The Positive Deviant Solution to Our Health Care System

Just over a year ago, CAP hosted seminars in a new method of social change called “positive deviance.” The basic idea of positive deviance is that, within any given community possessing any given problem, some members through their own actions will fare better than others given equal resources. Observing what makes these “deviants” positive can unlock the secret to solving the challenges facing the community.

Recently the New Yorker ran a widely-praised article by Atul Gawande about the problem of health care costs in the U.S., focusing on the unlikely town of McAllen, Texas. As a follow up, the New Yorker posted a transcript of his commencement address to Northwestern University the Pritzker School of Medicine at the University of Chicago, in which Gawande explains the concept of positive deviance and  suggests applying a positive deviance approach to the national health care crisis:

Jerry Sternin was for awhile the director of a Save the Children program to reduce malnutrition in poor Vietnamese villages. The usual methods involved bringing in outside experts to analyze the situation followed by food and agriculture techniques from elsewhere.

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

If you attended our positive deviance seminars, led by a friend of the Sternins, you know this story by heart. Positive deviance has gone on to a distinguished history of discovering innovative, community-based solutions, particularly in healthcare. It’s shown success in reducing hospital infection rates by, gasp, encouraging medical staff to wash their hands thoroughly.

Gawande looks through this lens of positive deviance and sees solutions to today’s runaway health care costs that go unaccompanied with improved health:

Like the malnourished villagers, we are in trouble. But the public doesn’t know what do about it. The government doesn’t know. The insurance companies don’t know. …

Well, let us think about this problem the way Jerry Sternin thought about that starving village in Vietnam. Let us look for the positive deviants.

This is an approach we’re actually familiar with in medicine. In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful—the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.

Likewise, when it comes to medical costs and quality, we should look to our positive deviants. They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural Pennsylvania; Intermountain Health Care in Salt Lake City. They are in low-cost, high-quality cities like Seattle, Washington; Durham, North Carolina; and Grand Junction, Colorado. Indeed, you can find positive deviants in pockets of most medical communities that are right now delivering higher value health care than everyone else.

We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do—how they make it possible to withstand incentives to either overtreat or undertreat—and spread those lessons elsewhere.

I have visited some of these places and met some of these doctors. And one of their lessons is that, although the solutions to our health-cost problems are hard, there are solutions. They lie in producing creative ways to insure we serve our patients more than our revenues. And it seems that we in medicine are the ones who have to make this happen.

Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.

Yet the positive deviants do not seem to ignore the money, either. Many physicians do, and I think I am one of them. We try to remain oblivious to the thousands of dollars flowing through our prescription pens. There’s nothing especially awful about that. We keep up with the latest technologies and medications in our specialty. We see our patients. We make our recommendations. We send out our bills. And, as long as the numbers come out all right at the end of each month, we put the money out of our minds. But we do not work to insure we and our local medical community are not overtreating or undertreating. We may be fine doctors. But we are not the positive deviants. `

Instead, the positive deviants are the ones who pursue this work. And they seem to do so in small ways and large. They join with their colleagues to install electronic health records, and look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears or their cancer follow-up. They think about how to create the local structures and incentives to make better, safer, more appropriate care possible.

I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

I met another positive deviant, a thoracic surgeon named Dr. Mathew Ninan, who joined a group of pulmonologists, surgeons, and oncologists in Memphis to change the quality of care for lung-cancer patients in their city. “Our approach is simple,” he told me. “We will see every patient regardless of insurance status. We will make every attempt to see patients jointly in one visit. We will discuss every new patient that we see in a multi-disciplinary format on the same day and decide on a plan of treatment. We will follow every patient to track whether they receive the right treatment. And we will enroll as many patients as we can in clinical trials dedicated to improving lung-cancer care.”

To insure that unnecessary costs are avoided, they took yet further steps. The toughest was that the surgeons agreed to do no operations on lung-cancer patients unless the pulmonologist and oncologist agree that it is indicated. This is radical. “I have had to swallow my ego repeatedly to stick to this principle,” he said. Sometimes he’s had to persuade them an operation was best. More often, however, they persuade him to drop his plan and with it the revenue. And he did—because it was the right thing to do.

Jerry Sternin recently passed away from a long battle with cancer. May he rest in peace.