How is success achieved by individuals innovating for patient safety and quality in the NHS?
© The Author(s). 2017
Received: 10 April 2017
Accepted: 1 September 2017
Published: 11 September 2017
Innovation in healthcare is said to be notoriously difficult to achieve and sustain yet simultaneously the health service is under intense pressure to innovate given the ever increasing demands placed upon it. Whilst many studies have looked at diffusion of innovation from an organisational perspective, few have sought to understand how individuals working in healthcare innovate successfully. We took a positive deviance approach to understand how innovations are achieved by individuals working in the NHS.
We conducted in depth interviews in 2015 with 15 individuals who had received a national award for being a successful UK innovator in healthcare. We invited only those people who were currently (or had recently) worked in the NHS and whose innovation focused on improving patient safety or quality. Thematic analysis was used.
Four themes emerged from the data: personal determination, the ability to broker relationships and make connections, the ways in which innovators were able to navigate organisational culture to their advantage and their ability to use evidence to influence others. Determination, focus and persistence were important personal characteristics of innovators as were skills in being able to challenge the status quo. Innovators were able to connect sometimes disparate teams and people, being the broker between them in negotiating collaborative working. The culture of the organisation these participants resided in was important with some being able to use this (and the current patient safety agenda) to their advantage. Gathering robust data to demonstrate their innovation had a positive impact and was seen as essential to its progression.
This paper reveals a number of factors which are important to the success of innovators in healthcare. We have uncovered that innovators have particular personal traits which encourage a propensity towards change and action. Yet, for fruitful innovation to take place, it is important for relational networks and organisational culture to be receptive to change.
KeywordsInnovation Positive deviance Qualitative research Patient safety Healthcare organisations
Healthcare innovation has been defined as “a novel set of behaviours, routines and ways of working that are directed at improving healthcare outcomes, administrative efficiency, cost effectiveness or users’ experience and that are implemented by planned and co-ordinated actions” . The healthcare sector in the United Kingdom is under continual pressure to innovate given the ever increasing efficiency demands placed upon it . Yet, the challenges of implementation and diffusion mean that achieving sustained innovation in healthcare is notoriously difficult . A number of interacting factors have been identified to underpin the speed of implementation and diffusion as well as its sustainability . These relate to the innovation itself, the intended adopters, communication and influence, both the inner and outer organisational/system context and the process of implementation .
Ever since Roger’s seminal work on diffusion of innovations theory , a body of literature has emerged concerning how innovations are spread, diffused or implemented in many sectors including healthcare. Several recent papers have examined healthcare innovation in different ways. McMullen et al. (2015) used the diffusions of innovations model to understand the results of a trial which tested a novel rapid HIV test in UK primary care . Illott et al. (2012) assessed the implementation of healthcare innovations arising from a region in the North of England . Barnett et al. (2011) were interested in factors which obstructed or facilitated the implementation and diffusion of innovation in healthcare organisations . Other research teams have looked at innovations in relation to a precise clinical area e.g. why transcatheter aortic valve implantation showed rapid diffusion in Germany but not elsewhere . These studies have addressed the issue of diffusion and spread, but significantly less work has emphasised how innovation is developed and achieved or the role of individuals in producing healthcare innovations. Due to the paucity of knowledge in this area, our research team became increasingly interested in understanding how innovation is achieved by individuals in the NHS with regards to patient safety and quality.
Patient safety is a key government and NHS concern  but little is known about how individuals working within healthcare organisations are able to achieve innovations specific to patient safety and quality. Attempts to improve patient safety within healthcare organisations often rely on identifying when patient safety is compromised via methods such as mortality reviews, audits and incident reporting. The emphasis on ‘find and fix’ or “what goes wrong and how often, why errors occur, and who or what is at the root of the problem… tell us little about the presence of patient safety, alerting us instead to its absence” . Despite this negativity, the majority of care that is delivered is of a high quality and safe . Approaches which focus on strengths and resources - looking at why things go right in order to learn from success – are beginning to gain credence . One such approach is that of ‘positive deviance’ . Positive deviance has its roots in international public health research  but has recently begun to be applied to western healthcare settings to address patient safety topics such as reducing surgical site infections , and the promotion of hand hygiene . A central tenent of the positive deviance approach is that solutions to problems facing a given community usually exist amongst certain members of that community, which can then be taken and spread to other members . Despite facing similar constraints as others, ‘positive deviants’ are able to succeed by demonstrating different or uncommon behaviours . Most studies which have identified and conducted work with positive deviants have been focused at the level of the organisation rather than the individual . Of those studies which have focused on individual positive deviants in healthcare, most use quantitative methods [14, 16]. One exception is Kim et al. (2008) who identified the strategies used by positively deviant nurses (and patients) when focusing on communication about family planning programmes in Indonesia . There is little other literature of a sufficient methodological quality regarding individual positive deviants. In this study, our aim is to understand how individuals working within the NHS manage to implement innovations which benefit patient safety. This is one of the first studies to use the positive deviance approach to examine how innovators for quality and safety in the NHS achieve success.
-What do successful individuals believe helped them to achieve their innovation?
-What do innovators believe they do differently to others with a similar role and status?
-Do the innovators see themselves as unusual? How and in what ways?
-What approach to leadership do the innovators take?
A qualitative research design was employed, undertaking semi-structured in depth interviews with innovators in patient safety and quality. In depth interviews were selected because they often lead to rich narratives, which permit the researcher to analyse how the participants make sense of the topic under investigation . As this study was exploratory in nature, we did not begin with an a priori hypothesis. We took a positive deviance approach whilst grounding ourselves in an applied health services research paradigm. Ethical approval for the study was granted by the University of Leeds in March 2015.
Participants and recruitment
We set out to interview around 15 innovators working in the area of patient safety and quality, within the NHS. Potential participants were identified from the Health Services Journal (HSJ) supplement ‘Top 50 innovators in Healthcare’ in 2014  and 2013 . HSJ is a weekly journal read by healthcare staff and NHS managers. Potential participants were people who had won a national award for their work in innovation in healthcare. We selected participants to approach from the HSJ Innovators awards list whose innovation had made a substantial contribution to patient safety or quality (or had the potential to do so), as judged by all three authors. They also had to be a healthcare professional currently or recently working for the NHS. We excluded innovators if: their area was not patient safety or quality, their work had no direct impact on patients, their work related only to a technical invention, high level infomatics or cost effectiveness/cost reduction.
The main innovation of participants
Led the implementation and adoption of an organisational development approach within a NHS Hospital Trust, working with teams in difficulty.
Took the concept of enhanced recovery in surgical patients and introduced it for medical patients.
Improved the use of health informatics in the NHS, setting up systems to collect and review real-time performance data.
Introduced the use of PROMs with patients undergoing orthopaedic surgery to improve the efficiency of follow-up clinics.
Designed a new, safer technique for glaucoma surgery including anti-scarring treatment.
Developed a rehabilitation pathway using digital media to engage patients more in the process.
Redesigned patient pathways to improve outcomes for dialysis patients as well as deliver efficient and more sustainable dialysis services.
Led the implementation and adoption of an organisation-wide intervention to improve patient safety in an NHS hospital trust.
Scaled up and rolled out a tele-health initiative across a region of England
Lead the implementation of specialist geriatric-led service for older elective surgical patients
Developed a patient experience campaign focusing on improving communication between staff and patients
Implemented and scaled up a novel method for stimulating successful communication in healthcare teams in order to improve patient safety outcomes
Led a large scale reconfiguration of the centralisation of stroke services in a major city in the UK
Developed an approach to improve the process of ward rounds in order to reduce errors relating to patient safety
Led the transformation of primary care services in a major city in the UK
Fifteen interviews were conducted by LS and CJ between June and September 2015. LS is a medical sociologist and CJ is a health psychologist. Both have worked in health services research for almost fifteen years each and have significant qualitative expertise. Both are educated to doctorate level in their respective fields. Of the fifteen interviews, five interviews were conducted face-to-face in the offices of participants and ten were conducted over the telephone. The approach was dependent on the location and/or preferences of the participant.
All interviews were conducted using a topic guide to ensure consistency across participants; however, the format was flexible in order to allow participants to voice what they considered important. Interviews began with a discussion of the innovation which led to their HSJ award, then progressed to examining the levers around successful innovation, paying particular attention to the individual circumstances of the participant and their role (including leadership) in the NHS organisation where they worked. The behaviour change wheel  informed the interview questions. This considers capability, motivation and opportunity for behaviour (in this case, innovation). Using a positive deviance approach as outlined previously, we explored whether these innovators were doing anything differently to other clinicians, and if so, how they managed to become a positive deviant in terms of innovation. Interviews lasted between 20 and 50 min and were all digitally audio-recorded. The voice files were transcribed verbatim by a professional transcriber.
We employed thematic analysis . This approach is both inductive (themes emerge from the data and are not imposed upon it by the researchers) and iterative (data collection and analysis occur simultaneously). The iterative nature of the analysis meant that preliminary insights gathered during fieldwork then assisted in partially shaping the resultant coding framework. Comparative analysis was also carried out; this method allows data from different participants to be compared and contrasted. Discordant cases were actively sought throughout the analysis and emerging ideas and themes were modified in response. Data analysis involved a process of organising the data, descriptive coding, interpretive coding, writing and theorising. Data were managed using a qualitative computer software package (NVivo) to aid sorting and categorisation of the data analysis process. LS and CJ developed the coding framework collaboratively after in depth readings of four transcripts considered typical of the dataset. CJ then coded all the transcripts and LS conducted the next level of analysis and writing. Agreement regarding interpretation was reached through consensus discussion.
Four themes were identified from the analysis: a) personal determination b) brokering relationships and making connections c) navigating organisational culture d) using evidence to influence others. Below, we outline broad factors across the themes which allow for an exploration of what helped these participants achieve their innovations and potential ways in which they were deviating from the norm. The themes arose inductively from the interviews conducted with the 15 participants and each has been ascribed a number to protect their identity.
It’s about believing in what you do and someone saying ‘you’re the guy with the bee in your bonnet’ (P4).
Divergence existed in the sample as to whether these were a group of people who were constantly innovating (“serial innovators”) or whether they had one main idea which they sought to propel forward and spread. A few participants did not feel comfortable being referred to as innovators and somewhat rejected the label.
I ended up being seen as a radical and a troublemaker rather than somebody who’s fighting every day to try and make it a little bit better for the patients and for the staff I work with (P14)
It was felt that clinicians needed to be at a certain point of seniority in their career where “rocking the boat” (P3) or “going against the trend” (P7) was not perceived as too detrimental to their status amongst their colleagues and within their organisation. Overall, we observed distinct personal traits related to determination, focus, persistence and being able to challenge the status quo were essential to ensure innovation happened.
Brokering relationships and making connections
[We’re] trying to show people how they can be innovative around services and how you can get collaboration going between specialities that haven’t traditionally collaborated, like [innovator’s team], anaesthetists and surgeons (P10).
Innovations which required cross working from diverse sections of the health system were said to be difficult to implement or set up but fundamentally necessary.
Of importance to the spread of some innovations were the fostering of collaborations or relationships between different directorates or wards of the same hospital who may not usually work together. In some cases, this was through local clinical networks (both formal and informal) or by clinical peers informally attesting to the value of the innovation with each other. P12 described making her innovation as easy as possible for people to test on their ward in order to foster uptake. Many innovators spoke about social media and in particular the importance of Twitter in order to disseminate ideas around innovation. Some participants were already opinion leaders on Twitter and used this platform to engage others in their innovation idea whilst others took to Twitter and became recognised as a result of public attention garnered from their innovation. In the case of a few participants, Twitter activity propelled debate about their innovation onto a global platform.
I don’t like the attention that comes with it because I’d rather the attention be on the team and the data, like the fact that the team’s made a difference and the data is amazing, like in terms of the improvement. So I just feel uncomfortable with like individuals taking recognition for something that isn’t really about individuals (P12)
Navigating organisational culture
To challenge, hopefully not in an unpleasant way, but to raise the questions and bring ideas from elsewhere (P2).
The context and circumstances in which innovators were navigating (or trying to navigate) organisational culture often played a large part in seeing their innovation to fruition. The safety and quality agenda was said to have come to the fore in the UK over the past ten years and five participants discussed how they felt this had facilitated their innovation. Some participants talked about the organisation in which they worked being culturally ready for change and the innovation taking hold because it was introduced “in the right place at the right time” (P13). This was particularly the case for innovations which involved large scale system change, which were sensitive to national policy or a change in governmental direction. It is interesting here to contrast the experiences of two participants - P13 and P14. P13 presided over a £20m radical structural reconfiguration of acute care which encountered comparatively little resistance despite anticipating the opposite. This contrasts with P14 who described feeling frustrated that his relatively small scale innovations were not taken on board by management within the organisation where he worked. This was despite some of these innovations – mostly relating to improving processes on hospital wards – achieving international attention and being implemented at hospitals in several other countries.
The difficult thing is the timescale that the bureaucracy works at is about a thousandth of the time that I work at. So it’s very frustrating to know what needs to be done and to have to wait a year whilst all the dots are dotted and the crosses are crossed. I think this is the story of the NHS really…I think innovation now, the system is such a mess, it’s so muddled and sticky (P15)
Just because I can put in a lot of extra time cos I believe in it, that can’t be the model of sustainability. Somebody has to take it off you and create sustainability around it; in the NHS nobody does that. So when you’ve done something and it seemed to have worked, they’ll expect you to carry the can (P7)
A few participants remarked that it was dangerous for just one person or a small group of people to be pushing an innovation forward as the sustainability of the innovation was liable to collapse if it was not embedded more widely. Finances were often integral to the above issue and a couple of participants remarked how there was a lack of willingness to take innovation forward by the organisation if little or no money was attached to it. Conversely, one participant had achieved re-design of a hospital service by using small pots of money and building up incrementally in order to show that the new model worked before applying for large scale funding.
When we first started there was a lot of resistance; I don’t think, you know, people really understood why or how [team] could add value to something as high tech as surgery and anaesthesia…would we be taking a lead where we shouldn’t be taking a lead? How that was going to infringe on their own clinical areas…Some of the consultants initially said that they didn’t want us seeing their patients (P10)
Notable exceptions existed to the above with P12 being surprised at the ease with which her innovation was adopted by clinical peers throughout the hospital and then the wider region. P11 seemed amazed at the speed and coverage her innovation took hold in the public consciousness and throughout healthcare nationally and internationally. It is important to note that few participants spoke about how their innovation had been completely curtailed by bureaucracy or a lack of sustainability, although there was a sense that some innovations progressed slower than would have been desired.
Using evidence to influence others
Quite quickly we started to see results, improvement in reducing falls, and that gave a massive sort of momentum and belief that it makes a difference. And then basically we then got lots of natural spread, probably six months later...I was confident we’d got data to say to my colleagues, can you do it seven days a week, you know, five days a week we’ve achieved this, imagine what we could do if we did seven days a week?... Normally you send an email asking people to do something, and you’ll get like a flurry of resistance. But there was no resistance and a few people said, you know “Great data, of course I’ll do that.” (P12)
Some participants were able to demonstrate statistically significant statistics such as reductions in mortality, reduced hospital admissions, shortened lengths of stay and significant improvement in falls data. These results had been persuasive in the spread of the innovation regionally and nationally. Getting quick, robust data which demonstrated the innovation worked was influential to some participants whereas others worked for several years to build up a robust dataset before they could show the innovation had positive impact. Several participants mentioned the importance of ensuring that data collection processes were built into the testing or roll out of the innovation.
In this study, we used the positive deviance approach to learn from individuals who are high profile innovators within the NHS in order to explore their perceptions of how they achieved their innovation. When investigating ‘what works’ at the level of individual, we found that the main factors were around: personal determination, the ability to connect people and teams, the ways in which innovators were able to use organisational culture to their advantage and their ability to use evidence to influence others. It is important to acknowledge that determination, focus, persistence were important personal characteristics as were skills in challenging the status quo. Innovators were able to connect sometimes disparate teams and people, being the broker between them in negotiating collaborative working. Some participants were able to use the culture of their organisation and the current patient safety agenda to their advantage (others found organisational culture stifling and this is discussed further below). Gathering robust data to demonstrate that their innovation had a positive impact was seen as essential to its progression.
The majority of these themes are reflected in the broader literature on how change takes place in organisations. For example, the Consolidated Framework for Implementation Research , − which is a meta-theoretical conceptual framework that synthesizes constructs from theories about innovation, organisational change and knowledge translation, amongst others - is particularly relevant. Two of its five core constructs are pertinent: inner setting and characteristics of individuals. The inner setting construct outlines how important the quality of social networks and informal communication are within an organisation. Relationships between individuals and a sense of ‘community’ are said to sometimes be more important than individual attributes. This relates heavily to our finding that the ability of our participants to connect people and teams was often intrinsic to the success of their innovation. However, the authors of the framework  state that personal attributes such as motivation, values, capacity and intellectual ability have received inadequate attention by those interested in how change is implemented. A major theme arising from this study was about the personal attributes and, essentially, the personal determination which this group of participants had to push forward their innovation. The fact that these intrinsic traits have been little studied in relation to organisational change is perhaps not surprising given that it may seem ‘common sense’ that what allows individuals to achieve innovation is their inherent sense of self. However, this study has shown which personal traits the participants identified themselves as being important for innovative practice.
It is interesting to see that although our explicit focus was on the positive, many of the participants spontaneously discussed what had hindered their particular innovation or, more generally, their innovative creativity or practice. This negative element of the findings can be derived across the main themes although mainly relates to that of ‘organisational culture’ particularly issues of bureaucracy, sustainability and resistance from peers. We felt it was important for the content of the themes to arise inductively from the dataset and so we have paid attention to describing the holistic account of what participants felt was important to them when asked to talk about how they achieved their innovation. But in doing so we have unveiled elements of ‘the way things are done’ in the NHS which frustrated – and sometimes hindered – a number of our participants. Of interest is the fact that these participants were working at a high level and usually mostly in influential positions. Therefore, the implications for how innovations take hold and spread within the health service needs thought and attention paid to it if those at the top of the structure have difficulty. This ties into the wider literature about the inability of shop floor NHS staff to make improvements to services . Sometimes, it not enough for a clinician to simply have a great idea and the determination to succeed. Success is often related to the complex interplay of services from different disciplines working together and a culture of ‘organisational readiness’ to change .
Our overt focus was on innovators who were working in the patient safety and quality field. It is therefore interesting that despite being encouraged to talk during the in depth interviews about the specifics of their innovation, many of the main messages arising from the findings section are general in nature and could apply to innovation in disparate fields. Two of the themes are of particular interest here – brokering relationship and making connections; navigating organisational culture. For instance, innovators were often trying to influence groups of wider colleagues with whom they may not ordinarily interact to address specific clinical issues. Therefore, the importance of relational aspects of the innovation was voiced as integral to its perceived success by our group of participants. That the findings are general rather than specific is useful as this may allow for these insights to be applicable to those working in healthcare areas other than patient safety and quality.
The concept of leadership was part of our original focus and one of the a priori research questions. The topic guide contained several questions about leadership and participants answered these questions to varying degrees. However, when analysing the dataset we did not get the impression that leadership per se was a point of interest to these participants. In fact, leadership was rarely spontaneously mentioned and answers to the topic guide questions about leadership were sometimes perfunctory. Therefore, we did not include leadership as a theme within our write up. Contemporary literature on leadership within the NHS highlights a discursive move from previous forms of traditional hierarchical leadership to new forms of distributed leadership where people have the skills and relationships to work across multiple levels and with a variety of stakeholders . Martin & Learmonth (2012)  note that leadership is said to be no longer exercised by just those in formal positions of authority but “something to be brought out across and beyond the health service”. For major change to be embedded in a healthcare system, it has been shown that elements of both hierarchical and distributed leadership are necessary . It is interesting that none of our participants explicitly spoke about distributed leadership as an approach they take. Yet, in describing how they approached the task of delivering the innovation, this is the style of leadership most participants implicitly adopted in order to connect people and teams, sometimes in challenging situations or environments.
The findings of this paper suggest that innovations are not easy to achieve in the current NHS and that innovation is certainly not conceived as part of the ‘day job’ of clinicians. When seeking those people for roles that require innovation, recruiters may benefit from paying particular attention to the ability of applicants to connect people and to challenge the status quo. Determination and a sense of moral responsibility to improve patient care may also be traits worth examining. Lessons for NHS organisations also emerge from these data. At a senior level, recognition of and support for innovators to bring different people together to address a problem may be key, particularly where this can bypass bureaucracy that might otherwise stymie progress. Indeed this is one of seven recommendations for diffusing innovations outlined by Berwick (2003) . The problem remains, however, how can those working in healthcare be supported to become innovators? One approach is to provide an opportunity for aspiring innovators to be embedded within a community of similarly minded peers at a local and national level. This approach is reflected in the Q community  established by NHS England and the Health Foundation to improve the quality of health and care services. The ability to call on similar others for advice and the opportunities for learning together that such a community might provide could help future innovators to overcome the challenges they so often face. This study has important implications, recognising, as it does, the importance of relationships across the healthcare setting for making change happen. As well as supporting innovators, leaders in healthcare organisations could engage in strategies to encourage a culture of innovation. These might include opportunities for multi-disciplinary training and projects and engaging frontline staff in improvement projects. Other initiatives such as shadowing across staff groups, improvement training and mentoring that encourage a better understanding of the health system as a whole, may well serve to help innovations develop and flourish.
Strengths and limitations
To our knowledge, this is the first study to take a positive deviance approach to understand how innovations which benefit patient safety are achieved within the NHS. We interviewed a sample of exceptional innovators who were able to provide insight at the highest level of innovation in patient safety – across a range of types of innovations in different clinical areas. One limitation of our study could be the small sample size although, as previously described, interviewing ‘elite’ participants allows for this. In taking a positive deviance approach, we were explicitly looking for the factors which allow innovations to succeed in the NHS. It could be that had we conducted a more traditional ‘barriers and levers’ style study (such as Barnett et al. ) which paid equal attention to what discourages or prevents innovation then we would have gained a more rounded view of patient safety and quality innovation. However, whilst describing the process of innovating, participants did articulate the hurdles they had to overcome. Perhaps by describing how they achieved this we learn more about what is required by innovators, their colleagues and managers to deliver improvements to quality and safety. Finally, our sample of participants were those drawn from a national award list of NHS innovators, representing highly successful and – for the most part – influential people. We may have garnered different answers to our research questions if we had interviewed participants who were perhaps not known on a national level and were delivering innovations with a smaller impact or reach.
We interviewed patient safety and quality innovators using a positive deviance approach to understand how they achieve success. The main factors identified were: i) personal determination of the individuals including their ability to challenge the status quo, ii) their capacity to connect people and teams, and encourage collaborative working, iii) the ways in some which innovators were able to use organisational culture to their advantage and iv) using evidence to influence others. Whilst innovation in healthcare is said to be difficult to achieve, we have uncovered a number of the key aspects which we believe may lead to successful innovation by individuals working in the NHS. These findings can be used by those who recruit, train and support potential innovators in the NHS and those who are responsible for setting the policy agenda. For successful innovation to occur, both the relational and structural position of the innovator are critical.
Thanks to the participants who generously gave their time to take part in an interview for this study. All participants have agreed to be acknowledged by name. In alphabetical order: Gordon Caldwell, Ruth Chambers, Piers Clifford, Alison Cracknell, Maxine Craig, Jugdeep Dhesi, Marc Farr, Clare Gerada, Kate Granger, Kerri Jones, Samantha Jones, Peng Tee Khaw, Sandip Mitra, Bibhas Roy, Anthony Rudd.
The research was funded by the NIHR CLAHRC Yorkshire and Humber. http://clahrc-yh.nihr.ac.uk/. The views expressed are those of the author(s), and not necessarily those of the NHS, the NIHR or the Department of Health.
Availability of data and materials
Unpublished data is not available.
LS and RL conceived the idea for the study. LS and CJ designed the study. LS and CJ collected all data. LS and CJ both drafted the coding framework and CJ coded the data. LS interpreted the data and wrote the first draft of the paper. All authors edited the first draft of the paper. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the School of Psychology Research Ethics Committee, University of Leeds on 13th March 2015 (Ref: 15–0081). All participants gave informed consent to take part in this study.
Consent for publication
No individualised data is presented in this paper.
The authors declare they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Greenhalgh T, Robert G, Macfarlane F. Diffusions of innovations in service organisations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629.View ArticlePubMedPubMed CentralGoogle Scholar
- Ilott I, Gerrish K, Booth A. Testing the consolidated framework for implementation research on health care innovations from South Yorkshire. J Eval Clin Pract. 2012;19:915–24.PubMedGoogle Scholar
- Berwick D. Disseminating innovations in healthcare. JAMA. 2003;289(15):1969–75.View ArticlePubMedGoogle Scholar
- Rogers E. Diffusion of innovations. New York: Free Press; 1962.Google Scholar
- McMullen H, Griffiths C, Leber W, Greenhalgh T. Explaining high and low performers in complex intervention trials: a model based on diffusion of innovations theory. Trials. 2015;16:242.View ArticlePubMedPubMed CentralGoogle Scholar
- Barnett J, Vasileiou K, Djemil F, et al. Understanding innovators’ experience of barriers and facilitators in implementation and diffusion of healthcare service innovations: a qualitative study. BMC Health Serv Res. 2011;11:342.View ArticlePubMedPubMed CentralGoogle Scholar
- Merkel S, Eikermann M, Neugebauer et al. The transcatheter aortic valve implementation (TAVI)--a qualitative approach to the implementation and diffusion of a minimally invasive surgical procedure. Implementation Science. 2015;6:10:140.Google Scholar
- Department of Health. A mandate from the government to NHS England: April 2014 to. London: Department of Health. March 2015:2014.Google Scholar
- Lawton R, Taylor N, Clay-Williams R, Braithwaite J. Positive deviance: a different approach to achieving patient safety. BMJ Q&. 2014;23:880–3.Google Scholar
- Hollnagel E, Braithwaite J, Wears R. Resilient healthcare. UK: Ashgate; 2013.Google Scholar
- Bradley E, Curry L, Ramanadhan S, et al. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25.View ArticlePubMedPubMed CentralGoogle Scholar
- Sternin J, Choo R. The power of positive deviancy. An effort to reduce malnutrition in Vietnam offers an important lesson about managing change. Harv Bus Rev. 2000;78:14–5.PubMedGoogle Scholar
- Awad S, Palacio C, Subramanian A, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg. 2009;198:607–10.View ArticlePubMedGoogle Scholar
- Marra A, Luciana R. De Araujo et al. positive deviance: a new strategy for improving hand hygiene compliance. Infection Control Hospital Epidemiology. 2010;31:12–20.View ArticlePubMedGoogle Scholar
- Baxter R, Taylor N, Kellar I, Lawton R. What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Q&S. 2016;25(3):190–201.Google Scholar
- Kraschnewski J, Sciamanna C, Pollak K, et al. The epidemiology of weight counselling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37:751–3.View ArticleGoogle Scholar
- Kim Y, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context; a positive deviance study. Int J Nurs Stud. 2008;45:1411–21.View ArticlePubMedGoogle Scholar
- Pope C, Mays N. Qualitative research in healthcare. third ed. London: BMJ Books; 2006.View ArticleGoogle Scholar
- Health Services Journal. Top 50 innovators in Healthcare 2014. http:// www.hsj.co.uk. Accessed 5 June 2015.
- Health Services Journal. Top 50 innovators in Healthcare 2013. http:// www.hsj.co.uk. Accessed 5 June 2015.
- Baker S, Edwards R. How many qualitative interviews is enough? National Centre for research methods review paper. 2007.Google Scholar
- Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;16:42.View ArticleGoogle Scholar
- Guest G, Macqueen K, Namey E. Applied thematic analysis. London: Sage; 2012.View ArticleGoogle Scholar
- Damschroder L, Aron D, Keith R, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.View ArticlePubMedPubMed CentralGoogle Scholar
- Sheard L, Marsh C, O’Hara J, et al. The patient feedback response framework – understanding why UK hospital staff find it difficult to make improvements based on patient feedback: a qualitative study. Soc Sci Med. 2017;178:19–27.View ArticlePubMedPubMed CentralGoogle Scholar
- Weiner B. A theory of organisational readiness for change. Implement Sci. 2009;4:61.View ArticleGoogle Scholar
- McKee L, Charles K, Dixon-Woods D, et al. New and distributed leadership in quality and safety in health care, or old and hierarchical? An interview study with strategic stakeholders. Journal of Health Services Research & Policy. 2013;18(S2):11–9.View ArticleGoogle Scholar
- Martin G, Learmonth M. A critical account of the rise and spread of leadership: the case of UK healthcare. Soc Sci Med. 2012;74:281–8.View ArticlePubMedGoogle Scholar
- Turner S, Ramsay A, Perry C, et al. Lessons for major system change: centralisation of stroke services in two metropolitan areas of England. Journal of Health Services Research & Policy. 2016;21(3):156–65.View ArticleGoogle Scholar
- Berwick D. Disseminating innovations in health care. JAMA. 2003;289(15):1969–75.View ArticlePubMedGoogle Scholar
- Health Foundation. Q: A connected community working together to improve health and care quality across the UK. https://q.health.org.uk/ Accessed: 17th August 2017.