<\/span><\/h2>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cFirst, positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream.\u201d [p xiii, 3%]\n<\/p>\n\n\n\n
<\/span>C1: Against All Odds<\/span><\/h2>\n\n\n\nSummary.<\/em><\/strong> Introduces examples of positive deviance, outlines PD approach, warns that it\u2019s not as simple as it may seem and that understanding and working with social system\/local culture is key. <\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cPositive deviance is founded on the premise that at least one person in a community, working with the same resources as everyone else, has already licked the problem that confounds others. \u2026In most cases, this person does not know he or she is doing anything unusual. Yet once the unique solution is discovered and understood, it can be adopted by the wider community and transform many lives. From the PD perspective, individual difference is regarded as a community resource. Community engagement is essential to discovering noteworthy variants in their midst and adapting their practices and strategies.\u201d [p 3\/6%, location 214]\n<\/p>\n\n\n\n
\n \u201cThe basic premise is this: (1) Solutions to seemingly intractable problems already exist, (2) they have been discovered by members of the community itself, (3) these innovators (individual positive deviants) have succeeded even thought they share the same constraints and barriers to action.\u201d [p 3-4]\n<\/p>\n\n\n\n
\n \u201c[The] distinction between \u201ctechnical\u201d and \u201cadaptive\u201d work. Adaptive problems are embedded in social complexity, require behavior change, and are rife with unintended consequences. By way of contrast, technical problems (such as the polio virus) can be solved with a technical solution (the Salk vaccine) without having to disturb the underlying social structure, cultural norms, or behavior.\u201d [p 7\/8%, location 279]\n<\/p>\n\n\n\n
\n \u201cThe secret sauce of the PD process is how it engages and transforms the social dynamics that have kept things stuck.\u201d [9%, location 340]\n<\/p>\n\n\n\n
<\/span>C2: Childhood Malnutrition in Vietnam<\/span><\/h2>\n\n\n\nSummary.<\/em><\/strong> The chapter describes an effort \u2013 the discovery or ur-instance of the Positive Deviance methodology \u2013 to reduce childhood malnutrition in an impoverished area of Vietnam in a relatively short time (6 months). Emphasizes the difficulty (and necessity) of getting the local community involved and getting community members to do the work. <\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cOne of the first steps in the process \u2026 has been for the local facilitators to listen to as many people as possible, irrespective of the added value to the listeners learning curve. This engenders the broadest ownership.\u201d [p 32 \/ 18%, location 658]\n<\/p>\n\n\n\n
\n \u201cWhat we needed to do was create an opportunity for people to practice, rather than merely know about, the successful PD behaviors the villagers discovered.\u201d [p 35]\n<\/p>\n\n\n\n
\n \u201cFor two weeks every month, mothers or other caretakers would bring their malnourished children to a neighbor\u2019s house for a few hours every day. Together with the health volunteer, they prepared and fed a nutritious, supplemental meal to their children. \u2026 These sessions provided an opportunity to practice successful behaviors identified during the positive deviance inquiry, such as active feeding and washing the caretakers\u2019 and children\u2019s hands with soap and water over the course of the meal whenever they touched an unclear object. \u2026It was the concern for the sustainability of behavioral change that lead to the introduction of the mandatory \u201cdaily contribution\u201d component of the nutrition sessions. Every day, each mother or caretaker was required to bring a handful of shrimps, crabs, or greens as the price of admission to the sessions. For two weeks every month, someone in the family (a spouse, an older sibling) had to go out to the rice paddy early in the morning and, ankle deep in mud, collect the required shrimps or crabs. By the time the two week session was over for that month, the trip to the rice paddy with a small net and empty container had become routine.\n<\/p>\n\n\n\n
\n \u2026 \u201cIt\u2019s easier to act your way into a new way of thinking, than to think your way into a new way of acting.\u201d [p 37-38]\n<\/p>\n\n\n\n
\n \u201cPeel the onion and, not surprisingly, the concept harnesses incontrovertible principles of social psychology: Enactment (behaving differently in front of your peers is the shortest distance to thinking differently) and consistency (having staked out a position, we strive to behave accordingly). \u2026 Enactment is most effective in shifting a person\u2019s attitudes, self-image, and behavior if involvement is active, public and effortful. [p 46-47]\n<\/p>\n\n\n\n
\n \u201cFrom the inside, there is a pressure to bring self-image into line with action. From the outside, there is a social pressure \u2013 a tendency to adjust this image according to the way others perceive us. And because others see us a as believing what we have written or said (even when we\u2019ve had little choice in the matter), we experience a pull to bring self-image into line with the written statement.\u201d [p 48]\n<\/p>\n\n\n\n
<\/span>C3: Female Circumcision in Egypt<\/span><\/h2>\n\n\n\nSummary<\/em><\/strong>. The intractable problem was female circumcision in Egypt. The chapter describes the slow process of finding positive deviants, and the use of workshops to first enable them to share their experiences with one another, and then to train themselves on how to share their experiences with less sympathetic audiences. The process also involved expanding the notion of what a positive deviant was: not just a non-circumcised woman, but others \u2013 woman, mothers, Sheiks \u2013 who had prevented others from being circumcised.<\/em>\n<\/p>\n\n\n\n<\/p>\n\n\n\n
Excerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cYou can\u2019t practice not circumcising someone. \u2026 Those first volunteers practiced reciting the stories, role-played how they would discuss this sensitive issue with community members, and shared their own stories with one another. They practiced the deviant behavior of speaking out, gaining trust, and breaking a taboo. Once they began speaking with others, the practice of speaking out took on a life of its own and began to spread.\u201d [p 77]\n<\/p>\n\n\n\n
<\/span>C4: Hospital Infections<\/span><\/h2>\n\n\n\nSummary<\/strong>. The intractable problem was MRSA, a type of infection that leads to extended hospital stays and fatalities. It can be decreased\/eliminated by improving hygienic practices, but that is of course a multi-faced and challenging problem. The chapter describes a campaign to change this. The PD approach needed to be adapted to fit into the pace and structure of hospital life, and to address all categories for workers, from physicians to maintenance. It developed an action-oriented approach called Discovery and Action Dialogs (DADs) which concentrated all phases of PD into brief ~45 minute sessions. DADs lead to the discovery of a large number of solutions, as well as the invention\/discovery of new solutions arising out of the increased awareness and understanding of hospital workers. Both the concentrated sessions and the inclusion of discovery (rather than just promotion of endemic solutions) went beyond \u2018traditional\u2019 PD. The importance of actually implementing the solutions \u2013 and identified the detailed tactics (who will do X, when will they do it, and whose authorization is needed?) \u2013 immediately was emphasized.<\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cData needs to be dramatized, personified and socialized. \u2026 Whether in the form of chocolate pudding, as in the earlier [MRSA] transmission simulation, or macaroni [number of people infected in a year], the community needs a format that brings abstractions to the ground.\u201d [p 98]\n<\/p>\n\n\n\n
* Using PD to increase the rates of student retention in Argentina by discovering that some teachers developed \u2018learning contracts\u2019 with each set of parents* [p 94-96]<\/em>\n<\/p>\n\n\n\nThe PD approach needed to be \u2018reformatted\u2019 to work in the context of a hospital. They developed action-oriented Discovery and Action Dialogs [DADs].<\/em>\n<\/p>\n\n\n\n\n \u201cSessions would kick of with attention getting MRSA transmission statistics. Participants would then try on blood pressure cuffs, remove gloves, and fold gowns, all to reveal how bacteria contaminate a sterile area. Then facilitators, previously self-selected from the ranks, would jump to the crucial question: Is there anyone here who has overcome these challenges?\u201d p 102]\n<\/p>\n\n\n\n
\n \u201cStaff had seen many hospital campaigns ebb and flow. This time, making change stick could not be left to chance. Accordingly, ideas captured during the DAD sessions needed to be acted upon immediately, and feedback loops confirming results achieved needed to reach every corner of the hospital. Changing the emphasis of the sessions from discover to action had this effect. Facilitators drilled down when ideas surfaced. \u201cGreat idea! What would it take to do that in this unit? Is there anyone who wants to volunteer to take those steps? Can you do it alone, or do you need help? is there anyone who needs to be part of that decision who isn\u2019t here in this group now? How do we get her to the table?\u201d \n
\n \u2026\n<\/p>\n\n\n\n
\n \u201cEvidence of action convinced people throughout the hospital that the PD initiative was not business as usual. The news spread rapidly. Elimination of MRSA became prominent in staff awareness. As mindfulness emerged, new solutions began to pop up in likely as well as unlikely places.\u201d[p 103]\n<\/p>\n\n\n\n
This PD process went beyond just discovering existing practices to developing new ones.<\/em> \u201cBut essential aspects of the PS process (the community\u2019s ad individual\u2019s decision to opt in or opt out, taking ownership of the process, investing sweat equity in mapping common practices and outcomes, discovering preexisting Pads, designing an action learning approach to spread discoveries to others) remain intact.\u201d [p 103]\n<\/p>\n\n\n\nFrom its beginning in July 2005, the incidence of MRSA at the VAPHS hospital was reduced by 50% in just over a year. Within three years the PD initiative on MRSA had spread to over 40 hospitals and health care centers in the US.<\/em>\n<\/p>\n\n\n\nLessons learned at VAPHS were shared in a 3-day \u201ctraining of PD facilitators\u201d workshop. New facilitators returned to their sites, ad DAD events were organized \u2013 the particular content being decided on individually at each site. DADs were initially applied in beta tests in one or two units of each site, where they were critiqued and refined with the help of external PD trainers. <\/em>\n<\/p>\n\n\n\n\n \u201cIt became clear over time that although existing PD practices and new ideas were routinely discovered during the thirty- to forty-minutes DAD sessions, often many were left to wither o the vine. Today facilitators drill down and \u201ccapture\u201d a good idea as so as it is discovered and then translate it into action. \u2026This gets into pretty tactical stuff, such as: Who will change the hand-hygiene signs in the room? When will they do it? Whose support or authorization is required?\u201d [p 115]\n<\/p>\n\n\n\n
\n \u201cPerhaps one of the most striking examples of culture changes at VAPHS \u2026 is the shift in power relationships from a few designated leaders in the hospital organization hierarchy to distribution throughout the entire informal network of staff and patients. Shared authority has enabled patients, janitors, and social services assistants to impact MRSA outcomes collectively and exponentially more effectively than a blizzard of top-down reminders from the CDC and the chief surgeon.\u201d [p 117]\n<\/p>\n\n\n\n
Emphasis on the importance of experts [physicians] not be the source of answers. <\/em>\n<\/p>\n\n\n\n\n \u201cI was mortified. Every time I asked a question, if there was a pause of more than five seconds, I stepped in and gave the right answer. I was doing most the talking and putting words into the participants\u2019 mouths.\u201d\n<\/p>\n\n\n\n
\u2026 A result of this was the \u201ctwenty second deep breath and be silent\u201d mantra.<\/em>\n<\/p>\n\n\n\n<\/span>
C5: Early Gains, Squandered Wins: Pioneering the PD Process at Merck<\/span><\/h2>\n\n\n\nSummary.<\/em><\/strong> This chapter looks at two applications of PD in the corporate world: at Merck Mexico, and Goldman Sachs Private Wealth Management Unit. The chapter draws on a mostly implicit model of organizational behavior it refers to as \u201cthe standard model.\u201d This envisions corporations as entities that specialize in \u201cprocess standardization,\u201d and that moreover tend to over-standardize their processes and to \u201chardwire them\u201d into organizational mechanisms like corporate structure, pricing, key performance indicators, pay for performance, and so on). In this view, a large portion of an organization\u2019s diversity and experimentation happen at the interface between the organization and its customers (often the sales force), but the \u201cStandard Model\u201d is not well geared to \u2018listen\u2019 to or learn from these experiments; moreover there is a tendency (\u201corganizational drift\u201d) for the organization\u2019s practices to revert to those that have been standardized. <\/em>\n<\/p>\n\n\n\n Merck Mexico was having difficulty selling Fosamax; an article led a Latin American VP to try to apply PD to the process. He presented the idea to his team, and allowed people to opt in or out; most abstained. District managers took it forward, holding focus groups among sales reps, and after a while began hearing repeated mentions of reps who might be PDs. A workshop was convened, and divided into groups of eight reps that were asked to identify the high performing districts and practices that correlated with better results. It became clear that some sales reps were ignoring the rules \u2013 e.g., the \u201cRule of Seven\u201d that mandated seven sales calls a day. Those that made three calls a day were outperforming those that made seven \u2013 they were focusing on cultivating relationships with physicians: giving gifts, attending children\u2019s graduation, soliciting ideas for content in Merck-sponsored events. By the end of the year all districts were at quota (from being at 70% of quota), and a year later they were 30% over quota. However, this success did not spread to other drugs or other countries. The story told is that the organizational culture was not friendly to the decentralized PD approach, and that the transfer of supportive high-level executives inhibited the adoption of PD elsewhere, and undermined its continuance in Mexico. <\/em>\n<\/p>\n\n\n\n The last part of the chapter looks at an effort to shift Goldman Sachs Wealth Management Unit from a brokerage income model to fee-based advice. The process followed is described at times as PD, although the process was developed in-house. It also strikes me as a bit more top-down than I would expect a PD person to be comfortable with\u2026 This part does not provide details on the sorts of changes in practices that positive deviants had developed.<\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cPeople in organizations make thousands of decisions, and these sum to define an organization\u2019s trajectory. The arc of these internalized \u201ctruths\u201d is invisible but inexorable\u201d How \u2018big\u2019 does an opportunity have to be to be \u2018interesting\u2019? How are budgets negotiated? \u2026 These interpretations reinforce the conventional wisdom about \u2018the way things work around here.\u2019 When adaptive change becomes necessary, subtle undercurrents embedded it eh social system can inflict death by a thousand cuts and undermine needed change.\u201d [p 130-131]\n<\/p>\n\n\n\n
\n \u201cThere is a term for the undertow that draws organizations toward traditional patterns. It is called \u2018organizational drift,\u2019 and it exercises influence subliminally. Existing political arrangements usually ensure that novel initiatives rarely get a fair day in court.\u201d [p 134-145]\n<\/p>\n\n\n\n
\n \u201cAlbert North Whitehead once said: \u2018Civilization advances by extending the umber of operations which we can perform without thinking about them.\u2019\u201d [p 138]\n<\/p>\n\n\n\n
\n \u201cA bottom up process interjects diversity. The enlarges what we call \u2018the solution space.\u2019 Up to a point more diversity means more adaptive capacity. Small and obscure components\u2014easily overlooked\u2014can be ital. \u2026 Attention to detail matters and attention to small details matters a lot. I nature, such detail is manifested I gene pools and tiny mutations. Organizational mutations occur among those closest to the action via small adaptations in the face of adversity or opportunity. Those closer to the bottom of the organizational pyramid (for example, in companies where delivery of services or the manufacture of products actually takes place) participate I \u2018experiments\u2019 every day. But the standard model isn\u2019t especially well geared to listening, let alone learning through this bottom up channel. [p 141-142]\n<\/p>\n\n\n\n
\n \u201cThe biggest limitation of the standard model is that it takes process standardization too far. It losses its potency when local knowledge and aesthetic judgment matter.\u201d [p 142]\n<\/p>\n\n\n\n
Goldman Sachs example \u2013 not much detail offered. <\/em>[p 142-146]\n<\/p>\n\n\n\n<\/span>C6: Girl Soldiers in Uganda<\/span><\/h2>\n\n\n\nSummary. <\/em><\/strong>Discusses a mid-course correction of a not-very-well-applied PD approach in Uganda. The original team had identified exceptional cases as per orthodox PD, but had then collapsed the distinct steps of the PD Process (i.e. engage the community, define the problem, establish baseline conditions, document common practices, and discover PD strategies) into one, and were using experts(NGO trainers) and not the community or repatriated girls themselves to present the workshops that disseminated the solutions. The mid-course correction involved addressing three issues: reframing problems; facilitating group discussions to mobilize action; ensuring that the community does the work. <\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cThe initial framing of the problem often turns out to be a placeholder. If experience teaches one lesson, it is that problem reframing usually occurs along the way. The surest way for a community to recognize a problem as its own is for people to frame it in their own words and ground it in their own reality. Stakeholders need to imprint on a problem\u2026\u201d [p 155]\n<\/p>\n\n\n\n
\n \u201cThe term \u2018group conversations\u2019 is ear the opposite end of a continuum [from focus groups]. The term group conversations is chosen to signal that something very different is required. Certain kids of questions help groups take ownership. Questions can be more transforming than answers. Powerful questions don\u2019t dig for information, but instead cause respondents to think. They evoke a choice for commitment and accountability.\u201d [p 161]\n<\/p>\n\n\n\n
\n \u201cIn the PD process, the real objective [of group conversations] \u2026 is engagement, creating a buzz, mobilizing people to take action.\u201d\n<\/p>\n\n\n\n
\n Example of discovery of two problems — conspiracy to exploit girls and lack of (culturally traditional) counseling by \u2018grandmothers\u2019 — in group conversations. [p 165-167]\n<\/p>\n\n\n\n
<\/span>C7: Infant Mortality<\/span><\/h2>\n\n\n\nSummary. <\/em><\/strong>Aim was to reduce 8.5% infant mortality rate among the Pashtun. Initially created discussion groups of men, who used colored pebbles and paper to create map of village and various birth outcomes at various houses. After a few weeks the men decided there should be a woman\u2019s group, and so one was created and they used beans to develop a map. After this, groups went to visit various households, and began identifying PD practices. Examples included laying the infant on a pillow rather than the ground, use of a clean razor to cut the umbilical cord, and providing honey rather than breast milk for first few days of infant\u2019s life. To disseminate the findings the women\u2019s team employed a grab bag where they pulled out items (e.g. a pillow) and had to explain its use; similarly, the men\u2019s team created a bazaar, where the audience selected things to buy and then had to provide a rationale. They also showed a simulation of putting ink on a knife blade and slicing an onion, to communicate transfer of infections\u2026. After the workshops, volunteers gathered to develop a strategy for enabling the community to put the solutions into practice and to continue learning \u2013 this involved the men meeting once a month at a tea shop to discuss recent newborns, new practices, etc. The chapter claims that as a result of PD husbands and wives began communicating more, initially about the birthing practices, and then gradually about broader matters.<\/em>\n<\/p>\n\n\n\nExcerpts<\/em><\/strong>\n<\/p>\n\n\n\n\n \u201cDissemination workshops tended to follow a trajectory. They led off with an introduction of technical PD practices (e.g., clean razor blades) but turned inevitably to the importance of the husband\u2019s involvement and support of his wife.\u201d [p 178]\n<\/p>\n\n\n\n