Identifying and understanding positive deviants for service transformation

Identifying positive deviants using routinely collected data

Lead: Professor Rebecca Lawton


  • Professor Andrew Street (University of York)
  • Dr Nils Gutacker (University of York)
  • Dr Katja Grasic (University of York)
  • Dr Jane O’Hara (University of Leeds/BIHR)
  • Dr Laura Sheard

In healthcare we often focus on what goes wrong, where there is harm to the patient, and where individuals or systems have failed. A significant problem with this focus is that we have traditionally paid little attention to what goes right, and how to replicate these successes. This latter approach is called ‘positive deviance’. The EBT Theme is currently working on a project that will examine two key questions: i) can we use routinely collected quality and safety outcomes to identify ‘positive deviants’ - services and teams that provide exceptional care for patients?; and ii) what is it about those services and teams that results in this high quality care? This innovative project is a collaboration between a number of NHS trusts (including Leeds Teaching Hospitals Trust, and Bradford Teaching Hospitals NHS Foundation Trust) and the universities of Leeds and York. The ultimate aim is to share this knowledge to support services in making improvements in patient safety across the YH region, based on what works well rather than what went wrong. It will also provide health services with improvement methods focused on building system, team and individual ‘resilience’ and not just eradicating risk.

You can read about the positive deviance approach for patient safety improvement here:


Identifying and understanding positive deviants in clinical teams and primary care

 PhD Student: Ruth Baxter

Supervisors: Professor Rebecca Lawton | Dr Ian Kellar | Dr Natalie Taylor

Within healthcare settings various methods have been used to conduct positive deviance research but little guidance exists about how the approach should be applied. Throughout this PhD we will explore how positive deviance can be used to improve patient safety within two distinct healthcare settings – primary and secondary care. In addition we aim to advance the methods used for positive deviance research within healthcare, through asking a number of questions:

  • Can we identify positively deviant clinical teams, which deliver exceptionally safe patient care, using routinely collected data?
  • What strategies and behaviours do positively deviant clinical teams use to deliver exceptionally safe patient care?
  • How do team dynamics and culture differ between positively deviant and averagely performing clinical teams?
  • Do positive deviants successfully deliver safe patient care by being deviant or by doing things differently to others?

To achieve this, a systematic review will explore the methods have previously been used for positive deviance research conducted within healthcare organisations. The results of this will inform the design and methods of the following studies. The second study will be conducted on acute elderly medical wards. Routinely collected safety data will be analysed to identify positively deviant ward teams within Yorkshire and Humber. This data will be triangulated with patient and staff perspectives about safety to validate whether we have identified wards that are truly exceptional. Qualitative methods (focus groups and field work diaries) will be used to explore how ward teams successfully deliver this safe patient care and comparisons will be made with wards that have good-average safety performance. We aim to identify concrete strategies and behaviours used as well as explore how concepts such as team dynamics and culture influence success. The third study will be conducted in primary care and follow a similar approach to the study above. Routinely collected data will be used to identify positively deviant GP surgeries and qualitative methods will be used to explore, both on concrete and abstract level, what these teams do to successfully deliver safe patient care. Within this study we also hope to unpack the concept of positive ‘deviance’ more fully to understand how this type of deviance may be operationalised within the context of healthcare.