37 | issue= 2 | pages= 266-274 | pmid=29401005 | doi=10.1377/hlthaff.2017.1209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29401005  }} </ref>.
* ital infections.
* Hospital infections<ref name="LindbergClancy2010">{{cite journal|last1=Lindberg|first1=Curt|last2=Clancy|first2=Thomas R.|title=Positive Deviance|journal=JONA: The Journal of Nursing Administration|volume=40|issue=4|year=2010|pages=150–153|issn=0002-0443|doi=10.1097/NNA.0b013e3181d40e39}}</ref><ref name="LindbergSchneider2013">{{cite journal|last1=Lindberg|first1=Curt|last2=Schneider|first2=Marguerite|title=Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance|journal=Leadership|volume=9|issue=2|year=2013|pages=229–253|issn=1742-7150|doi=10.1177/1742715012468784}}</ref><ref name="pmid30288392">{{cite journal| author=Sreeramoju P, Dura L, Fernandez ME, Minhajuddin A, Simacek K, Fomby TB | display-authors=etal| title=Using a Positive Deviance Approach to Influence the Culture of Patient Safety Related to Infection Prevention. | journal=Open Forum Infect Dis | year= 2018 | volume= 5 | issue= 10 | pages= ofy231 | pmid=30288392 | doi=10.1093/ofid/ofy231 | pmc=6166267 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30288392  }} </ref>.
* Antimicrobial stewardship in hemodialysis
* Antimicrobial stewardship in hemodialysis<ref name="pmid30253815">{{cite journal| author=D'Agata EMC, Lindberg CC, Lindberg CM, Downham G, Esposito B, Shemin D | display-authors=etal| title=The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities. | journal=Infect Control Hosp Epidemiol | year= 2018 | volume= 39 | issue= 12 | pages= 1400-1405 | pmid=30253815 | doi=10.1017/ice.2018.237 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30253815  }} </ref><ref name="pmid31566346">{{cite journal| author=Lindberg CM, Lindberg CC, D'Agata EMC, Esposito B, Downham G| title=Advancing Antimicrobial Stewardship in Outpatient Dialysis Centers Using the Positive Deviance Process. | journal=Nephrol Nurs J | year= 2019 | volume= 46 | issue= 5 | pages= 511-518 | pmid=31566346 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31566346  }} </ref>
* Anticoagulation with [[warfarin]] and [[dabigatran]]
* Anticoagulation with [[warfarin]]<ref name="pmid28367699">{{cite journal| author=Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA et al.| title=Results of a Regional Effort to Improve Warfarin Management. | journal=Ann Pharmacother | year= 2017 | volume= 51 | issue= 5 | pages= 373-379 | pmid=28367699 | doi=10.1177/1060028016681030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28367699  }} </ref><ref name="pmid22299722">{{cite journal| author=Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM et al.| title=Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration. | journal=Health Serv Res | year= 2012 | volume= 47 | issue= 4 | pages= 1541-60 | pmid=22299722 | doi=10.1111/j.1475-6773.2011.01377.x | pmc=3401398 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22299722  }} </ref> and [[dabigatran]]<ref name="pmid25871670">{{cite journal| author=Shore S, Ho PM, Lambert-Kerzner A, Glorioso TJ, Carey EP, Cunningham F et al.| title=Site-level variation in and practices associated with dabigatran adherence. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1443-50 | pmid=25871670 | doi=10.1001/jama.2015.2761 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871670  }} </ref>
* Diabetes chronic care
* Diabetes chronic care
** Assessment.
** Assessment<ref name="pmid23690393">{{cite journal| author=Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC| title=A positive deviance approach to understanding key features to improving diabetes care in the medical home. | journal=Ann Fam Med | year= 2013 | volume= 11 Suppl 1 | issue=  | pages= S99-107 | pmid=23690393 | doi=10.1370/afm.1473 | pmc=3707253 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23690393  }} </ref>.
** Improvement
** Improvement<ref name="pmid29401005">{{cite journal| author=Tanenbaum J, Cebul RD, Votruba M, Einstadter D| title=Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations. | journal=Health Aff (Millwood) | year= 2018 | volume= 37 | issue= 2 | pages= 266-274 | pmid=29401005 | doi=10.1377/hlthaff.2017.1209 | pmc=7003658 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29401005  }} </ref>
* Public health problems in developing regions
* Public health problems in developing regions<ref name="pmid17783464">{{cite journal| author=Katz SH, Hediger ML, Valleroy LA| title=Traditional maize processing techniques in the new world. | journal=Science | year= 1974 | volume= 184 | issue= 4138 | pages= 765-73 | pmid=17783464 | doi=10.1126/science.184.4138.765 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17783464  }} </ref>
* Improvement in efficiency of care delivery by examining heterogeneity in costs of care by providers
* Improvement in efficiency of care delivery by examining heterogeneity in costs of care by providers<ref name="pmid27623461">{{cite journal| author=Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C et al.| title=Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. | journal=JAMA | year= 2016 | volume= 316 | issue= 10 | pages= 1061-72 | pmid=27623461 | doi=10.1001/jama.2016.12226 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27623461  }} </ref><ref>Ederhof M, Chin AL, Jopling JK. Hospital cost accounting data: a valuable underused resource. Health Affairs Blog. July 2, 2018 (https://ramaonhealthcare.com/hospital-cost-accounting-data-a-valuable-underused-resource/).</ref>
* Thoracic surgery complications
* Thoracic surgery complications<ref name="pmid26188970">{{cite journal| author=Ivanovic J, Anstee C, Ramsay T, Gilbert S, Maziak DE, Shamji FM et al.| title=Using Surgeon-Specific Outcome Reports and Positive Deviance for Continuous Quality Improvement. | journal=Ann Thorac Surg | year= 2015 | volume= 100 | issue= 4 | pages= 1188-94; discussion 1194-5 | pmid=26188970 | doi=10.1016/j.athoracsur.2015.04.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26188970  }} </ref><ref name="pmid29315152">{{cite journal| author=Ivanovic J, Mostofian F, Anstee C, Gilbert S, Maziak DE, Shamji FM et al.| title=Impact of Surgeon Self-evaluation and Positive Deviance on Postoperative Adverse Events After Non-cardiac Thoracic Surgery. | journal=J Healthc Qual | year= 2018 | volume= 40 | issue= 4 | pages= e62-e70 | pmid=29315152 | doi=10.1097/JHQ.0000000000000130 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29315152  }} </ref>
* Medication errors
* Medication errors<ref name="pmid27497977">{{cite journal| author=Ferracini FT, Marra AR, Schvartsman C, Dos Santos OF, Victor Eda S, Negrini NM | display-authors=etal| title=Using Positive Deviance to reduce medication errors in a tertiary care hospital. | journal=BMC Pharmacol Toxicol | year= 2016 | volume= 17 | issue= 1 | pages= 36 | pmid=27497977 | doi=10.1186/s40360-016-0082-9 | pmc=4976064 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27497977  }} </ref>


==See also==
==See also==

Revision as of 02:11, 2 December 2021

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In quality improvement, Positive deviance is a "bottom-up" approach to quality improvement[1]. An description of this method was[2]:

  • "Develop case definitions"
  • "Identify four to six people who have achieved an unexpected good outcome despite high risk"
  • "Interview and observe these people to discover uncommon behaviours or enabling factors that could explain the good outcome"
  • "Analyse the findings to confirm that the behaviours are uncommon and accessible to those who need to adopt them"
  • "Design behaviour change activities to encourage community adoption of the new behaviours"
  • "Monitor implementation and evaluate the results"

A more recent listing of the steps is[3]:

  • Identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care)
  • Study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance
  • Test hypotheses statistically in larger, representative samples of organizations
  • Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practice

Positive deviance is consistent with complexity leadership[4][5][6] and learning health systems[7]

Positive deviance may include grounded theory, ethnography methods, guided conversations/interviews, and focus groups[8].

Not all QI measures may be appropriate[9].


Methods

Overviews of methods are available[3][10].

Positive deviance is a viable strategy with variation in performance is present. Variation in performance has been measured with the coefficient of variation[11].

1. Identifying deviants

Ideally, positive deviants should be identified by blinded comparison to control groups[12], yet this is infrequently done[1] and instead deviants are informally identified by reputation[13][14].

Various statistical approaches are used to identify the true deviants[15][16][17][9].

Performance rates may need adjustment before comparison[18].

Inadequate sample may hinder identifying deviants[19]. Regression to the mean may confound identifying postive deviances and the assessment of improvement[20].

Psychology, barriers and promoters of shared learning

Main article: https://www.wikidoc.org/index.php/Industrial_and_organizational_psychology § Personality_traits

Learning of success can inspire others[21] to perform. On the other hand, "Individuals with higher levels of [Performance‐prove goal orientation] PPGO have decreased self-efficacy and performance when observing higher performing coworkers"[22] Coworker envy make occur depending on relationships between colleagues and managers[23].

Interventions and assessments using positive deviants

Clinical problem Variation found Organizational issues among causes found
Acute myocardial infarction[24] Adjusted mortality: mean 15.4% (SD, 1.5%; range, 11.5% to 21.7%) Fostering an organizational environment in which clinicians are encouraged to solve problems creatively
Having physician and nurse champions rather than nurse champions alone
Sepsis[11] Length of stay: median (IQR) 4.9 (3.0-7.9) Not queried
Beta-blockers after myocardial infarction[25] Rates not reported shared goals for improvement
substantial administrative support
strong physician leadership advocating beta-blocker use
use of credible data feedback
Dabigatran adherence[26] 74% (IQR: 66%-80%) Organizational strategies not assessed

Reports of using positive deviance to assess the tactics behind successful performance have been published:

Reports of using positive deviance to assess and improve performance have been published[10] Specific examples include:

See also

External links

References

  1. ↑ 1.0 1.1 1.2 Baxter R, Taylor N, Kellar I, Lawton R (2016). "What methods are used to apply positive deviance within healthcare organisations? A systematic review". BMJ Qual Saf. 25 (3): 190–201. doi:10.1136/bmjqs-2015-004386. PMC 4789698. PMID 26590198.
  2. ↑ Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M (2004). "The power of positive deviance". BMJ. 329 (7475): 1177–9. doi:10.1136/bmj.329.7475.1177. PMC 527707. PMID 15539680.
  3. ↑ 3.0 3.1 3.2 3.3 Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM (2009). "Research in action: using positive deviance to improve quality of health care". Implement Sci. 4: 25. doi:10.1186/1748-5908-4-25. PMC 2690576. PMID 19426507.
  4. ↑ Belrhiti Z, Nebot Giralt A, Marchal B (2018). "Complex Leadership in Healthcare: A Scoping Review". Int J Health Policy Manag. 7 (12): 1073–1084. doi:10.15171/ijhpm.2018.75. PMC 6358662. PMID 30709082.
  5. ↑ 5.0 5.1 Lindberg, Curt; Clancy, Thomas R. (2010). "Positive Deviance". JONA: The Journal of Nursing Administration. 40 (4): 150–153. doi:10.1097/NNA.0b013e3181d40e39. ISSN 0002-0443.
  6. ↑ 6.0 6.1 Lindberg, Curt; Schneider, Marguerite (2013). "Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance". Leadership. 9 (2): 229–253. doi:10.1177/1742715012468784. ISSN 1742-7150.
  7. ↑ McLachlan S, Potts HWW, Dube K, Buchanan D, Lean S, Gallagher T; et al. (2018). "The Heimdall Framework for Supporting Characterisation of Learning Health Systems". J Innov Health Inform. 25 (2): 77–87. doi:10.14236/jhi.v25i2.996. PMID 30398449.
  8. ↑ Curry LA, Nembhard IM, Bradley EH (2009). "Qualitative and mixed methods provide unique contributions to outcomes research". Circulation. 119 (10): 1442–52. doi:10.1161/CIRCULATIONAHA.107.742775. PMID 19289649.
  9. ↑ 9.0 9.1 O'Hara JK, Grasic K, Gutacker N, Street A, Foy R, Thompson C; et al. (2018). "Identifying positive deviants in healthcare quality and safety: a mixed methods study". J R Soc Med. 111 (8): 276–291. doi:10.1177/0141076818772230. PMC 6100151. PMID 29749286.
  10. ↑ 10.0 10.1 Rose AJ, McCullough MB (2017). "A Practical Guide to Using the Positive Deviance Method in Health Services Research". Health Serv Res. 52 (3): 1207–1222. doi:10.1111/1475-6773.12524. PMC 5441507. PMID 27349472.
  11. ↑ 11.0 11.1 11.2 Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C; et al. (2016). "Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality". JAMA. 316 (10): 1061–72. doi:10.1001/jama.2016.12226. PMID 27623461.
  12. ↑ Bock, L. (2015). The Two Tail. In: Work rules!: Insights from inside Google that will transform how you live and lead. Twelve.
  13. ↑ McAlearney AS, Garman AN, Song PH, McHugh M, Robbins J, Harrison MI (2011). "High-performance work systems in health care management, part 2: qualitative evidence from five case studies". Health Care Manage Rev. 36 (3): 214–26. doi:10.1097/HMR.0b013e318201d1bf. PMID 21646881.
  14. ↑ Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T (2013). "In search of joy in practice: a report of 23 high-functioning primary care practices". Ann Fam Med. 11 (3): 272–8. doi:10.1370/afm.1531. PMC 3659145. PMID 23690328.
  15. ↑ Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM (2018). "A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems". Health Serv Res. 53 (3): 1851–1869. doi:10.1111/1475-6773.12693. PMC 5980166. PMID 28384376.
  16. ↑ Berlowitz DR, Christiansen CL, Brandeis GH, Ash AS, Kader B, Morris JN; et al. (2002). "Profiling nursing homes using Bayesian hierarchical modeling". J Am Geriatr Soc. 50 (6): 1126–30. PMID 12110077.
  17. ↑ Rubens, Fraser; Chen, Li; Ramsay, Tim; Forster, Alan; Wells, George; Sundaresan, Sudhir (2018). "The development of a positive deviancy strategy to identify excellence in patient experience". European Journal for Person Centered Healthcare. 6 (4): 540. doi:10.5750/ejpch.v6i4.1542. ISSN 2052-5656.
  18. ↑ Wholey DR, Finch M, Kreiger R, Reeves D (2018). "Public Reporting of Primary Care Clinic Quality: Accounting for Sociodemographic Factors in Risk Adjustment and Performance Comparison". Popul Health Manag. 21 (5): 378–386. doi:10.1089/pop.2017.0137. PMID 29298402.
  19. ↑ Singh S, Goodwin JS, Zhou J, Kuo YF, Nattinger AB (2019). "Variation Among Primary Care Physicians in 30-Day Readmissions". Ann Intern Med. 170 (11): 749–755. doi:10.7326/M18-2526. PMC 6743324 Check |pmc= value (help). PMID 31108502.
  20. ↑ Joshi S, Nuckols T, Escarce J, Huckfeldt P, Popescu I, Sood N (2019). "Regression to the Mean in the Medicare Hospital Readmissions Reduction Program". JAMA Intern Med. doi:10.1001/jamainternmed.2019.1004. PMC 6596330 Check |pmc= value (help). PMID 31242277.
  21. ↑ Quinn, Ryan W; Myers, Christopher; Kopelman, Shirli; Simmons, Stefanie A. (2020). "How Did You Do That? Exploring the Motivation to Learn from Others' Exceptional Success". Academy of Management Discoveries. doi:10.5465/amd.2018.0217. ISSN 2168-1007.
  22. ↑ Downes PE, Crawford ER, Seibert SE, Stoverink AC, Campbell EM (2020). "Referents or role models? The self-efficacy and job performance effects of perceiving higher performing peers". J Appl Psychol. doi:10.1037/apl0000519. PMID 32463258 Check |pmid= value (help).
  23. ↑ Breidenthal, Amy P.; Liu, Dong; Bai, Yuntao; Mao, Yina (2020). "The dark side of creativity: Coworker envy and ostracism as a response to employee creativity". Organizational Behavior and Human Decision Processes. 161: 242–254. doi:10.1016/j.obhdp.2020.08.001. ISSN 0749-5978.
  24. ↑ 24.0 24.1 Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP; et al. (2012). "Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction". Ann Intern Med. 156 (9): 618–26. doi:10.7326/0003-4819-156-9-201205010-00003. PMC 3386642. PMID 22547471.
  25. ↑ 25.0 25.1 Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM (2001). "A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed?". JAMA. 285 (20): 2604–11. PMID 11368734.
  26. ↑ 26.0 26.1 Shore S, Ho PM, Lambert-Kerzner A, Glorioso TJ, Carey EP, Cunningham F; et al. (2015). "Site-level variation in and practices associated with dabigatran adherence". JAMA. 313 (14): 1443–50. doi:10.1001/jama.2015.2761. PMID 25871670.
  27. ↑ Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL; et al. (2018). "How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study". Circulation. 138 (2): 154–163. doi:10.1161/CIRCULATIONAHA.118.033674. PMC 6245659. PMID 29986959.
  28. ↑ Ritchey MD, Hannan J, Wall HK, George MG, Sperling LS (2020). "Notes from the Field: Characteristics of Million Hearts Hypertension Control Champions, 2012-2019". MMWR Morb Mortal Wkly Rep. 69 (7): 196–197. doi:10.15585/mmwr.mm6907a5. PMC 7043391 Check |pmc= value (help). PMID 32078589 Check |pmid= value (help).
  29. ↑ 29.0 29.1 29.2 Tanenbaum J, Cebul RD, Votruba M, Einstadter D (2018). "Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations". Health Aff (Millwood). 37 (2): 266–274. doi:10.1377/hlthaff.2017.1209. PMC 7003658 Check |pmc= value (help). PMID 29401005.
  30. ↑ Greene J, Hibbard JH, Alvarez C, Overton V (2016). "Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels". Ann Fam Med. 14 (2): 148–54. doi:10.1370/afm.1904. PMC 4781518. PMID 26951590.
  31. ↑ Sreeramoju P, Dura L, Fernandez ME, Minhajuddin A, Simacek K, Fomby TB; et al. (2018). "Using a Positive Deviance Approach to Influence the Culture of Patient Safety Related to Infection Prevention". Open Forum Infect Dis. 5 (10): ofy231. doi:10.1093/ofid/ofy231. PMC 6166267. PMID 30288392.
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