Enhancing Agency and Reducing Risk: A Case for Positive Deviance Adam J. Parrish University of Central Florida An Equal Opportunity University

Structuration Theory (Giddens, 1984) Structures- “Rules and resources drawn upon in the production and reproduction of social action.” Rules- Reasons for acting Resources- Material and nonmaterial tools Systems- Patterns of interactions (Giddens, 1984)

Purpose Organizations face external and internal threats. Internal threats can be generated by the structures developed and reinforced within a system. Positive deviance research challenges systems effectively, yet remains atheoretical and somewhat unpopular.

The Duality of Structure The rules that we create to govern the use of resources (i.e., structures) can enhance, constrain, destroy, or transform a system. Agency- The ability and freedom of a person to “act otherwise.” (Giddens, 1984)

A Traditional Structure Rules are made by people at the top of the organization. Resources are controlled by the same people. People at the top of the organization have the most agency.

The Case In 2005, VAPHS implements CDC program to reduce MRSA transmission in six hospitals. The program failed. A skeptical administrator attempted a novel method (i.e., positive deviance).

Positive Deviance Method Within every system, there are agents who have found ways to behave to their benefit, despite having to better access to material or nonmaterial resources. The PD method takes an “all in” rather than a “top-down” approach to systems, structures, and agency.

Profound Results Jerry and Monique Sternin were asked to find a way to reduce childhood malnutrition in Vietnam. Researchers looked for children were healthy, even though their parents had no better access to food or money. Childhood malnutrition rates dropped by 85% within two years.

PD Systems Who can devise solutions to complex problems? The usual suspects- Administrators, physicians, infection control experts… The unusual suspects- Valets, chaplains, custodians, cafeteria workers…

PD Structures Nontraditional material resources- “The Pudding Play.” Nontraditional nonmaterial resources- Creativity, dialogue, involvement

PD Agency Two groups were excluded initially from the PD intervention. Patients The dementia ward Resistant Bacteria: Methicillin Resistant Staphylococcus aureus and Vancomycin Resistant Enterococcous” VS “Keeping America’s Veteran’s Healthy—A Guide to MRSA—A Simple Way to Shorten Your Stay.”

Transformation MRSA infection rates dropped by 50 percent in the first six months. MRSA screening and hygiene behaviors increased by 90 percent. Communication networks expanded creating a more proactive, inventive, and democratic system.

Limitations Findings are not gerneralizable. Other theoretical explanations are possible. PDI sounds like it’s magic, but it requires significant time, resources, and buy-in from stakeholders.

Future Directions PD can be effective in the development and diffusion of innovations. PD may be effective in risk and crisis preparedness. “If you’re going to be deviant, be positive.” –Chippy McNish