A systematic review of the use of positive deviance approaches in primary care.

ABSTRACT

BACKGROUND: The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care. OBJECTIVE(S) This review aimed to synthesize the extant research on applications of the PD approach in primary care. METHODS: Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS). RESULTS: In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels. CONCLUSION: Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.

The positive deviance approach is focused on identifying people/organizations performing particularly well, in spite of having similar challenges and resources to others, and learning about how they work so well. Recently, this approach has been used in healthcare to learn about how to improve the quality and safety of care for patients. This review aims to explore how the positive deviance approach has been used in primary care settings and to summarize the findings from this research. Overall, 27 studies were included in the review. We found that studies typically focused on identifying positive deviants (i.e. those performing particularly well) and finding out what helps them do that, without looking to see if these same practices work elsewhere or teaching others about them. The positive deviance approach was used to improve several different parts of primary care including; care effectiveness, management of chronic diseases, preventative care, prescribing, and health promotion. Several success strategies were identified from the studies' findings and were organized into a framework describing what practices contribute to particularly good performance in primary care. This framework will be useful for those looking to improve quality of care in primary care.