At Harvard Medical School I was exposed to a wide variety of hospitals, consultancies, and general practices as I completed each component of my physician training. As I rotated through each medical setting, I was struck by the variety between them despite having similar goals and facing similar constraints. 

Turning variation into a positive

One particularly well-run clinic had its staff divided into teams of medical personnel that worked together and were responsible for an assigned portion of the patients. This effectively meant that the patient always saw the same medical personnel, allowing constructive relationships to flourish.   However, it also allowed for the variation I saw on the macro-level between hospitals to exist on a micro-level between medical teams. 

This clinic however, had turned this variation into a system for iterative improvement: once per month each team would come up with a positive action that they thought they did differently from other teams. Then, at a clinic-wide meeting, these actions would be discussed and all the teams would agree on one action that they wanted to implement over the coming month. At the next meeting the whole clinic would discuss the effect of the positive action and whether or not they wanted to implement the change permanently. And then the process would begin again, with a new discussion of positive actions.

And it was working.

Positive deviance: a methodology for positive changes

I recently learned that this mode of iterative improvement has a name: ‘positive deviance’.   According to the Positive Deviance Initiative, positive deviance is ‘based on the observation that in every community there are certain individuals or groups whose uncommon behaviours and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges.’

At a recent talk at the Health Foundation given by Lars Thuesen, former head of innovation at the Danish Ministry of Justice, Department of Prison and Probation, positive deviance was discussed in greater depth. He gave several examples from his work with prisons, but perhaps one of the most illustrative examples was that of Jerry and Monique Sternin, who first came up with the concept of positive deviance.

Jerry and Monique, both American aid workers, were tasked with the mission of improving nutrition in a rural village in Vietnam. As foreigners with a minimal budget it seemed an impossible task. Rather than feel discouraged, they began to weigh the children of a village and, in the process, discovered that not all of the children were malnourished. Intrigued, they began to investigate what these families were doing differently: regular hand-washing, the inclusion of non-traditional foods, and more frequent meals. Once this was discovered, they invited those families to cook with other members of the community and share these simple methods. 

The story demonstrates what the Positive Deviance Initiative calls the ‘four D’s’: define the problem (malnourishment), determine the norm (weighing the children), discover positive deviance (some children weren’t malnourished), and disseminate the positive deviant behaviour. 

The strength of positive deviance

What I find most valuable about positive deviance as an agent for change is its strong emphasis on engaging the targets of the solution. With positive deviance the answer comes from the people closest to the situation, and is implemented directly by them; leadership only facilitates. This is a radical deviation from the traditional top-down models where management is responsible for discerning and implementing best practices.

Importantly, positive deviance produces successful results without additional resources. When small ‘positive deviant behaviours are made mainstream, they add up to a large and effective change: in the Vietnam example, childhood malnutrition fell by 65-80% with minimal external support and resources. 

Given his background in the Danish Ministry of Justice, Lars emphasized that he had to change his leadership style in order to successfully use positive deviance; he also emphasised that these changes were not always easy. However, if leadership wants to be a part of creating sustainable and long-term solutions to some of the biggest problems, then making an effort to incorporate some of the positive deviance methodology into our ‘improvement toolbox’ could yield encouraging results.     

This is especially important as the NHS faces unprecedented challenges. However, by using the four D’s of positive deviance, small positive actions have the potential to be transformed into a large movement towards excellence.