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A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people
  1. Ruth Baxter1,
  2. Natalie Taylor2,
  3. Ian Kellar3,
  4. Rebecca Lawton1,3
  1. 1 Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
  2. 2 Cancer Research Division, Cancer Council, Sydney, New South Wales, Australia
  3. 3 School of Psychology, University of Leeds, Leeds, UK
  1. Correspondence to Dr Ruth Baxter, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, BD9 6RJ, UK; ruth.baxter{at}


Background The positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people.

Methods A qualitative positive deviance study was conducted on four positively deviant and four slightly-above-average matched comparator wards, which had been identified using routinely collected NHS Safety Thermometer data. In total, 70 multidisciplinary staff participated in eight focus groups to explore staff perceptions about how their teams deliver safe patient care. A thematic analysis was conducted in two stages: first to identify the tools, processes, strategies, and cultural and social contexts that facilitated safety across all wards; and second to generate hypotheses about the characteristics that facilitated ‘positively deviant’ patient care.

Results Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented.

Conclusion This study exemplifies that there are no ‘silver bullets’ to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes.

  • health services research
  • implementation science
  • patient safety
  • qualitative research
  • quality improvement methodologies

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Twitter @RuthMBaxter @LawtonRebecca

  • Contributors RB, RL, NT and IK were involved in the design of the overall study. RB collected and analysed the data with input and guidance from RL, NT and IK. RB wrote the first draft of the manuscript, and all authors have contributed to the drafting and reviewing of it. All authors have approved the final version of this manuscript for submission.

  • Funding This article was funded by the Health Foundation, PhDs in Improvement Science.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Research ethics approval was granted by South East Scotland Research Ethics Comittee (ref 14/SS/1085) and permissions were gained from all NHS Trusts involved.

  • Provenance and peer review Not commissioned; externally peer reviewed.