Exploring and understanding what characterises a positively deviant, elective hip & knee service

Lead:                        Dr Laura Sheard (BIHR)
Collaborators:   Dr Lesley Dewhurst (BIHR), Lisa Pinkney (York Teaching Hospitals Foundation Trust),  Andrew Street (University of York), Cath Jackson (University of York; Valid Research)

This study involved researching the concept of  ‘positive deviance’, which is essentially about high performance in healthcare and how services achieve their success. The main idea behind positive deviance is that highly performing services are doing something different to the norm (‘deviating’) in a positive manner to other healthcare providers. In this study, we wanted to look at orthopaedic services – and in particular hip and knee replacement healthcare - to understand how services operate and what they might be doing differently to each other to achieve their performance level. The focus was on why the service was successful rather than the usual approach of finding problems.

The research team undertook a thorough exercise to categorise all the Trusts in the Yorkshire and Humber region based on their performance in relation to: i) emergency readmissions ii) Patient Reported Outcome Measures. We then categorised all these Trusts into four categories: excellent, good, average and poor. In this research, we worked with four Trusts, three of whom are in the excellent category and one who is in the good category.   

We used qualitative methods to uncover how different hospitals were achieving their success.
  1. Mapping exercise using focus groups and documentary analysis. Clinicians will be asked where they think areas of positive deviance may lie (at all four Trusts)
  2. Orientation stage – researchers will observe staff members on the ward and in different settings, looking for areas of positive practice (at two Trusts)
  3. Focus stage – researchers will hone in on where they think the positive deviance lies by conducting further observations and interviewing key people (at two Trusts)
We used a method of analysis called ‘constant comparison’. We sought to produce novel findings which focus on success rather than the usual emphasis in healthcare research which tends to focus on improving previous failures.

The areas of positive deviance found at the exceptional service/trust are based on five overarching themes:
protocol and pathway procedure
optimising patients
ways of working
clinical practice
culture and behaviour

A questionnaire based on the findings of this work was developed, testing Stage 3 of Elizabeth Bradley's Positive Deviance framework, and has been sent out nationally to all orthopaedic services.  This questionnaire is ‘stage 3’ in Bradley’s positive deviance framework.