Research in action: using positive deviance to improve quality of health care
Research in action: using positive deviance to improve quality of health care
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DOI：
10.1186/1748-5908-4-25
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发表时间：
2009-05-08
影响因子：
7.2
通讯作者：
Krumholz, Harlan M.
中科院分区：
文献类型：
--
作者：
Bradley, Elizabeth H.;Curry, Leslie A.;Krumholz, Harlan M.
背景：尽管几十年来一直在努力提高卫生保健质量，但在许多方面仍然存在不良表现。在国家对医学研究的巨大投资中，只有不到1%的投资集中在改善医疗保健服务上。此外，当发现临床护理的有效创新时，这些创新的吸收往往是延迟和不完整的。在本文中，我们建立在“积极偏差”的既定原则上，提出了一种方法来确定提高医疗质量的做法。方法：我们综合了有关积极偏差的现有文献，描述了主要的替代方法，提出了积极偏差方法对于旨在提高医疗保健质量的研究的好处和局限性，并描述了该方法在改善急性心肌梗死患者医院护理中的应用。积极的偏差方法，如适用于医疗保健，假设现有的组织中存在关于“什么有效”的知识，这些组织表现出一贯的卓越绩效。这种方法的步骤：识别“积极的偏差”，即，在感兴趣的领域一贯表现出极高业绩的组织（e.例如，在一个实施例中，在这方面，应采取的措施包括：（a）确保适当的药物使用、及时的护理）;（b）利用定性方法深入研究各组织，提出关于使各组织能够取得最佳业绩的做法的假设;（c）在较大的、有代表性的组织样本中对假设进行统计检验;（d）与包括潜在采用者在内的主要利益攸关方合作，传播关于新确定的最佳做法的证据。这种方法特别适用于以下情况：可以根据有效的业绩衡量标准对组织进行可靠的排名;一个行业内的业绩存在很大的自然差异;实现卓越业绩的做法是公开的;以及有一个积极参与的群体来促进采用所发现的做法。识别和检查的医疗机构，表现出积极的偏差提供了一个机会，以表征和传播的战略，以提高质量。
Background: Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality.Methods: We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction.Results: The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e. g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices.Conclusion: The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.