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

Solutions to quality and safety problems exist within healthcare organisations, but to maximise the learning from these positive deviants, we first need to identify them. Methods for identifying performance outliers have been used for 50 years in healthcare (e.g. ‘tracers’ ) but are fraught with methodological and conceptual issues, including multiple ways of measuring the same thing, as well as problems with the simple act of ‘measurement’ itself. While the identification of outliers in healthcare is not new, focussing on the ‘positive’ end of the distribution is more novel. 

Positive deviance is no mere statistical or technical exercise; it is an improvement method that seeks to understand the nature of the ‘deviance’ and to spread sustainable solutions to the wider healthcare community. But if the method is to be used more widely than healthcare research, it is important to understand whether routinely collected data can be used to understand variation in quality and safety across services, and whether it is possible to identify positive outliers from these existing data sources

This study explored using routinely collected, publicly available data in England to identify positively deviant services in one region of the country.  A mixed methods study undertaken July 2014 to February 2015, employing expert discussion, consensus and statistical modelling to identify indicators of quality and safety, establish a set of criteria to inform decisions about which indicators were robust and useful measures, and whether these could be used to identify positive deviants. Analysis was based on routinely collected, administrative English hospital data. 

Our overall aim was to explore the identification of hospital services that demonstrate exemplary quality and safety performance in a single region in England using routinely collected, publicly available data. 


  1. Identify quality and safety indicators that are publicly available or can be constructed from routinely collected datasets, and develop criteria for assessing the suitability of available indicators for identifying positive deviants. 
  2. Using these criteria, assess the suitability of available indicators for identifying positive deviants. 
  3. Critically examine a sample of shortlisted indicators as candidates for the identification of positive deviants.

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


  1. Identifying positive deviants in healthcare quality and safety: A mixed-methods study: