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Identifying positive deviants in healthcare quality and safety: a mixed methods study

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Publication details

JournalJournal of the Royal Society of Medicine
DateAccepted/In press - 2 Apr 2018
DatePublished (current) - 1 Aug 2018
Issue number8
Number of pages291
Pages (from-to)276
Original languageEnglish


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. This study explores using routinely collected, publicly available data in England to identify positively deviant services in one region of the country.

Design and setting:
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.

We identified 49 indicators of quality and safety from acute care settings across 8 data sources. Twenty six indicators did not allow comparison of quality at the sub-hospital level. Of the 23 remaining indicators, 12 met all criteria and were possible candidates for identifying positive deviants. Four indicators (readmission and patient reported outcomes for hip and knee surgery) offered indicators of the same service. These were selected by an expert group as the basis for statistical modelling, which supported identification of one service in Yorkshire and Humber showing a 50% positive deviation from the national average.

Relatively few indicators of quality and safety relate to a service level, making meaningful comparisons and local improvement based on the measures, difficult. It was possible, however, to identify a set of indicators that provided robust measurement of the quality and safety of services providing hip and knee surgery.

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