Positive deviance
In quality improvement, Positive deviance is a "bottom-up" approach to quality improvement. An description of this method was:
- "Develop case definitions"
- "Identify four to six people who have achieved an unexpected good outcome despite high risk"
- "Interview and observe these people to discover uncommon behaviours or enabling factors that could explain the good outcome"
- "Analyse the findings to confirm that the behaviours are uncommon and accessible to those who need to adopt them"
- "Design behaviour change activities to encourage community adoption of the new behaviours"
- "Monitor implementation and evaluate the results"
A more recent listing of the steps is:
- 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
- Work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practice
Positive deviance is consistent with complexity leadership and learning health systems
Positive deviance may include grounded theory, ethnography methods, guided conversations/interviews, and focus groups.
Not all QI measures may be appropriate.
Positive deviance can provide structure to Quality circles (QCs). Quality circles are "small groups of 6 to 12 professionals from a similar background who meet at regular intervals to discuss and review their clinical practice...QCs select the issues they want to deal with themselves, decide on their method of gathering data, and determine a way of finding solutions to prioritized problems. Facilitators observe and lead the group through the circle of quality improvement".

# Methods
Overviews of methods are available.
Positive deviance is a viable strategy with variation in performance is present. Variation in performance has been measured with the coefficient of variation.

## 1. Identifying deviants
Ideally, positive deviants should be identified by blinded comparison to control groups, yet this is infrequently done and instead deviants are informally identified by reputation.
Various statistical approaches are used to identify the true deviants.
Performance rates may need adjustment before comparison.
Inadequate sample may hinder identifying deviants. Regression to the mean may confound identifying postive deviances and the assessment of improvement.

## 2. Sharing knowledge
Comparing the performance of participants, at least when done without providing solutions to improvement, to named peers is harmful.

# Psychology, barriers and promoters of shared learning
Learning of success can inspire others to perform. On the other hand, "Individuals with higher levels of  PPGO have decreased self-efficacy and performance when observing higher performing coworkers" Coworker envy make occur depending on relationships between colleagues and managers.

# Interventions and assessments using positive deviants
Reports of using positive deviance to assess the tactics behind successful performance have been published:
- In hospital cardiac arrest
- Hypertension (see also below)
- Surgical care.
- The National VA Surgical Risk Study
- Intensive care. Differences in outcomes were "related more to the interaction and coordination of each hospital's intensive care unit staff".
Reports of using positive deviance to assess and improve performance have been published Specific examples include:
- Ambulatory Care-Sensitive Hospitalizations
- Myocardial infarction treatment including:
beta-blockers
Percutaneous coronary intervention door to balloon time
- beta-blockers
- Percutaneous coronary intervention door to balloon time
- Patient activation
- Reduction in hospital readmission.
- Hospital infections.
- Antimicrobial stewardship in hemodialysis
- Anticoagulation with warfarin and dabigatran
- Diabetes chronic care
Assessment.
Improvement
- Assessment.
- Improvement
- Hypertension (see also above) using 
- Public health problems in developing regions
- Improvement in efficiency of care delivery by examining heterogeneity in costs of care by providers
- Thoracic surgery complications
- Medication errors