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An Inside Job: Best Practices from Within

The best solutions to an organization’s problems may be found among its members.

(originally published by Booz & Company)

Many organizations must wrestle with the challenge of how to identify best practices and ensure their effective implementation. In 2001, the Veterans Health Administration Pittsburgh Healthcare System (VAPHS) faced such a situation: The number of patients contracting preventable hospital-acquired infections at these facilities was increasing at an alarming rate. Although the solution — better hygiene — seemed simple, actually changing staff behavior in the complex hospital environment was a daunting task.

In search of a new organizational framework to confront the problem, VAPHS’s management turned to experts trained in the Toyota production system (TPS). For three years, the TPS team worked to uncover systemic problems and standardize procedures. By some metrics, the approach worked. In both the surgical ward and intensive care unit at the University Drive facility where the team of experts introduced TPS, the staff addressed a few of the obstacles, including mismanagement of supplies that thwarted sanitary protocols, and infection rates dropped by 70 percent. But their success was limited. Even after significant investments in time, money, and outside expertise, the new practices — although successful in the two units — failed to trickle down to the rest of the units in the hospital that needed similar improvements.

Having tried outside consultants, management decided to switch gears after one of the hospital’s surgeons happened to read an article on a strategy called Positive Deviance (PD). This method, which has been used to combat malnutrition in Vietnam, is based on the idea that within any community or organization there are members whose unique behaviors let them find solutions to problems that most other people find difficult to address. Unlike TPS and familiar problem-solving methods, PD assumes the community already knows what needs to happen; it’s just a matter of finding the people who have the best ideas and encouraging them to spread those ideas.

For the Pittsburgh VA hospitals, the change in direction was exactly what was needed. Using PD in two facilities — University Drive and the H.J. Heinz III Center — management discovered dozens of staff-driven solutions to reduce the spread of bacteria, and infection levels dropped by 50 percent. But even more important, PD succeeded in causing a sea change. The solutions spread hospital-wide. Personnel at all levels adopted a culture of collective responsibility, and now identifying best practices isn’t limited to once-a-year evaluations — it happens every day.

Although within different organizations the exact process may vary, every PD program begins by letting the community be the experts. By shifting the responsibility away from outside consultants and top-level managers, the staff is more likely to take ownership of problem-solving methods. This is especially important in organizations, such as hospitals, where a rigid hierarchy normally dictates staff interactions. One of the chief complaints about TPS from management at the Pittsburgh facilities was a low level of staff involvement, because the program depended almost entirely on the TPS experts to function. In contrast, under the PD method, collective brainstorming sessions meant everyone from janitors to physicians came forth to share suggestions and ideas. That mentality remains. John Lloyd, a retired surgeon who now coordinates infection prevention for the Pittsburgh VA system, points out that in the past if you asked people to identify who was responsible for preventing the spread of infections they looked to the infection control physician. Recently management asked the same question at an all-hands meeting involving hundreds of staff and they all raised their hands.

The first task is to bring together staff from all levels to brainstorm solutions and identify the Positive Deviants, or the individuals among the group who are finding ways to work around problems by deviating from standard practices. Discussions at the hospital revealed that even before PD was introduced, certain staff members were already implementing best practices in creative ways. For example, one attendant incorporated hand sanitization into her patients’ evening entertainment activities. No one else had stopped to think that communal items like board games and TV remotes were facilitating the spread of bacteria.

Turning these individual solutions into organization-wide practices is the real challenge — and one that the TPS strategy didn’t successfully address. One of the advantages of PD is that it seeks to change behavior through doing, not telling. The idea is that change will meet less resistance if the Positive Deviants show the rest of the group why their solutions work. Equally important is demonstrating progress through hard data. In the year that PD was introduced, the infection rate declined 50 percent and the best practices proliferated in 14 different units in the hospital. The staff credits the prominent posting of weekly statistics as a major factor in helping everyone share responsibility for the results.

The final step is to encourage replication. One of the ways that PD caused a culture shift at the Pittsburgh facilities was by creating an environment in which change is a continuous process. The problem of finding better hygiene solutions resulted in a new set of practices, but these are by no means static. Regular unit briefings maintain the flow of ideas and encourage more and better staff-inspired solutions. And although hand sanitization was a starting point, the staff grew more attuned to the broader context and situations that facilitate the spread of bacteria and infection. Now, nurses actively investigate the sources of new infections; track closely the mobility of infected patients; and make sure that items like portable carts, equipment screens, and EKG wires do not serve as points of transmission.

The success of the PD program at the Pittsburgh VA hospitals has impressed more than just the staff and management at those facilities. Now other health-care centers are paying attention. In 2005, the Robert Wood Johnson Foundation awarded nearly US$300,000 to the Plexus Institute, a nonprofit focused on applying ideas emerging from the science of complexity to solving social and organizational problems, to implement PD and reduce hospital-acquired infection rates in as many as 40 hospitals nationwide. An additional 18 VA hospitals have already launched similar programs and by the end of 2007 the entire network of 160 VA facilities will do the same.

If you ask John Lloyd to explain why PD works and scales more effectively than other change programs, he gives a simple reason. “Where TPS was an outside job on the system,” says Lloyd, “PD was an inside job.” And as the results of the hospital project suggest, more inside jobs might be exactly what the outside world needs.

Author profiles:

Lisa Kimball ( is executive producer of Group Jazz, a consulting company that works with organizations on collaboration and change. Her current focus is on applying ideas emerging from the science of complexity to large-scale problems. She is a member of the board of directors of the Organization Development Network and the Plexus Institute. 
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