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Positive Deviance in Health Care: Beware of Pseudo-Equifinality

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Abstract

Objective Identification of best practices constitutes an important strategy for organizational improvement. We compared different criteria (different measurement thresholds, different comparators, and performance consistency over time) on identification of high-performing facilities, especially positive deviants.

Methods The design was serial cross-sectional, using yearly VHA administrative data (2009–2013). Our primary outcome measure was facility-level rate of HbA1c overtreatment of diabetes in patients at risk for hypoglycemia. Outlier status was assessed by three methods.

Results From 2009 to 2013, the rate of overtreatment overall based on a threshold of 6.5% decreased from 28.6% in 2009 to 22.7% in 2013; the rate of undertreatment increased from 7 to 10.3%. Fourteen facilities were identified in the lowest decile of overtreatment. Undertreatment rates among these facilities were compared to the mean overall undertreatment rate; several facilities identified as positive deviants based on overtreatment rates had exceptionally high rates of undertreatment.

Conclusion Because two facilities may arrive at the same results via very different pathways, it is important to consider that a best practice may actually reflect a separate worst practice.

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Acknowledgements

Funding. The work was supported by grants from the Veterans Health Administration (VHA) Health Services Research & Development Service and its Quality Enhancement Research Initiative (QUERI) to Dr. Aron (SCE 12-181), to Dr. Pogach (RRP-12-492), and to Dr. Tseng (IIR 11-077).

Disclaimer. The opinions expressed are solely those of the authors and do not represent the views of the Department of Veterans Affairs.

Author information

Authors and Affiliations

  1. Department of Veterans Affairs, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd., Cleveland, OH, 44106, USA

    David C. Aron

  2. Case Western Reserve University School of Medicine, Cleveland, OH, USA

    David C. Aron

  3. Department of Veterans Affairs, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd., Cleveland, OH, 44106, USA

    Brigid Wilson

  4. Department of Veterans Affairs, New Jersey Healthcare System, 385 Tremont Ave, East Orange, NJ, 07018, USA

    Chin-Lin Tseng & Leonard M. Pogach

  5. Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, NJ, USA

    Chin-Lin Tseng & Leonard M. Pogach

  6. Department of Veterans Affairs, New Jersey Healthcare System, 385 Tremont Ave, East Orange, NJ, 07018, USA

    Orysya Soroka

Authors
  1. David C. Aron
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  2. Brigid Wilson
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  3. Chin-Lin Tseng
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  5. Leonard M. Pogach
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Corresponding author

Correspondence to David C. Aron .

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Editors and Affiliations

  1. School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia

    Joachim P. Sturmberg

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Aron, D.C., Wilson, B., Tseng, CL., Soroka, O., Pogach, L.M. (2018). Positive Deviance in Health Care: Beware of Pseudo-Equifinality. In: Sturmberg, J. (eds) Putting Systems and Complexity Sciences Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-319-73636-5_14

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  • DOI: https://doi.org/10.1007/978-3-319-73636-5_14

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