Positive Deviance

Surgeons following the trauma logs began to see, for example, a dismayingly high incidence of blinding injuries. Soldiers had been directed to wear eye protection,but they evidently found the issued goggles too ugly. As one soldier put it, "They look like something a Florida senior citizen would wear." So the military bowed to fashion and switched to cooler-looking Wiley-brand ballistic eyewear. The rate of eye injuries decrease markedly.

--- Better: A Surgeon's Notes on Performance, Atul Gawande, p. 64

Not too many books laden with statistics and medical terminology are too compelling to put down for dinner. Better: A Surgeon's Notes on Performance, by Atul Gawande, discusses the reaches and limits of medical performance -- including the very human limitations of doctors and their abilities to make good decisions. How do doctors improve outcomes for patients? An endless array of tiny choices accrue to make good medical practice a demanding art.

This book is a worthwhile read, not just because it is a quick but engrossing book. The dilemmas of how to measure and improve the performance of the practice of medicine are relevant to the headlines we see each day about heath care reform. And the truth is, doctors' performance, like most other human performances, are spread out roughly along a bell curve. Much as we'd like to believe that our doctors are, like the children in Lake Woebegone, all above average, they are not. Even as overall medical outcomes improve, this characteristic of the system holds true. Gawande's concern is to illuminate the ways in which doctors can encourage the best outcomes and thus improve their performance.

Don Berwick believes that the subtleties of high-performance medical practice can be identified and learned. But the lessons are hidden because no one knows who the high performers really are. Only if we know the results from all can we identify the positive deviants and learn from them. If we are genuinely curious about how the best achieve their results, Berwick believes, then the ideas will spread. The test of Berwick's theory is now under way. In December 2006, the Cystic Fibrosis Foundation succeeded in persuading its centers to make public their individual results ...

-- p. 226

Gawande gives advice to medical students about how to put themselves in the best position to become those positive deviants:

1. Ask unscripted questions. Don't treat your patients or your colleagues like cogs in the machine, look for what makes each one unique.
2. Don't complain. It drags down the morale of the team, and wears away the belief that improvement is possible.
3. Count something. Approach the world around you through the eyes of a scientist. "If you count something you find interesting," he writes, "you will learn something interesting."
4. Write something. Communicate. Add your observations to the world.
5. Change. Recognize the inadequacies in what you do and be willing to try something new.

The work of a software engineer, unlike a doctor, very rarely puts a human life in the balance. The risks and responsibilities we have in society are very different. Still we have the challenge of knowing how we are doing and if we are doing the best job that we can. Attempting to become positive deviants is not a bad place to start.

Staying Unstuck

Just as I was posting Getting Unstuck, another blogger I know was reflecting about “getting out of a rut”. For this writer, the interesting direction was not generating new ideas, but establishing new behaviors. As anyone who’s ever tried to change their own behavior knows, establishing a new habit takes much more that just identifying what the new practice should be.

Things that help to establish new routines can include the following:

• Have a buddy. I like to learn how to do something, such as use a new tool, and then find someone on my team to teach it to. Teaching someone else to do something builds understanding. And when I forget to use my new tool, I now have someone who will remind me.
• Make it part of the routine. Redefine the process to depend on the new behavior. For example, peer review before check-in. Someone can see that a rule is being violated. That works best with a new behavior we want to put on the critical path for product release.
• Make the desired behavior visible. The example that comes to mind on this is documentation of test processes and the like that’s internal to the team. When I added a “what’s been documented this week?” section to weekly status reports, it was a lot easier to get documentation tasks done.
• Match rewards with the desired behavior. What we reward we do, even if the only reward is recognition. But sometimes there’s a disincentive to the new behavior that has to be addressed.
• Understand why. Have an answer to the question, why are we doing this? And assess – is it working? Knowing that a change brings us closer to a desired goal is a powerful motivator.