Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study

Abstract

Background: Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multi disciplinary strategies and recommendations to improve operating room (OR) efficiency. Methods:We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours.Results: Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). Conclusion:The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR. Contexte :Les séminaires de déviance positive (DP), une approche qui a déjà donné d'excellents résultats en termes d'amélioration de la qualité des pratiques chirurgicales, recourent à la rétroaction sur le rendement individuel pour identifier les membres des équipes dont le rendement excède celui de leurs pairs; les stratégies associées à tout rendement exemplaire servent à améliorer les pratiques des membres des équipes. Notre étude visait à utiliser la DP comme approche pour les chirurgiennes et chirurgiens et le personnel infirmier spécialisés en arthroplastie afin d'identifier des stratégies et des recommandations multidisciplinaires pour améliorer l'efficience des blocs opératoires (BO). Méthodes : Nous avons recruté 5 spécialistes dont le volume d'interventions pour arthroplastie primaire était élevé et qui oeuvraient dans des blocs à 4 interventions chirurgicales depuis 2012, et 29 membres du pers...

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

“…In six articles, the criteria for the selection of PDs were unclear or unspecified [ 39 , 47 , 50 , 76 , 143 , 145 ] and in the remaining papers, the selection of PDs does not apply as they are systematic reviews [ 20 , 57 , 59 , 63 ] and adoption program papers that are implemented based on best practices identified from other positive deviant practices [ 28 , 51 , 54 , 67 , 92 , 119 ]. However, performance-based criteria have been used to identify PDs at individual, health facility or health system levels in majority of the articles [ 11 , 23 , 24 , 26 , 27 , 30 , 32 , 33 , 35 – 38 , 40 – 46 , 48 , 53 , 55 , 56 , 60 – 62 , 65 , 66 , 68 – 75 , 77 , 78 , 80 – 88 , 90 , 93 , 95 – 97 , 99 – 105 , 107 – 118 , 121 , 122 , 124 – 142 , 144 ].…”

“…Utilizing the PD approach in healthcare safety and quality programs has led to huge time and cost savings. For instance, Gold R, et al (2023) revealed that the application of the PD approach has resulted in great improvements in time management in surgical cases across all time intervals of procedures with an overall time of 49.84 min saved per day compared to the baseline values [ 32 ]. Similarly, an improvement in operating room time management after successive value improvement initiatives has also been reported [ 30 ].…”

“…Furthermore, limited study setting/s [ 30 , 31 , 41 , 44 , 80 , 82 , 88 , 90 , 101 ], difficulty of performing statistical tests due to small sample size [ 33 , 65 , 83 ], difficulty of adjusting confounders [ 30 , 34 , 63 , 68 , 114 ], lack of comparison and, or difficulty of doing comparative analysis [ 24 , 71 , 82 ], and issues of generalizability/transferability [ 11 , 30 , 42 , 44 , 64 , 72 , 80 , 82 , 84 , 91 , 96 , 98 , 100 , 102 , 143 ] are also reported as common limitations in several articles. In addition, the none-probability sampling methods used to recruit participants [ 94 ] and the Hawthorne effect, a type of reactivity in which individuals modify an aspect of their behavior in response to their awareness of being observed as positive deviant are included in many articles as limitations in using the approach of PD [ 30 , 32 , 49 , 66 , 71 ]. These limitations highlight the need for careful consideration of a balanced method when using the PD approach [ 146 ].…”

“…The scoping review findings have supported this statement and depicted that the selection process of PDs appeared to be too complex and dependent on the unique circumstances of each study or project. As a result, different articles and studies have utilized a range of methods and criteria to identify PDs including peer recommendations [ 25 , 49 , 52 , 106 , 120 , 123 ], and performance-based criteria such as lowest risk-adjusted morbidity [ 139 ], mortality [ 82 , 87 , 93 , 102 ], timely service [ 26 , 32 , 33 , 84 , 95 , 99 , 113 , 116 , 134 ], and standardized composite performance measures including high composite quality scores [ 86 , 115 , 137 ], high composite performance/healthcare service scores [ 11 , 23 , 27 , 43 – 45 , 53 , 62 , 65 , 69 , 75 , 78 , 109 , 110 , 117 , 118 , 122 , 124 , 131 , 138 , 140 , 144 ], and better clinical outcome scores [ 37 , 38 , 111 , 118 , 125 , 130 ]. This justifies the absence of a one-size-fits-all approach to selecting PDs, and the criteria used can vary greatly based on the specific domain and goals of initiatives.…”

“…Furthermore, researchers have proved that the utilization of PD has helped them be successful in various healthcare services and quality improvement programs including in the reduction of medication errors [ 28 ], enhancing effectiveness in time management and/or financial expenditure [ 30 , 32 , 143 ], in improving hand hygiene practice and, or reducing infection rates [ 26 , 27 , 36 , 39 , 51 , 61 , 63 , 92 , 98 , 106 , 119 ], in improving surgical care quality and reduction of complications [ 34 , 37 ], and in other reported outcome measures including an increase in the proportion of controlled blood pressure (< 140/90 mmHg) among adult patients in the USA [ 111 ], a consistent increase in the use of dual-method contraceptives among women in Uganda [ 70 ], improvement in cardiovascular quality service outcomes [ 114 ], and improvement in personal functioning’s and reduction of stigma and discriminations among patients with severe mental illnesses after implementation of PD-based programs have indicated the huge potential of utilizing PD in healthcare service quality and other outcome improvement efforts [ 145 ]. These successes from the utilization of the PD approach are supported by other studies from different programs.…”