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To cite: Kassie AM, Eakin E,
Abate BB, et al. Use of the
positive deviance approach
for healthcare system service
improvement: a scoping
review protocol. BMJ Open
2023;13:e078809. doi:10.1136/
bmjopen-2023-078809
► Prepublication history and
additional supplemental material
for this paper are available
online. To view these files,
please visit the journal online
(http://dx.doi.org/10.1136/​
bmjopen-2023-078809).
Received 12 August 2023
Accepted 01 December 2023
© Author(s) (or their
employer(s)) 2023. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
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BMJ.
1
School of Public Health, Faculty
of Medicine, The University
of Queensland, Brisbane,
Queensland, Australia
2
School of Nursing, College
of Health Sciences, Woldia
University, Woldia, Ethiopia
3
College of Medicine and Health
Sciences, Bahir Dar University,
Bahir Dar, Ethiopia
4
International Institute for
Primary Health Care, Addis
Ababa, Ethiopia
Correspondence to
Ayelign Mengesha Kassie;
​Ayelignmengesha59@​gmail.​
com
Use of the positive deviance approach
for healthcare system service
improvement: a scoping review protocol
Ayelign Mengesha Kassie ‍ ‍,1,2 Elizabeth Eakin,1 Biruk Beletew Abate ‍ ‍,2
Aklilu Endalamaw ‍ ‍,1,3 Anteneh Zewdie,4 Eskinder Wolka,4 Yibeltal Assefa ‍ ‍1
ABSTRACT
Introduction Healthcare systems are currently facing
challenges in enhancing access and improving the quality
of healthcare services around the world, and one of the
innovative strategies that have been used to address
such challenges is the positive deviance (PD) approach.
The approach assumes that identifying, examining,
understanding and disseminating solutions to problems
that are already available within the community and
organisations including the healthcare system can help in
bringing improvements at scale. However, to the best of
the researcher’s knowledge, there is no scoping review,
that is, conducted to map and synthesise the available
evidence on the use of the PD approach for healthcare
system service improvements. Hence, this scoping
review aims to map and synthesise resources on the
methodologies and reported outcomes and identify gaps
and potentials regarding the use of the PD approach in the
healthcare system.
Methods and analysis Articles will be searched and
retrieved in research databases such as PubMed,
Embase and Scopus. Retrieved articles will be screened
independently for inclusion through a title and, or abstract
review. Then, articles that passed the title and abstract
review will be screened by reading the full texts. A
descriptive mapping and synthesis of the literature will be
employed to present data using the Preferred Reporting
Items for Systematic Reviews and Meta-­Analysis extension
for Scoping Reviews checklist and data will be presented
in text, figure and table formats.
Ethics and dissemination The results of this scoping
review will be published in peer-­reviewed reputable
international journals. Furthermore, it will also be
disseminated through conference presentations, and
popular press to the wider community. However, formal
ethical approval is not required as primary data will not be
collected.
BACKGROUND
Achieving universal health coverage goals
without the provision of high-­quality health-
care services is an impossible vision.1 Quality
of care is the extent to which healthcare
services provided for people increase the like-
lihood of better health outcomes.1 2 However,
healthcare systems are facing lots of chal-
lenges in enhancing access and delivering
Kassie AM, et al. BMJ Open 2023;13:e078809. doi:10.1136/bmjopen-2023-078809
Protocol
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ This scoping review is going to be conducted in
line with the updated Preferred Reporting Items for
Systematic Reviews and Meta-­Analysis extension
for Scoping Reviews guideline.
⇒ However, this scoping review is focused on the sup-
ply side and will only address the application of pos-
itive deviance at the health system, health facility
and health worker levels.
⇒ Therefore, only the articles that have measured the
performance and behaviour of those entities either
directly or indirectly in their therapeutic relationships
with patients and the community will be included.
quality healthcare services around the world
including poor data collection and moni-
toring systems, ineffective organisational
team culture and capacity limitations, inef-
fective leadership, failure to promote good
performance3 and lack of evidence-­ based
health policies to assist implementation and
enhance the expertise of healthcare profes-
sionals.4 Therefore, designing innovative
strategies to improve healthcare delivery,
including quality, has been one of the top
agendas in the healthcare system in the last
decades. One of the innovative strategies that
has been used in different quality enhance-
ment programmes throughout the world is
the positive deviance (PD) approach.5
PD is an innovative approach that seeks
to identify practices that result in a better
outcome for the people and organisations
that practice it compared with the rest of
the community and other organisations.6 It
is an asset-­based approach, recognising the
values of prevailing expertise and experience
to solve intractable issues and is community-­
driven with its dynamic optimistic future
having a positive effect, among others.7 The
approach assumes that solutions to problems
are already available within the community,
and identifying and sharing those solutions
can help other people identify their strengths
1
Open access
and be prepared to resolve potential issues with the
limited resources they have in their hands.6 7 According
to Jason Gordon8, there are always people, groups and,
or organisations who are positively deviant and who excel
in their performance to rules concerning organisational
issues, despite having similar constraints and resources
as everyone else and if given the opportunity, they are
willing to share their experiences with other people as far
as leaders are able to step back and facilitate the process.8
PD is believed to have been introduced into the
international healthcare system between the 1960s
and 1970s.5 9 A healthcare system is an organisation
consisting of people, institutions and other resources,
that delivers healthcare services to meet the healthcare
needs of diseased individuals and the general popula-
tion.10 Therefore, if the healthcare system is to ensure
that the public receives the best possible health services,
it has to identify and recognise people and healthcare
organisations who have had exceptional performance
in their healthcare practice and learn from them.11 As
a result, there is a growing need to explore and use
innovative approaches, as of PD, to improve and bring
quality healthcare services into the healthcare system
arena around the world.11 12
According to a literature review conducted by
Schooley and Morales, PD has been tested successfully
in improving the nutritional status of children in several
countries, including; Haiti, Vietnam, Pakistan and
India.13 In addition, it has also been used in the preven-
tion and treatment of undernutrition, overweight and
obesity in socioeconomically vulnerable mothers and
the adult population.13–15 Furthermore, several studies
have used the approach in different situations, including
in nursing leadership,16 in healthcare organisations,17
patient safety,18 healthcare equity in quality and obstet-
rical safety,19 healthcare quality and safety,20 in family
planning and community-­based health interventions11 21
and for primary care.22
However, the available evidence on PD is mixed
and there are controversies on the effectiveness of the
approach, particularly in complex and demanding
settings including the healthcare system. This is due in
large part to methodological limitations of the extant
studies including inconsistencies in the quality of strat-
egies employed to identify PDs or positive deviant prac-
tices. For instance, it has been reported that studies
that applied the PD approach for quality improvement
with complex interventions lack methodological quality
and details in their work.17 23 Despite these controver-
sies, to the best of the researchers’ knowledge, there is
no scoping review that has been conducted to map and
synthesise the available evidence on the methodologies,
strategies used to identify PDs, achievements reported
and prospects of using PD in healthcare systems. There-
fore, this scoping review aims to map and synthesise
resources and identify lessons, including successes, gaps
and potentials regarding the use of the PD approach in
the healthcare system.
2 Kassie AM, et al. BMJ Open 2023;13:e078809. doi:10.1136/bmjopen-2023-078809
BMJ Open: first published as 10.1136/bmjopen-2023-078809 on 14 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 29, 2023 by guest. Protected by copyright.
Research questions
The research questions guiding this scoping review are:
(1) What research designs and methods are used in imple-
menting PD in the healthcare system service improvement
activities?; (2) What are the strategies applied to identify
positive deviants or measure positive deviant practices
and identify positive deviants?; (3) What outcomes have
been achieved using the PD approach?; and (4) What are
the limitations in usage of the PD approach, and what
is its potential for use in the healthcare system research,
and quality and safety improvement programmes?
METHODS
The Preferred Reporting Items for Systematic Reviews
and Meta-­Analysis extension for Scoping Reviews check-
list (PRISMA-­ScR) will be used as a guide for extraction,
analysis and presentation of the scoping review results.
The PRISMA-­ScR is designed to help researchers map
evidence to other stakeholders including, patients or
consumers, publishers, healthcare providers, policy-
makers and guideline developers to have a greater under-
standing of relevant terminologies, core concepts and
key items to report for scoping reviews.24 The popula-
tion, concept and context (PCC) framework will also be
employed to assess the research question’s appropriate-
ness. According to the PCC framework, the target popu-
lation will include people of any gender and age who are
considered as study participants in patient and health-
care worker therapeutic relationships, or, in any health-
care service-­ related studies in the health system and
the concept will be dealt with the context of using a PD
approach in healthcare system research. Furthermore,
the context aspect will incorporate articles that took
healthcare settings and health systems as part of study
settings and that used the PD approach to identify high-­
performing individuals, teams, groups and/or healthcare
facilities and health systems themselves, in any healthcare
services, understand their strategy and disseminate their
findings to the global audience, irrespective of the loca-
tion, country and region of study.
Literature search strategy
International databases including PubMed, Embase,
Scopus, Web of Science, CINAHL and Google Scholar
will be explored to retrieve resources related to PD and
its application in the healthcare system domain. More-
over, hand search and article reference tracking will also
be employed to find additional literature from Google
sources. Articles released through 01 June 2023, will be
included, as PD is believed to be introduced into the
world in the early 1970s,5 9 and a database search will
be carried out between 15 May 2023 and 15 June 2023.
For duplication avoidance and citation purposes, refer-
ences retrieved from each database will be stored in
the EndNote desktop V.x20 separately and a complete
search strategy for all major database has been included
as an online supplemental file 1 in the protocol and will

Table 1 Identified terms/concepts/phrases for the scoping review search strategy development
Theme 1 AND Theme 2
‘Positive Devian*’ OR Method* OR
‘Positive Deviant’ OR Procedure* OR
‘Positive deviance’ OR Technique* OR
‘Deviance Approach’ OR Strateg* OR
‘Deviant Approach’ OR Achieve* OR
‘Positive Outlier’ OR Success* OR
‘Positive Development’ Accomplish* OR
Attain* OR
Outcome* OR
Prospect* OR
Challenge* OR
Limit* OR
Potential* OR
Opportunit*
be included as an appendix in the subsequent scoping
review. In addition, the key terms and, or phrases written
in table one below will be used, after being refined to fit
different databases, to identify the necessary articles and
the Boolean operators of ‘OR’ and ‘AND’ will also be
applied to combine the key terms and phrases. Further-
more, the asterisk search operator will also be used to
search terms that have similar word stems or start with
the same letters (table 1).
Inclusion and exclusion criteria
Articles published only in the English language will be
considered due to feasibility issues in garnering a trans-
lator and the limitation of resources. In addition, confer-
ence proceedings, oral and poster presentations, abstract
articles, correspondence articles, comments to the
editor, commentator, brief communication and literature
review articles other than systematic review and meta-­
analysis will be excluded as the scoping review requires a
detailed methodological exploration and full-­text results
for review and data extraction. Therefore, both primary
articles including observational and case studies, eval-
uation studies, randomised and non-­ randomised trials
and systematic reviews and meta-­analysis articles will be
included. Only peer-­ reviewed and published literature
conducted using the PD approach in the healthcare
system areas will be considered for reasons of credibility.
However, to be included, studies must report the
methods used to measure individuals, teams, groups or
the healthcare facility’s strategies and interventions that
are employed to bring change in the healthcare services
including financial protection for patients, individuals
and the community at large. Therefore, community-­based
studies that used the PD approach to identify strategies
for any health-­related outcomes without the involvement
of any health workers in the health system including
community health workers will not be included unless it
Kassie AM, et al. BMJ Open 2023;13:e078809. doi:10.1136/bmjopen-2023-078809
Open access
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AND Theme 3
Health* OR
Healthcare* OR
‘Health Care*’ OR
‘Health System*’ OR
‘Health Service*’ OR
‘Health Equity’ OR
‘Quality Of Health Care*’ OR
‘Quality Improvement*’ OR
‘Health Behavior*’ OR
‘Health Promotion*’ OR
‘Diseases Prevention’ OR
Treatment* OR
‘Palliative Care’ OR
‘Rehabilitative Care’
clearly shows the extent of healthcare settings and health
systems involvement in the study. Because the results in
a community setting may not truly reflect whether the
outcome is due to the involvement of healthcare facilities,
local health departments and their staffs or not.
In addition, studies that are conducted in the health-
care settings at the patient level will be excluded if the
results do not show that the outcomes of patient-­level data
are due to the healthcare services rendered by the health
facilities. The reason for this is that this scoping review
is designed to synthesise and map available evidence in
the usage of PD in the healthcare system as a supply side.
However, the measures for performance of being positive
deviant from the supply side can be patient outcomes
including morbidity and mortality rate reductions, immu-
nisation coverage and financial protection.
Screening
All articles’ citations will be imported into the Covidence
online tool and assessed independently for inclusion
through a title and, or abstract read. Then, studies that
passed the title and abstract review by the principal inves-
tigator will be screened by two independent reviewers
with full-­text reading. In case of duplication, the full-­
text published article will be retained and others will
be removed. However, articles without full access and
those that did not report the outcomes of interest will be
excluded.
Data extraction
The data extraction platform will be developed on the
Excel sheet, and data examination, extraction and sorting
will be done using key themes; author(s) name, publication
year, article type, study design and method, study setting,
participant type, study domain or topic, WHO geograph-
ical category/region, World Bank group and, or country,
intervention and other measures in using the PD approach
3
Open access
for research and initiatives in all healthcare settings around
the world. The data extraction sheet will be piloted using
five randomly selected papers and then, the extraction
form will be adjusted after having the piloted template and
be used to customise the Covidence data extraction format
2.0. The principal investigator will independently extract
all the necessary data from each article using the custom-
ised data extraction format in the Covidence online tool
and then undergo a second check-­up after completion of
extraction from all articles. For articles that did not provide
details concerning their study background, corresponding
authors will be contacted through email and asked for rele-
vant information, such as study time, outcome measure-
ment method and other significant variables.
Patient and public involvement
No patient or public will be involved.
Data analysis and presentation
A descriptive mapping and synthesis of literature will be
employed to present data both in text and table formats
using five major themes: Methodologies used in imple-
menting PD; criteria researchers used to identify positive
deviants; the strategies of positive deviants that make them
successful apart from others; outcomes reported from the
usage of PD approach; and the prospects of PD in future
health service research areas and quality improvement
programmes. The results of this scoping review will be
reported based on the PRISMA-­ScR guideline,24 and the
entire process of study screening, selection and inclusion
will be shown with the support of a flow diagram. Further-
more, the PCC framework will be used to guide the presen-
tation of the scoping review results to the wider community.
Ethics and dissemination
This scoping review protocol will be registered and
be made freely available to the wider community by
publishing it in one of the following platforms: Figshare,
Open Science Framework, Research Square, Research-
Gate and, or other similar databases. However, it will not
be registered in the International Prospective Register
of Systematic Reviews (PROSPERO), as the database is
not currently registering scoping reviews.25 The scoping
review findings will be presented at conferences at The
University of Queensland in Australia, the Postgraduate
Institute of Medicine. In addition, it will be published in
peer-­reviewed, reputable international journals. Further-
more, it will also be disseminated to the wider community,
through conference presentations at different interna-
tional research symposiums and popular press. However,
formal ethical approval is not required as primary data
will not be collected.
Timeline for review
Start date: 15 May 2023.
End date: 30 November 2023.
Stage of review: Review ongoing.
4 Kassie AM, et al. BMJ Open 2023;13:e078809. doi:10.1136/bmjopen-2023-078809
BMJ Open: first published as 10.1136/bmjopen-2023-078809 on 14 December 2023. Downloaded from http://bmjopen.bmj.com/ on December 29, 2023 by guest. Protected by copyright.
DISCUSSION
Achieving the universal health coverage goals without
enhancing access and the provision of high-­ quality
healthcare services is an impossible vision.1 Quality of
care is the extent to which healthcare services provided
for people increase the likelihood of better health
outcomes.1 2 However, delivering high-­ quality health-
care services is facing lots of challenges in the healthcare
quality improvement programmes, including poor data
collection and monitoring systems, organisational team
culture and capacity limitations, leadership weakness,
failure of promoting good performance3 and lack of
evidence-­based health policies, to assist implementation
and enhance the expertise of healthcare professionals.4
Hence, designing innovative strategies to improve health-
care service delivery, including quality, has been one
of the top agendas in the healthcare system in the last
decades. One of the innovative strategies that have been
used in different healthcare services, including quality,
enhancement programmes throughout the world is the
PD approach.5 26 It is a strategy based on a core assump-
tion that community members, including individuals and
organisations, already have the answers to many issues
and that by studying, comprehending and disseminating
these solutions to other members of the community,
improvements can be made at a large scale.26 Despite this
fact, evidence on the methodologies, strategies employed
in selecting positive deviants, achievements in using the
approach, the possible limitations and challenges of using
it in practice and its potential for future use in the health-
care system are not well documented.5 17 In addition, the
utility of the PD approach is reported to be limited in
complex settings including the healthcare system in some
earlier articles. For instance, Baxter et al stated that using
PD in complex and demanding healthcare settings poses
challenges, citing engaging staff more broadly in quality
enhancement programmes as a known difficult aspect.17
However, several sources across the literature have indi-
cated the merit of using a PD approach in multiple
quality improvement programmes of the healthcare
system including in increasing hand hygiene compliance
rate,27–29 infection prevention,30 31 reduction of postoper-
ative complications,32 reducing medication errors33 and
improving vaccination coverage rates within healthcare
systems.34 Therefore, this scoping review aims to map
evidence, synthesise the available literature and identify
gaps on the use of the PD approach for health system
service improvement and analyse its prospects for future
healthcare quality, safety and other service improvement
programmes in the healthcare system.
CONCLUSION
This global scoping review protocol is designed to map
and synthesise the methodologies used and strategies used
in selecting positive deviants, achievements and the pros-
pects of using PD in different healthcare settings, iden-
tify the gaps and answer the critical research questions

that are developed in line with the proposed title. More-
over, the findings of the scoping review will add a body
of knowledge and provide insight to policymakers and
service providers regarding the opportunities of using
PD in healthcare system research and healthcare quality
improvement programmes.
Twitter Biruk Beletew Abate @biruk
Contributors AMK and YA conceived the idea. AMK planned and designed the
study protocol. AMK and YA planned the data extraction and statistical analysis.
AMK wrote the first draft. YA, EW, AZ, AE, EE and BBA reviewed the draft and
provided critical insights. All authors have reviewed, participated in editions and
approved the submission of the final protocol.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Ayelign Mengesha Kassie http://orcid.org/0000-0003-1505-9390
Biruk Beletew Abate http://orcid.org/0000-0003-0833-2504
Aklilu Endalamaw http://orcid.org/0000-0002-9121-6549
Yibeltal Assefa http://orcid.org/0000-0002-8636-1282
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5