Perspectives in Perioperative Quality Improvement: Case Studies in Positive Deviance Using Real-World Data

Healthcare quality/safety efforts frequently carry negative themes. This 'find and fix' method typically highlights little about the presence but rather the absence of quality and safety. Positive deviance (PD) is an approach that instead focuses on spreading success rather than eliminating errors. We describe four PD case studies from two pediatric health systems where procedural quality outcomes were improved.

Utilizing common continuous quality improvement methods, multidisciplinary teams assessed and improved clinical processes. AdaptX (Seattle, WA), a software solution that allows clinicians to extract continuously updated, aggregated health data from EMRs, was used to analyze data using statistical process control methods. Funnel charts identified PD providers for key processes. The team leader interviewed, observed, and documented their practice. Team members tested these new processes in clinical practice utilizing Plan-Do-Study-Act (PDSA) cycles. The team monitored real-time data to guide each PDSA cycle decision. Once finalized, the team disseminated this new best practice standard across the staff.

Reduction in surgical prep time yielded a sustained 35% increase in monthly procedure volumes. Gastroenterology anesthesia improvements coupled with a second procedural room led to a sustained 74% increase in monthly case counts. Improvements in Post-Anesthesia Care Unit duration and on-time performance reduced case durations, staff overtime, and increased operational capacity. Balance measures were unchanged.

These PD methods successfully improved the timeliness of procedural processes and capacity without adverse impacts on other quality measures. Real-time, democratized access to data made finding PD providers easy and eased the spread of this practice, facilitating sustained improvement in outcomes. This approach aligns with clinicians' desire to provide the best care, thus enhancing staff engagement.

The PD approach improved procedural efficiency in two unique and unaffiliated pediatric healthcare systems. Future efforts will focus on PD beyond the procedural domain and in additional healthcare institutions.