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Accentuate the Positive: Improving Patient Safety by Focusing on What’s Being Done Well

By Kimberly Mitchell | Monday, October 20, 2014

A recent article in BMJ Quality & Safety reminds us that there is value in looking to what is working well; doing so can increase safety and buoy the morale of those working hard to improve patient care.  Joelle Baehrend is Fellowship Director at IHI and the Content Manager for IHI’s Patient Safety Focus Area.


At IHI we’re often reminded by our dear colleague and intrepid patient safety expert, Carol Haraden, that “hope is not a plan.” It’s become common wisdom here in the office and among the thousands of improvers who commit to moving beyond hoping things will improve to taking specific, targeted action to make patient care safer and more reliable. But while hope alone will not move us closer to the health system we all deserve — caregivers and cared-for alike — it is a critical factor that influences our ability to take on and sustain the difficult work of improvement.

There is also evidence that looking to the positive, instead of a relentless focus on errors and other problems, can have a measureable effect on outcomes. A recent article in BMJ Quality & Safety (Lawton et al. Positive deviance: A different approach to achieving patient safety) discussed the potential of a “positive deviance” approach, citing studies that showed improvement in hand hygiene and door-to-balloon time for the treatment of acute myocardial infarction (AMI). In the hand hygiene study (Marra et al.), those who were known to be reliable in their hand hygiene recruited others to help improve hand hygiene compliance. In the AMI door-to-balloon time study (Bradley et al.), those seeking to improve identified high-performing organizations, studied their processes, and disseminated the learning about best practice.

IHI has long sought to raise joy in work to help build a better health care workforce. Through so much of our work with health care professionals and organizations — such as in Breakthrough Series Collaboratives, the 100,000 Lives and 5 Million lives Campaigns, the IHI Open School, and Web&ACTION programs — a key underpinning of the work, and sometimes the only bar to entry, is that we agree to learn together. We share our learning about what works and what doesn’t, acknowledge and celebrate “wins” — and give people the tools to test and adapt successful changes in their local settings.

The focus on “the positive” is not new, but the stakes have never been higher. A beleaguered workforce is often ill-prepared to meet the challenges of the evolving health care environment. Indeed, the health care industry’s ability to attract a talented and resilient workforce is bound to suffer if we do not address issues of morale and restore a sense of positivity and hopefulness.

While still a second-year nursing student, Molly Case was frustrated and disheartened by the onslaught of negative press that England’s National Health Service (NHS) was receiving. Her poem, “Nursing the Nation,” delivered in a spoken word performance at the Royal College of Nursing (RCN) Congress, is an impassioned plea to acknowledge the good, life-and comfort-giving work she and her colleagues undertake as their life’s work — and a clarion call to all of us to adopt approaches that celebrate instead of condemn.

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