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This 10-minute video explains positive deviance and how clinicians at United Hospital used the process to improve how they help patients manage pain.
My favorite quote in all-- in education comes from Socrates, who said, there is nothing so well learned as that which is discovered. And I deeply believe that. And positive deviance is a way for teaching to just emerge out of a group of people, all of whom have a lot of knowledge, a lot of experience, a lot of expertise, but to bring it out and make it available and put it to work. Anyone who goes into the process of positive deviance intrinsically sees how it can be helpful. First developed in 1990, positive deviance is a change process that was initially used to address serious social and health-related issues in developing countries. Eventually, Positive Deviance, or PD, was used to significantly reduce hospital-related infections in the United States. Today, the PD process has been utilized in several hospitals in the Allina Health system in Minnesota. The first facility in Allina to use positive deviance is United Hospital in St. Paul. The problem, pain management. I would say that pain is one of the more complex entities that it's dealt with, because there are many behaviors among many disciplines that contribute to this. Despite the complexities involved, United Hospital is making strides in pain management by focusing on an underlying principle of positive deviance. The individuals, groups, and resources necessary for positive change already exist in any given community. Yet, they often remain invisible. So much of what we do in health care we kind of do in silos without seeing our fellow nurses and physicians and other people giving care. Positive deviance is a way of lifting all that up and finding out what works best. The PD process is best explored by adhering to the four D's-- define, determine, discover, and design. First of all, define the problem and establish a measurable outcome. For United Hospital, the problem with inadequate pain management as measured by patients. Achieving much better pain management satisfaction on a consistent basis was the goal. --and your lunch. In the old days when there wasn't as much communication around the pain plan, patients would come out of anesthesia and have their postoperative pain meds but a really different regimen that they would be receiving on the floor. And so there was this disconnect when they transferred. So there are ways to make that transfer for the patient very smooth. To make this transition, the community must determine if there are certain people or groups in the community who are achieving better outcomes than their colleagues who have access to the same resources. Social network surveys and discovery and action dialogues are two ways to determine which individuals or groups are achieving the best outcomes. The key is to share with colleagues outside of one's normal circle of influence, such as on a different unit or department. United Hospital has shown that this type of communication can be incorporated into a normal shift without adding to the workload. Traditionally, initiatives for system-wide change have come from above working their way downward to fix something that is broken. Positive deviance takes a different approach. I think the reason this works is that essentially all the stimulus comes from the ground up. It really emanates from real problems that people are being confronted with every day. Because positive deviance emanates from the ground up, everyone in the community is invited to participate. This would include staff often in direct contact with patients, yet traditionally least likely to be involved in system change. It doesn't matter what your role is. If you're a nursing assistant, if you're in transport, we want to hear how you make someone more comfortable. --a pillow. Positive deviance is not a mandate. So participation is not mandatory. Yet, the staff often discovers that they already possess the necessary knowledge and skills to make the PD process work. And this generates momentum. I hear from a lot of staff, I don't want to be told how to do my job. And we're not telling them how to do their job. We're asking them how they do it. We're asking them how they do it well. And then we're asking how they can teach someone else to do that same thing. Establishing effective communication is the first step necessary to discover the behaviors and strategies that enable the positive deviance to achieve the better outcomes. And this discovery can take many different forms. One thing I have found really valuable is to interact in simulations. You get people together in a room, what you discover is that you have ideas that other people haven't thought of before. Other folks observing you will say, hey, in that situation, what I do is this, and it seems to work really well. And all of a sudden, people are talking about this difficult situation. And you realize, there are four or five solutions in the room. And we just don't have access to them for. The final step is to design a process for the community to practice these positive behaviors and strategies until they become ingrained and self-sustaining. This portion of positive deviance is often very challenging, because designing the PD process is not a linear progression. And it is often very time-consuming. We set it up kind of slow and kind of mucky-- I think is the best way to describe it. We didn't really have a clear process. And being nurses, I think a lot of us wanted, like, we start here, we do this next, and we do this, and then we'll end here. But we didn't have that. That's not what positive deviance is. I noticed that there's an ebb and flow. It starts out slow. It's a lot of talking. It's, how do you handle pain. What do you do differently from other people. It's information gathering. And that goes on, not for hours, not for days, it goes on for months. And you can feel stalled. You can feel like nothing is happening. And then all of a sudden, you see change. You see people talking in ways they hadn't talked before. You see new ideas, ideas that I maybe heard on 6900 being talked about in my unit. That's my experience with positive deviance. This somehow, by osmosis, organically it works. And these things happen. And people start talking about pain. It is important for the community to remember that they are the catalyst for change, and the more positive results they generate, the more pride they often produce throughout their unit. This also generates momentum. It's been a highlight to watch staff bloom, to watch them have hope, because I think that was one of the most difficult things for me to see, was a lack of hope that things can be different. When you empower front-line staff to do something that they're already doing and to showcase how they're doing it well, it takes off and it blooms. I would notice a lot of pride in my unit. We discovered a lot of new techniques and different-- just different methods of helping patients and seeing different things. I mean, it was just-- It was eye-opening. And the patients were complimenting. The patients were saying that they could see something different was happening. They couldn't quite put their finger on it, but something was different. One of the main goals of positive deviance is sustainability. This is often accomplished by a continual emphasis on community leadership and ownership. --when they stood outside the room debating about going-- The excitement of positive deviance is contagious. What has changed in my practice since I started becoming involved with positive deviance, I just see the continuum of care from a broader perspective. I see how I treat pain impacts how the next nurse is going to treat pain, and how their experience with pain impacts how the patient is going to seek health care in the future. It's all a continuum. It starts from the very moment they enter the hospital. --much yes, but it looks like-- This is my passion now. This is-- I worked last night. So I've been up for 26 to 27 hours. This is how committed I am to this. I wanted to come and talk about this and really say how wonderful this is. and I've seen such a difference with my patients and my staff. It's just-- wonderful. I guess for me personally, I'm phasing out of inpatient nursing and into a next role as a nurse practitioner. So I see this as sort of a final hurrah in my inpatient nursing career. And that's why I personally am very passionate about it. And I'm probably going to start crying, because I feel like this is one of the first system changes that believes in us that believes in me. And so I'll preach it until the day I walk out this door for the last time. At United Hospital, positive deviance began as a way to achieve better pain management for patients. Significant and measurable progress has been made. But the PD process has also in many ways produced a cultural shift in how staff members interact with each other. And this has positively affected patient care beyond just the parameters of pain management. This transformation has not been easy. But developing more effective means of communication has produced dramatic results. Positive deviance depends on connections between people. And the more connections, the better. Hospitalists, in particular, like other doctors, are just very busy. But once folks have tried it and done it, they see the value in it. And it just builds and builds and helps. And that's why I think it works.