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Identifying positively deviant elderly medical wards using routinely collected NHS Safety Thermometer data: an observational study
  1. Ruth Baxter1,2,
  2. Natalie Taylor3,
  3. Ian Kellar2,
  4. Victoria Pye4,
  5. Mohammed A Mohammed1,5,
  6. Rebecca Lawton1,2
  1. 1 Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
  2. 2 School of Psychology, University of Leeds, Leeds, UK
  3. 3 Cancer Research Division, Cancer Council, Sydney, New South Wales, Australia
  4. 4 Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  5. 5 Faculty of Health Studies, University of Bradford, Bradford, UK
  1. Correspondence to Dr Ruth Baxter; ruth.baxter{at}


Objective The positive deviance approach seeks to identify and learn from exceptional performers. Although a framework exists to apply positive deviance within healthcare organisations, there is limited guidance to support its implementation. The approach has also rarely explored exceptional performance on broad outcomes, been implemented at ward level, or applied within the UK. This study develops and critically appraises a pragmatic method for identifying positively deviant wards using a routinely collected, broad measure of patient safety.

Design A two-phased observational study was conducted. During phase 1, cross-sectional and temporal analyses of Safety Thermometer data were conducted to identify a discrete group of positively deviant wards that consistently demonstrated exceptional levels of safety. A group of matched comparison wards with above average performances were also identified. During phase 2, multidisciplinary staff and patients on the positively deviant and comparison wards completed surveys to explore whether their perceptions of safety supported the identification of positively deviant wards.

Setting 34 elderly medical wards within a northern region of England, UK.

Participants Multidisciplinary staff (n=161) and patients (n=188) clustered within nine positively deviant and comparison wards.

Results Phase 1: A combination of analyses identified five positively deviant wards that performed best in the region, outperformed their organisation and performed consistently well over 12 months. Five above average matched comparator wards were also identified. Phase 2: Staff and patient perceptions of safety generally supported the identification of positively deviant wards using Safety Thermometer data, although patient perceptions of safety were less concordant with the routinely collected data.

Conclusions This study tentatively supports a pragmatic method of using routinely collected data to identify positively deviant elderly medical wards; however, it also highlights the various challenges that are faced when conducting the first stage of the positive deviance approach.

Trial registration number UK Clinical Research Network Portfolio (reference-18050).

  • quality in healthcare
  • positive deviance
  • quality improvement
  • implementation science

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  • Contributors RB, RL, NT and IK developed the idea for the study. RB, MAM and VP conducted the analyses to identify positive deviants. RB collected and analysed the primary data to assess staff and patient perceptions of safety. RB drafted the manuscript. All authors provided comments and approved the final version.

  • Funding The Health Foundation-PhD in Improvement Science.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval South East Scotland Research Ethics Committee (ref 14/SS/1085). NHS permissions were gained from all five NHS Trusts involved.

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

  • Data sharing statement Anonymised data are available on request.