How to achieve safety excellence on elderly medical wards: a positive deviance approach

Objectives: Within healthcare, the limited success of deficit based approaches in improving patient safety has led to an increasing focus on ‘how things go right most of the time’. Positive deviance, an asset based approach, learns from those who demonstrate exceptional performance despite facing similar constraints as others. This study applies the positive deviance approach to generate hypotheses about the abstract behaviours and concrete strategies that staff on positively deviant elderly medical wards use to deliver exceptionally safe patient care. Methods: A qualitative study was conducted on eight elderly medical wards within five NHS Trusts in the North of England. Wards were selected using a routinely collected outcome measure of overall safety; four wards were positively deviant (exceptional safety performances), and four wards were matched comparators (slightly above average safety performances). Semi structured, multi-disciplinary staff focus groups explored how safe patient care is delivered at ward level. The researcher made field notes following each focus group. Data from all wards were analysed thematically to create a framework of abstract behaviours and concrete strategies that facilitate high performance in general. This was then analysed to identify differences between positively deviant and comparison wards which enabled hypotheses to be generated about which behaviours and strategies were specifically related to positive deviance. Results: The thematic framework of factors influencing general high performance included five high-order observations, 12 themes, and 65 subthemes (all of which pertained to abstract behaviours), and 14 concrete strategies. This presentation will focus on the behavioural sub-themes that were specifically hypothesised to facilitate ward level positive deviance. Positively deviant behaviours related to staff relationships, integrated multidisciplinary ward teams, performance improvement efforts, and communication among team members. The concrete strategies that staff use to achieve these abstract behaviours will be highlighted. For example, holding daily ‘safety briefings’ or ‘board rounds’ that are timely and involve all staff regardless of their grade, emphasises the important role everyone plays in maintain safety, engenders a multidisciplinary approach, and facilitates relationships by enabling staff to get to know one another and by reducing work related frustrations. Conclusion: This research reports the first known application of the positive deviance approach within the UK’s National Health Service. Findings highlight the positively deviant behaviours that are hypothesised to facilitate not only good but exceptionally safe patient care at ward level. Furthermore, the specific, concrete and practical strategies that staff use to achieve these more abstract positively deviant behaviours are identified. Testing and spreading these to similar elderly medical wards may generate improvements in patient safety.