It is easier to act your way into a new way of thinking than think your way into a new way of acting. – Jerry Sternin1
This column is offered more as "food for thought" than as words for action, and it will hopefully stimulate some consideration and dialogue. During the past several months, many linear inches of the ACCP Report have been dedicated to the important discussion of a standardized process of care as an essential component of clinical pharmacy practice and the College’s Medicare benefit initiative (a.k.a. “provider status”). These topics are both related to the goal of evolving to a true interprofessional practice in which the clinical pharmacist assumes responsibility for drug therapy management and pharmacotherapy-related outcomes, as a member of the patient’s team of health care providers, in all environments of care. We believe this is a model in which clinical pharmacists “practice at the top of their license” (an unfortunate misnomer!) and have the greatest opportunity to positively affect patient outcomes. Given the triple aim of health care reform and the evolving accountable models of care delivery, there has probably never been a better opportunity for clinical pharmacy to achieve this desired state as a predominant model of practice.
However, the practical reality today is that most of us practice in a structure that falls short of this goal. Many clinical pharmacists function as consultants (formally or informally), or we are placed in a reactive policing mode, with recommendations often occurring after a decision by a prescriber that is made without prospective input by the clinical pharmacist. There are many real or perceived barriers and challenges to achieving the desired state of practice, including limited resources, an inadequate number of properly trained and credentialed clinical pharmacists, the political and regulatory environment, misaligned reimbursement and reward models, predominantly mercantile business models in the community, traditional well-entrenched practices, and historical expectations of pharmacists.
If you agree with the goal of collaborative, team-based care and accept the current state of practice described above as an accurate characterization, then a major problem we all face is how to redefine, implement, and execute a new team-based pharmacy practice across the health care delivery system with the goal of “getting the medications right” and improving patient outcomes.
Traditional problem solving, which has been central to our education and training, starts with defining the problem and desired outcome and then proposing potential solutions based on the best evidence (and often a bit of bias), seeking resources, testing potential solutions, and measuring and reporting results in the pursuit of describing “best practices.” The broader implementation and amplification of change is dependent on the importation and adoption of best practices, which often include repeated cycles of achieving buy-in, acquiring resources, documenting value (i.e., ROI), and much “reinventing of the wheel” at the local level. This approach is resource-intensive (i.e., expensive), analytic, iterative, leadership-driven, and typically slow. In fact, it often takes a decade or more for “best practices” to be incorporated into the mainstream. In the opening quotation above, this represents “think[ing] your way into a new way of acting.”
A positive deviant is a term meaning an individual or group within a community or organization whose uncommon practices or behaviors have led to success, despite their having faced the same or greater challenges and barriers as the rest of the community or organization. I’m quite certain the founding members of ACCP were a small band of positive deviants (though the term had not yet been coined), and I’m also certain that we continue to be surrounded by members who are positive deviants. Positive deviance (PD) as a change management process is based on the principle that the solution to the problem already exists within the community and that the community already possesses the knowledge and ability to solve the problem. The concept of PD, first published in the 1990s, is relatively new. Early successes focused on addressing serious social problems that were considered insurmountable without an infusion of resources from outside the community, such as severe childhood malnutrition in underdeveloped areas of the world. More recently, the application of PD theories has expanded to include reductions in hospital-acquired infections and improvements in public health challenges like smoking cessation, prenatal care, and the spread of HIV/AIDS. Positive deviance practices have also been adopted by the private sector, leading to improved business performance.
The PD approach is different in many ways from traditional problem solving. Both involve defining and understanding the problem or opportunity and the desired outcomes. However, PD assumes the solution exists in the community and therefore focuses on determining whether others in the community are already achieving the desired outcome and then discovering what uncommon behaviors are leading to that success. The traditional approach depends on importing solutions from the external environment, whereas PD depends on an internal emergence of practices and behaviors from within the community. It is more of a bottom-up, community-led process than a top-down, leadership-driven process. The community decides what strategies to adopt and then designs activities that teach others in the community to be successful. Dissemination of these behaviors through action is what leads to widespread change (i.e., communities “act [their] way into a new way of thinking”). Positive deviance works with existing assets and resources to solve the problem. You do what needs to be done, with what you have, where you are. The innovators in the PD movement have defined specific steps in the PD process that are beyond the scope of this column, and the description above is oversimplified.
In the process, we need to be wary of “TBUs” (true but useless solutions). Individuals may demonstrate uncommon behaviors that have led to a successful solution of the problem, but on further investigation, it is realized that these individuals do not face the same challenges as the balance of the community; they are “resource advantaged” in some way. The TBU information is not helpful in the PD process because the community cannot adopt such behaviors within the constraints of available resources and therefore cannot achieve the same successes. In clinical pharmacy, like in other communities, we have many examples of TBUs that may be presented as positive deviants to emulate but that are unlikely to lead to success. For example, highly successful clinical pharmacists who are funded through academic appointments are not typically beneficial as positive deviants to those in a pure practice environment, yet they may be beneficial to other academic clinicians. Similarly, grant-funded researchers cannot typically serve as positive deviants in the PD process, given the differences in resources between them and the rest of the practitioner community. The TBU definition is not meant to insult or demean the work of our successful colleagues in academic and research environments, but rather to point out that these examples represent problem solving using traditional methods that should not be misinterpreted as the uncommon behaviors found in a PD approach.
So can the PD process be applied to solving the practice evolution problem facing clinical pharmacy? Probably, in doing so, we would face many challenges. For example, how do we define the “community” of clinical pharmacy such that there is commonality of barriers and challenges? Does the “community” extend locally, regionally, or nationally? Are there many different “communities” within the discipline of clinical pharmacy? How do we identify and define the positive deviants within a specific “community” while separating the TBUs that may mislead the group? Can we successfully discover and disseminate through actions the uncommon behaviors and strategies of our colleagues who are positive deviant to change our way of thinking? These are but a few questions that would need to be considered.
Past surveys of members indicate that many of us are looking to ACCP and our academic colleagues for solid, defensible evidence of the value of clinical pharmacy. We also believe that compensation for clinical pharmacy services through provider status is necessary to move our services forward (i.e., promote the continued evolution of clinical pharmacy practice). In general, we are looking externally for a well-packaged “turnkey” solution to the problem that can then be applied locally to change the way we act, and we believe the solution depends on an infusion of additional resources. And we appear to be quite locked-in to this perspective. Advocates of PD would instead encourage us to look internally to see whether the solution already exists, and if it does, it should be achievable within existing resources. This is certainly an interesting (and a bit heretical?) prospect to consider.
I believe that a greater number of positive deviants are needed in clinical pharmacy if we are to identify and successfully disseminate uncommon behaviors that work across the different practice environments and regions of the country. How does one become a positive deviant? Is it possible to develop positive deviants, or are they inherently uncommon people with uncommon approaches to problems? In the afterword to his book Better, Dr. Atul Gawande recounts a lecture he presented to medical students in Boston in which he encouraged them to go out into the world of medicine and be positive deviants. Gawande had five simple recommendations for the medical students that I believe translate equally well to clinical pharmacy:
- Ask the unscripted question.
- Don’t complain.
- Count something.
- Write something.
We may go through our daily life caring for patients, interacting with team members and colleagues, and getting our work done very efficiently following our routine processes. Yet Gawande says we should routinely stop and ask unscripted questions (e.g., “Have you been to any good restaurants lately?” “Have you always lived in Rochester?”) that will make our interactions more memorable and more human. We will learn much more about those around us, make interactions more meaningful, establish trust, and build stronger relationships.
Those who complain about the current “state of affairs” are often boring, unproductive, and negative. Those who see the positives and use that energy to improve the situation for themselves and those around them are just the opposite. You can’t be a both a complainer and a positive deviant—they are simply not compatible.
We cannot truly understand a problem or identify a solution without counting something. Gawande encouraged his students to start simple, but to count something that was relevant to their interests. Starting with simple process measures will often evolve to quantifying more important measures like surrogate end points or true outcomes. Over time, we become more sophisticated in our ability to collect data and to apply these data to problem solving, but it all starts with simply counting something. In Three Signs of a Miserable Job, Patrick Lencioni argues that counting something (keeping score) is one of the three elements of job (professional) satisfaction. Like Gawande, Lencioni states that the item being counted must be relevant and within the individual’s control.
Reducing thoughts and observations to writing achieves a greater level of thoughtfulness, and sharing reflections with others connects the individual to a larger world. Whether the chosen audience is small or large, the writer will be concerned about how he or she is perceived and what influence he or she may have; the writer wants to contribute something meaningful. There is no substitute for writing when it comes to expressing meaningful and deep thought on a subject.
Finally, Gawande encouraged students to embrace change and be early adopters. Too many people are addicted to comfort and rarely venture outside their comfort zone. Constant change induces considerable discomfort, but positive deviants often thrive in the discomfort zone. Recently, a young colleague told me that if something does not cause his heart rate to increase and an uneasiness to form in his gut, it is not worth doing. I suspect he has a good chance of being a positive deviant throughout his career (as well as, perhaps, of dying young, strapped to an ultralight aircraft).
In conclusion, we should ask ourselves, Are the solutions to challenges in clinical pharmacy practice already present in the community, or do we need more evidence and resources to realize our goals? Should we focus on identifying and highlighting some of the positive deviants in different clinical pharmacy communities? I would enjoy hearing your thoughts on the potential for PD concepts to help clinical pharmacy practice evolve as well as your stories of positive deviants that you believe exist among ACCP’s members. And, most importantly, I hope you will consider becoming a positive deviant!
- Pascale R, Sternin J, Sternin M. The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Largest Problems. Boston: Harvard Business Press, 2010.
- Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-9.
- Basic Field Guide to Positive Deviance Approach. The Positive Deviance Initiative, Tufts University. 2010. Available at www.positivedeviance.org. Accessed July 15, 2013.
- Bradley EH, Curry LA, Ramanadhani S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci 2009;4:25.
- Singhal A, Greiner K. Chapter 10. Using the positive deviance approach to reduce hospital-acquired infections at the Veterans Administration Healthcare System in Pittsburgh. In: Suchman A, Slyter DJ, Williamson PR, eds. Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship-Centered Care. New York: Radcliffe Printing, 2011:177-209.
- Marra AR, Guastelli LR, de Araujo CM, et al. Positive deviance: a program for sustained improvement in hand hygiene compliance. Am J Infect Control 2011;39:1-5.