Positive deviance as a tool for organizational change.

The senior leadership in a hospital wants to increase reimbursement and hires a consulting firm to assist with improving its diagnosis related group (DRG) case mix. The consulting firm brings best practices from its other clients and implements a plan to enhance the DRG case mix.

Clinical documentation specialists hired by the hospital and trained by the consultants will review charts and post queries in the charts for the physicians to answer. Education sessions are held for the physicians. Initially, revenue soars, but after the first year, only minor improvements are seen.

Physicians become resistant to answering the queries. They either ignore them or throw them away. The chief executive officer asks the vice president for medical affairs: "Why won't the physicians cooperate? How can we get the physicians to do what we want them to do?"

Traditionally, efforts to bring about change are top-down, driven by senior management in an effort to fix what is broken or not working. Senior leaders become the champions of change. They are the "process owners."

In addition, these change initiatives tend to be outside in, with consultants brought in to study the underlying processes in depth, identify the problems and recommend solutions. Solutions are based on what has worked for other clients and best practices in the industry. It is a logic-driven approach, based on getting individuals to think into a new way of acting. (1)

The major problem with this approach, however, is this type of change initiative is very vulnerable to resistance. Resistance arises because outsiders impose the ideas for change. This is the answer to "Why won't the physicians cooperate?"

Positive deviance 

Richard Pascale and Jerry Sternin developed a different approach to bringing about organizational change. They refer to their approach as "positive deviance." (1) They believe the answer to successful change management lies in finding individuals or groups who already are doing things in a radically better way.

The process they advocate seeks to build upon the strategies of these positive deviants. Rather than identifying the problems and creating a solution, a solution is found and worked backward to solve the problem. How would this work in our scenario?

First, the senior leaders look within their institution to find groups or individuals who may have knowledge of a solution or solutions to the problem. In doing so, they discover that several of their physicians who also admit to another hospital have been using an electronic medical record at the other facility that provides them with electronic queries.

When they log into the patient's record, if a query has been generated, it appears and easily can be addressed and answered. With this new information, the senior leaders bring together and empower a group of physicians, coders and information system specialists to look at this pre-existing solution, and work backward to see if it or some variation of it may work to solve their problem. They, rather than the leaders, are the "process owners."

After examining the electronic medical record, they find it is not feasible to deploy it in their hospital. However, they do not give up. Instead, they take the "solution" of an electronic query concept, and look to see if they can leverage any current assets to make it work for them.

They discover their electronic dictation review and signature software has the flexibility to allow them to place electronic queries in the physician's folder. When the physician logs on to review and sign dictation summaries, he or she can review and electronically sign the queries. The queries, like the dictation summaries, are then electronically linked to the coders.

With physicians, coders, and information systems working together, the system is designed to work easily for each group. The result is less resistance by all three groups when the change is initiated.

By using positive deviance, the change process goes from outside in to inside out. Rather than relying on outside parties to determine best practices, it relies on using the knowledge within your institution to identify pre-existing solutions and amplify them.

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While traditional change efforts are deficit-based (Why can't we do what someone else is doing?) positive deviance is asset-based (How can we use our assets to leverage an already existing solution?).

Finally, with positive deviance, the process goes from one that is logic driven to one that is learning driven. The statement becomes, "This is how we can do what we want to do," rather than the question "How can we get them to do what we want them to do?"

While positive deviance as a method for creating organizational change is not perfect for all situations, it does provide a useful tool for situations where behavioral and attitudinal changes are required to succeed.

By beginning with what the people in your organization have, building on what they know and learning from what they discover, you have a greater chance to succeed.

David P. Tarantino, MD, MBA, is the executive medical director of Shock Trauma Associates, P.A., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at [e-mail]

References

1. Pascale RT, Sternin J "Your Company's Secret Change Agents." Harvard Business Review. May 2005, 72-81.

By David P. Tarantino, MD, MBA

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