Last Word


Prescribe Positive Deviance for radical and sustainable change in the heath sector

Source: National Health Executive Nov/Dec 2012

Jane Lewis discusses the concept behind Positive Deviance and adaptive leadership and its relevance for the health sector.

The healthcare sector in the UK is facing a programme of radical change to futureproof its existence and mitigate the expected increase in demand on its services from an evolving demographic and its health needs.

The NHS of the future will be a highly complex and devolved world where the citizen is expected to contribute more to their own wellbeing and community, both in individual lifestyles and in supporting others. The community lies at the heart of this change programme. Furthermore, the structure and processes operating within the health sector will need to evolve to meet these goals.

Top-down, technical change approaches will not create the desired outcomes

Many change processes have been tried in the NHS, but not in the face of such radical upheaval. The public service reform agenda has altered the relationship between the state and the citizen.

Using traditional top-down approaches has clear limitations in creating the environment for change in both the communities and the front line. ‘Adaptive leadership’ is encompassed in the NHS change model to generate radical service and business innovation and to deliver culture transformation. However, this doesn’t go far enough, especially when considering the change model’s desire to activate the energy and brainpower of its workforce, the people who use it and its partners.

Positive and sustainable change from existing hidden wisdom

Positive Deviance has been used across the globe to open small improvements that lead to significant changes in attitude, practice and culture. It has delivered an 80% reduction in malnutrition in Vietnam; in the US it has generated up to a 73% reduction in the transmission of MRSA in three hospitals in months rather than the two years it took a parallel Toyota Productions System project to achieve a 50% reduction (Pascale Sternin & Sternin 2010).

Unlike other change models such as Appreciative Inquiry and Coaching, Positive Deviance focuses on working with groups, finding positive behaviours and practices, and amplifying what works at a practical and detailed level. It is an energising and effective way to deliver sustainable change at the front line and small, resource-light changes can make a big impact.

Positive Deviance starts from the premise that both the staff within the NHS and the community members for which it caters have the knowledge and skills to create effective and lasting change. It recognises that front line staff know the culture they work in, while the community knows their own needs. There are solutions to even the most intractable of problems in existence, hidden within every organisation and community. These solutions are easy to implement, cost-efficient and extremely effective.

It is an evidence based approach and places the responsibility for change within the community; it is an ownership, not a buy-in approach. This generates sustainable change as people don’t turn their backs on their own creation and it creates ‘Communities of Capability’.

It has the power to change relationships between patients, service users and agencies, providing greater productivity, building better relationships and sustainable, continuing improvements. It can help build a health sector for the future.

Positive Deviance works

The Veterans’ Administration Pittsburgh Healthcare System (1) in the USA used PD to advance their ‘Getting to Zero MRSA Initiative’. Prior to PD, it had used the Toyota Production System to reduce transmission of MRSA and hospital acquired infections.

This had been successful and led to a 50% reduction in two years, however, it was incredibly resource intensive. They therefore decided to look at the more cost effective option of PD ‘culture change’, where infection control becomes everyone’s responsibility.

By engaging every person in the healthcare environment, from janitors to consultants, it was possible to find positive deviance practices that reduced the spread of infection by up to 62% across 11 wards within limited resources and within a much shorter timeframe of 9 months.

A very interesting example of PD practice comes from one particular hospital in the System – the Albert Einstein Medical Center – where a patient escort developed a unique method of disposing of his soiled gloves and gown. By quickly sliding out of the gown, inverting it, folding it tightly and precisely stuffing it into a medical glove, he was able to compress the potential biohazard into a wad the size of a cricket ball prior to proper disposal. This eliminated the threat of the virus spreading and the technique has since been circulated throughout the hospital and system.

This change was easy, cost effective and because the change was determined by a staff member – not a top-down instruction – it has resulted in lasting change. The solution to the problem was already within the hospital and using the staff’s internal wisdoms has had a huge impact, with a 62% reduction in the spread of infection.


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Jane Lewis created and led the UK’s first organisational PD project, which delivered significant social work time savings for Hertfordshire County Council. She has also led successful community projects with Gosport Borough Council and a national Home Office sponsored project on domestic violence.

With Dr Keith Ruddle, she has presented ideas to the Department of Health top management team about how a combined approach of ‘adaptive leadership’, using PD as one of many tools to empower staff at the front line, can help deliver this kind of change.

Woodward Lewis provides tailored 12 and 16 week programmes for organisations, licensed facilitator training and train-the-trainer events.


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