title: What methods are used to apply positive deviance within healthcare organisations? A systematic review.
abstract: BACKGROUND
  The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. 'Positive deviants' are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved.
  
  
  METHODS
  Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed.
  
  
  RESULTS
  37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources.
  
  
  CONCLUSIONS
  Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches.
  CRD42014009365.
authors.affiliation: School of Psychology, University of Leeds, Leeds, Yorkshire, UK Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK.
authors.forename: Ruth
authors.initials: R
authors.lastname: Baxter
authors.affiliation: Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.affiliation: School of Psychology, University of Leeds, Leeds, Yorkshire, UK Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: Kellar
authors.affiliation: School of Psychology, University of Leeds, Leeds, Yorkshire, UK Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Lawton
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D006282:Health Personnel; D006302:Health Services Research; D006801:Humans; D033183:Interdisciplinary Communication; D061214:Patient Safety / Q000592:standards*; D058996:Quality Improvement; D011787:Quality of Health Care; D017751:Safety Management; D014481:United States
keywords: Health services research; Healthcare quality improvement; Implementation science; Quality improvement; Quality improvement methodologies