
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39246029
10.7812/TPP/24.008
TPJ-24-008
Original Research
Positive Deviance Theory: Leveraging Compliments Data to Guide Strategic Planning for Patient Experience Improvement in a Large Rural Health Care System
https://orcid.org/0000-0003-2477-9365
Clark Kolu S Baysah DNP, MS, MPH, APRN 1
Manohar Nivethitha MD, MPH 2
Ahmad Jabeen PhD, MPH 3
https://orcid.org/0000-0002-7399-622X
Oliver Brant J PhD, MS, MPH, FNP-BC, PMHNP-BC 3 4 5
1 U Mass Memorial Medical Center, Worcester, MA, USA
2 Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX, USA
3 Chronic Health Improvement Research Program (CHIRP) at Dartmouth Health, Lebanon, NH, USA
4 Departments of Community & Family Medicine, Psychiatry, and the Dartmouth Institute for Health Policy & Clinical Practice, Giesel School of Medicine at Dartmouth, Hanover, NH, USA
5 Division of Care Experience, Value Institute, Dartmouth Health, Lebanon, NH, USA
Kolu S Baysah Clark, DNP, MS, MPH, APRN Kolu.S.Baysah.Clark.GR@Dartmouth.edu
2024
09 9 2024
28 3 223233
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

Patient-centered care (PCC) has been called for as a solution to improving care quality and patient outcomes. Patient experience, termed care experience, is a measurable aspect of PCC and aligns with coproduction. Identifying patterns of positivity and high performers is a Positive Deviance approach that can inform strategic improvement of the care experience.

Objective

To identify the characteristics of positive deviances from voluntary, unsolicited compliments from patients and family members about their care experiences.

Methods

The authors conducted a mixed-method analysis, including content and a thematic analysis of unsolicited comments from patients and families, submitted between January 2021 and January 2022. After removing duplicates and miscategorized comments, 213 compliments were included in the analysis using a single, blinded inductive coding to synthesize thematic statements.

Results

The main campus received the most compliments by location (89%); the most widely used patient sentiment was thankful (36.8%). Compassionate (26.8%), together with six others: competent (11.6%), communication (10.6%), cared for (8.5%), care team (8.0%), and supportive (8.0%), made up approximately 80% of drivers of care quality. Physicians (37.3%) and nurses (34.2%) were the most complimented personnel, although surgery (17.0%) were the most complimented services team. Similar characteristics were reported for exemplary individuals and their associated care teams.

Conclusion

The results align with previously reported work by the Beryl Institute and CMS 5-star rating on key drivers of patient experience. This approach provides a method by which exemplars can be identified within health systems, and that information is used to guide improvement and organizational planning.

Keywords:

Patient Experience of Care
Human Experience of Care
Patient Center Care
Positive Deviance
Quality Improvement
patient experience
Disclosures KSBC, ER, and NV have no relevant financial relationships to disclose. BJO is the System Vice President for Care Experience at the Value Institute, Dartmouth Health.
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pmcIntroduction

Patient experience (PE) has long been a core element of high-quality health care. It is essential in clinical practice, research, policy, and quality improvement (QI). The Agency for Healthcare Research and Quality (AHRQ) states that PE "encompasses the range of interactions that patients have with the health care system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other health care facilities."1 The Beryl Institute’s definition highlights the integrated, multidimensional nature of PE, calling us to go "beyond the distinct silos of patient experience, employee engagement, and community health, to focus on the common thread that binds each of these areas together—the human experience."2,3 Their definition guided the development of the “care experience” definition used by the health system the authors studied. "Care experience includes the feelings and perceptions of people resulting from interactions they have with the health system. Their experience is shaped by our culture and the needs and expectations of those we serve."4

Drivers for improving Patient Experience

Patient-centered care (PCC) has been called for by numerous agencies as a solution of improving care quality and outcomes for patients.1,5,6 Improved PE, a measurable aspect of PCC, has shown to increase adherence, engagement, and patient safety while lowering health care utilization.1,7–10 PE is becoming an explicit component of certification and compensation,11 with a well-documented relationship to clinical quality, better health outcomes, and increased connection for stigmatizing conditions like mental health services.7–9,12 There is universal agreement among studies that receiving patient feedback about their care experience is needed for high-quality care.7,13,14 Patients prioritize communication and other aspects of the provider-patient relationship as crucial components of quality and value it as highly as specific treatments and technical skills.7,10,14 Additionally, Golembiewski et al highlighted the need to consider the factors influencing the rural patients’ experience.15

Hospitals also have a financial incentive to improve PE, with the rise of public reporting and pay-for-performance programs. PE measures such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and its hospital version (HCAHPS) are widespread quantitative measures of PE in ambulatory settings.7,16 Since 2012, HCAHPS scores have played a role in hospital payment through the Hospital Value-Based Purchasing program.17 Hospitals are evaluated and compared by the Centers for Medicare and Medicaid Services' (CMS) Five-Star Quality Rating System.18 Many payers, including CMS, tie hospital and physician compensation to these ratings, incentivizing hospitals to prioritize PE.18

Informing strategy development

Historically, health care QI has focused predominantly studying and remedying deficits or defects. However, an emerging field of study focuses on the identification, spread, and scale of best practices and exemplar behaviors—Positive Deviance (PD).19–21 PD describes the behavior of an exemplary individual but can also describe the behaviors of successful teams and organizations. Originating in international public health projects,20 it was recently adopted to improve quality and safety of health care delivered in organizations.19,21 The Institute for Healthcare Improvement, along with health care QI experts, consider PD to be an important approach to improving health care.22,23 PD proposes that solutions exist within clinical communities rather than externally with policymakers or managers. Members of a community have the knowledge and wisdom needed to generate the solution. When solutions originate within the community, they are more likely to be accepted and successful, with greater adoption.19 Similarly, when health systems work to improve PE, they often focus on identifying problems: what went wrong, and why? However, solutions to problems frequently exist within high-performing people and teams in the health system. Few studies focus on the PD approach, and there needs to be more consensus on methods used for this approach. The authors’ analysis sought to reveal “patterns of positivity” and high performers, and categorize them in a way that is meaningful to inform improvement and workforce engagement efforts and related organizational strategic planning.

Methods

The authors conducted a retrospective descriptive mixed-methods analysis of unsolicited positive comments (compliments) received from patients and families by patient relations units in selected hospitals and ambulatory care centers in a rural academic health system.

Setting

The authors studied a rural academic medical center in New Hampshire, Dartmouth Health, a trauma Level I Adult and Level II Pediatric trauma center, with associated ambulatory clinics which serve residents of New Hampshire, Vermont and other New England states. As part of the data collection, the patient relations departments at these sites have established systems for how a patient can communicate with the hospital regarding their care experience. Comments are voluntary but highly encouraged by the organization to improve the care experience of patients. These include positive (complimentary) and negative (complaint) comments, usually involving someone who received care or their family member who wished to share specifics of care and other services involved, including outpatient services, illuminating their care experience.

Sample

The authors’ analysis describes results of a purposive convenience sample of unsolicited complimentary comments received from patients and families who received care at this health system between January 2021 and January 2022. Two hundred and thirteen (213) complimentary comments were included. All comments were anonymized and entered in analysis software by research personnel under the supervision of the principal investigator and then accessed by the researchers, who conducted data analysis (thematic coding). The data set was completely anonymized by system personnel prior to data analysis to remove any protected health information elements. This work has been reviewed by the Dartmouth Health Internal Review Board and approved with exempt status, categorized as an organizational QI activity.

Analysis

The authors conducted a thematic analysis using Dedoose, with 2 primary coders to collaborate asynchronously and code blindly. Dedoose, a cross-platform application for analyzing qualitative and mixed-methods data with text, photos, videos, and more, allows multiple coders to collaborate in real time.24 This involves sorting the codes into similar concepts to help identify recurring patterns.25 All authors read through the compliments data set to become familiar with the data, and 3 authors worked to develop the initial codebook (KBC, NM & JA). After independent coding, the 2 primary coders (KBC & NM) met to compare codes and revise the initial codebook. This process was repeated iteratively, with coders conferring to update and refine the codebook and delete, edit, and merge codes. The codebook was then used to sort codes into categories to identify patterns and develop broader themes regarding PE (Figure 1).

Figure 1: Flow chart of thematic analysis process.

The authors then conducted Pareto chart analyses to analyze frequency counts of comments in each thematic category. They applied the general Pareto economic principle that causes and outcomes tend to follow an 80/20 relationship, where 20% of causes impact 80% of total contribution toward outcomes. This highlights the need to identify the most influential causes, as focusing on them will dramatically impact results, and also creates a more cost-effective approach to improvement.26 The authors calculated frequencies of instances in each thematic category and determined which categories are primary drivers of compliments (positive care experiences) via Pareto analysis. They then collapsed overarching thematic statements into final major themes.

Results

Content Analysis

The content analysis generated 98 content codes from narrative comments. Some codes were duplicates and were used interchangeably (Table 1). The Lebanon location (the large academic medical center) received the most compliments by location (89%). The most widely used patient sentiment was thankful, with 36.8%. Compassionate was the most reported driver of care quality, with 26.8%; the authors define these drivers of care quality as the characteristics of high standards of care from a patient perspective. Pareto analyses of the codes by category revealed that 7 categories captured over 80% of care quality compliments in this category: compassionate (26.8%), competent (11.6%), communication (10.6%), cared for (8.5%), professionalism (8.2%), care team (8.0%), and supportive (8.0%; Figure 2).

Figure 2: Pareto chart displaying components that makeup care quality.

Table 1: Code counts and percentages across thematic categories

Descriptor	Count	Percentage	
Care Quality	
 Care Team	31	8.0%	
 Communication	41	10.6%	
 Compassionate	104	26.8%	
 Competent	45	11.6%	
 Courtesy	16	4.1%	
 Medical Care	28	7.2%	
 Patient-Centered	10	2.6%	
 Professionalism	32	8.2%	
 Supportive	31	8.0%	
 Transition of Care	15	3.9%	
 Work Ethic	2	0.5%	
 Cared For	33	8.5%	
Personnel	
 Anesthesia	11	3.4%	
 Call Center	8	2.5%	
 Doctors	119	37.3%	
 Greeters	5	1.6%	
 Housekeeping	11	3.4%	
 Interpreters	2	0.6%	
 Kitchen Staff	9	2.8%	
 Medical Assistant	1	0.3%	
 Medical Trainee	4	1.3%	
 Nurses	109	34.2%	
 Occupational Therapist / Physical Therapist	2	0.6%	
 Physician Assistant	4	1.3%	
 Parking Attendants	2	0.6%	
 Pharmacist	2	0.6%	
 Phlebotomist	3	0.9%	
 Podiatrist	2	0.6%	
 Security Officer	1	0.3%	
 Social Worker	5	1.6%	
 Technicians	16	5.0%	
 Volunteers	2	0.6%	
 Midwife	1	0.3%	
Patient Sentiments	
 Above and Beyond	65	21.4%	
 Attentive	14	4.6%	
 Awesome/Wonderful	68	22.4%	
 Comfortable	25	8.2%	
 Humor	9	3.0%	
 Listened to	11	3.6%	
 Thankful	112	36.8%	
Service Teams	
 1 East	2	0.9%	
 1 West	2	0.9%	
 2 West	2	0.9%	
 3 East	1	0.5%	
 3 North	1	0.5%	
 3 West	3	1.4%	
 4 East	2	0.9%	
 5 West	7	3.2%	
 Cardiology	19	8.7%	
 Dermatology	3	1.4%	
 Emergency Department	14	6.4%	
 Otolaryngology	1	0.5%	
 Endocrinology	5	2.3%	
 Front Desk	21	9.6%	
 Gastroenterology	9	4.1%	
 Hematology	6	2.8%	
 Intensive Care Unit	9	4.1%	
 Internal Medicine	5	2.3%	
 Mental Health	4	1.8%	
 Neonatal Intensive Care Unit	1	0.5%	
 Neurology	7	3.2%	
 Obstetrics	9	4.1%	
 Oncology	4	1.8%	
 Ophthalmology	8	3.7%	
 Orthopedics	6	2.8%	
 Pain Clinic	4	1.8%	
 Pediatrics	5	2.3%	
 Primary Care	4	1.8%	
 Pulmonology	6	2.8%	
 Radiology	6	2.8%	
 Respiratory Dept	1	0.5%	
 Rheumatology	1	0.5%	
 Surgery	37	17.0%	
 Trauma Team	2	0.9%	
 Urology	1	0.5%	

Three patient sentiments categories accounted for over 80% of the compliments: Thankful, Awesome/Wonderful, and Above and Beyond (Figure 3). Under personnel, physicians (doctors) and nurses were the most complimented (37.3% and 34.2%, respectively). Next were housekeeping and anesthesia, each receiving about 3.4% of compliments. Personnel (Figure 4) were heavily skewed, with the 4 categories (doctors, nurses, housekeeping, and anesthesia) making up 80% of compliments in the category and the first 2 (doctors and nurses) capturing over 70%. Surgery was the most complimented service team, receiving 17.0%, followed by front desk (9.6%), cardiology (8.7%), emergency department (6.4%), and OB (4.1%). Using a revised threshold of 60%, the distribution among service teams was broad, with the top 9 teams receiving 60% of the compliments (Figure 5).

Figure 3: Pareto chart of patient sentiments.

Figure 4: Pareto chart of service personnel.

Figure 5: Pareto chart of service teams.

Thematic Analysis

Our analysis identified 3 major themes: 1) an exemplary caregiver is a care champion who demonstrates compassion, is competent in their role, exhibits professionalism during medical care encounters, is often supportive, and is informative; 2) an excellent care team shows compassion, supportiveness, and professionalism when serving patients; and 3) care quality includes exemplary caregivers and care teams who were compassionate, competent, professional, supportive, provides good communication, and made the patient feel cared for. Each theme is discussed in turn below with exemplar quotes.

Theme 1: Exemplary Caregivers

An emerging theme from the complimentary comments by the patients regarding their care experience is that an exemplary caregiver can positively impact the care experience of patients and their families, which were most noted through the caregiver’s role, attitude, or action. Examples of patients describing the role of their caregiver were near ubiquitous in the compliments. Sometimes, such as in the excerpt below, the patient will remember specific names, but most often the praise is given to the doctor, nurse, MRI tech, etc. This excerpt also demonstrates staff were viewed as exemplary caregivers through their attitudes, such as delivering compassionate care. One patient described this in the following:

“My experience today with Dr. Simmons and the pharmacist Britney Fitch were the best that I have had over there thank you for that. Also I can’t say enough about Britney she makes her patient feel like you’re a human being and not beneath her and you can’t find that very much anymore. She’s a keeper don’t let her go.”

In addition, these caregivers were often described as competent, which patients most often viewed through the lens of the caregiver’s actions. The patient below told how it was the doctor’s competent actions, knowing just what to do, which put them at ease and gave them a positive experience:

“PT states the MD took no longer than a couple of minutes to enter the room and without panicking had the PT use a larger cuff which showed her vitals improving. PT states the workup she had done after this incident left her feeling confident and comfortable with her care. So much so that the PT states she did not feel a trip to the ED was necessary due to the confidence she had leaving the Urgent Care.”

Patients often commented on how they felt cared for by these exemplary caregivers. During care encounters, patients often find these exemplary caregivers also exhibited the right attitudes and actions through professionalism, are supportive, and are informative about the care and what to expect during the care experience.

“I was then greeted by Danielle (MRI tech). I do not know her last name. She was extremely nice and we were able to chat a bit about what to expect. I was still very confident. While moving me into the scanner, I unexpectedly had a panic situation. She was assisted by another MRI tech. to help, I did not catch her name. They were wonderful, patient, calm and caring with me. On the third attempt we were successful! I wholeheartedly believe that Danielle is a true asset to your facility.”

Exemplary caregivers stood out to patients from many departments, service teams, and locations; however, physicians and nurses were the roles most often viewed by patients and their families as exemplary caregivers, although surgery service was the most recognized department from the authors’ analysis. In conclusion, an exemplary caregiver is a care champion who demonstrates compassion, is competent in their role, exhibits professionalism during medical care encounters, is often supportive, and is informative to patients during their encounters. Patients felt cared for by these individuals and were thankful for their services. The following excerpts capture what patients look for in an exemplary caregiver, combining these different facets during medical encounters.

“Dr. P blew my husband and me away with her detailed understanding and knowledge of Graves’ Disease from our very first appointment with her. She has been compassionate, patient (we ask a LOT of questions!), and competent in all of our interactions. Not only has she demonstrated the utmost professionalism, but she also infuses her appointments with humor, which I so appreciate it. I’ve requested her by name several times now for upcoming appointments, and I always feel I am in the best of hands!”

“I had emergency surgery on Christmas Eve . . . . I am wondering if there is any way to get a message to a specific nurse I was fortunate to have in the OR with me that day. I do not remember her name but she was so kind to me when I was feeling my worst. She was so kind to me, speaking softly to me and wiping me with a cold compress just before I was put to sleep. I am hoping that I can get a message to this nurse. I want to thank you from the bottom of my heart for being so kind and caring to me when I was at my worst and I will never forget her kindness.”

Theme 2: Characteristics of excellent care teams

Receiving services from an excellent care team was viewed similarly to exemplar caregivers. An excellent care team has a positive impact on care experience. These teams include care champions or exemplar caregivers. The following quotes highlight what patients look for in an excellent care team. These teams were compassionate, supportive, and professional when serving others. The most complimented staff members were nurses and physicians (doctors); patients were most thankful for these team members.

“This team is so caring, make her feel special, she can see it in their eyes that they are caring for her and only her at that time. She so appreciates how wonderfully caring they are and all they have done to get her thru a difficult time and year.”

“I recently moved up here from Connecticut & was very pleased with my appointment with Dr. K. He was very attentive to my medical history and current concerns. I found him to be very thorough. He is a very likeable doctor who really seems to care about his patients. The staff were also very professional & welcoming during my visit.”

Good communication was often linked with these teams, enabling these teams to gain better insight from the patient for care management.

“. . . once admitted into a room, your RN, OT, PT and Trauma teams were ever helpful and kind throughout my stay. Peter and Mike spent the most time with me answering questions in a way I could understand the answer and impacts. They worked with me on my options and gave me a lot of visibility into what was happening. Your other teams were personable and professional.”

Theme 3: Care quality was considered above and beyond through a combination of technical skills, the right attitude, and PCC.

Patients often complimented care quality when it came from exemplary caregivers and care teams who were compassionate, competent, professional, and supportive, with good communication who made the patient feel cared for. The following excerpts exemplified what patients felt was above and beyond care.

“She is kind, compassionate, patient, and thorough and just what we needed (and more) in a genetic counselor. Devin not only noticed a mistake in our previous testing and supported us through correcting this but knowing that we only have one opportunity at this process, Devin reached back out weeks later saying she kept thinking about us and suggested additional testing that MGH [Massachusetts General Hopsital] had not thought of to help provide answers and inform our future decisions. She made what was at first shocking and heartbreaking news seem manageable and hopeful. As my husband put it, Devin is one of the few people who have helped to provide light at the end of a very long ‘dark tunnel’ and for that we are eternally thankful.”

“We sincerely feel that she cares for us and is invested in our well-being and long-term success. Personal experiences and employee interactions are what shape an organization’s reputation, so please know what an incredible asset you have.”

“He is the best PCP I (we) have ever had. At each o/v, Dr. Francis is present, mindful, focused, considerate, patient, listens with great intensity and is organized. His interest and care for others is genuine and heartfelt. Dr. Francis is an excellent physician to both my husband and myself and we trust him wholeheartedly. He is a kind and gentle human being. Dr. Francis has been very supportive to myself in particular, uses technical tools with great skill and is accessible. We are very happy with Dr. Francis. He is a great asset.”

Discussion

The authors’ analysis identified themes of PDs from unsolicited, voluntary comments submitted by patients and family members about their care experiences in the health system they studied. The authors’ goal was to identify patterns of positivity and high performers that will be used to inform strategic planning at the frontline of care delivery. They found that care quality was defined similarly by patients and families, regardless of whether the care was performed by an individual caregiver or by care teams. Key drivers of PE included compassion, competence, communication, cared for, professionalism, care team, and support. Many of these findings align with key drivers of human experience identified by the Beryl Institute,27 which specified the importance of good communication, treating the patient with courtesy and respect, and instilling confidence in the caregivers’ and teams’ abilities. Similarly, cared for (CMS responsiveness) and communication aligns with the CMS star ratings.17

Like other studies, which found that patients prioritize communication as a crucial component of quality,7,14 the authors’ analysis found communication as one of the core components of care quality. Additionally, the authors’ findings suggest that patients and families value care delivered by exemplary individuals; this includes compassionate, professional, and competent care that is informative. These skills are often appreciated when exhibited by physicians and nurses. The authors found cooccurrences of exemplary caregivers, an excellent care team, and care quality. Patients cared for by these individuals and care teams were often thankful for compassionate care delivered by care champions.

These results highlight characteristics, individuals, and service teams that stood out as possible areas for positive exemplars. In the setting the authors studied, they found that surgery, front desk, cardiology, ED, and other departments may have high performers, or drivers of strong PE that could be potentially studied, replicated, optimized, scaled, and standardized using improvement methods. These findings could also be applied to the organizational strategic planning to improve PE by targeting key programmatic activities and infrastructure investments to leverage, spread, and scale identified PD factors.

The authors’ analysis proposes a mixed-methods approach which combines qualitative thematic analysis of narrative comments with quantitative Pareto analysis of comment frequencies within categories. The approach seeks to provide context-specific patient-centered information to inform intelligent action by focusing on PD—what is being done right. Instead of focusing solely on negative factors (deficiencies), a positive approach can contribute to better morale, better staff engagement, and potentially less burnout. In a learning health system approach, positive deviance information could be used as feedback data to inform the system about its performance and identify strength areas that could be leveraged for improvement. By placing new emphasis on PD, there is potential to increase staff and patient retention15,28,29 by recognizing, celebrating, and optimizing the good. This can drive frontline improvement efforts toward scaling the good, by providing staff engagement and rewarding employees, contributing to overall job satisfactions, and aiding staff and patient retention; the literature has highlighted these as benefits of improving PE.13 Especially now in the postpandemic era of financial and resource constraints and with a strained health care workforce, we must identify exemplar performers/drivers of PE and use this to recognize top providers and services, and inform workforce engagement programs that are patient-centered. The ultimate result could be a process in which the patients’ voice can not only drive positive-deviance-oriented improvement, but also inform positive-deviance-oriented workforce engagement efforts. In the context the authors studied, this aligned well with their mission statement for care experience which recognizes patients, families, and workforce—“together, we strive to create a kind and trusting care environment for patients, families and health care teams.”

Limitations

This study should be considered early work using this mixed-methods analytic approach and should be replicated at greater scale for further development. The authors’ main limitation is that they had a small sample size—only 213 comments were analyzed, and they used a convenience sample of unsolicited comments. The authors did not employ a systematic sampling strategy or a randomized procedure, and their sample may not be fully inclusive, or representative of the population served by the health system they studied. They also did not study the entire health system—they focused on its largest academic medical center and 3 of its largest ambulatory outpatient care centers. Additionally, some comments (n = 62) were included and coded as “more information needed” and were not able to be fully specified from available narrative data. A dual-coding system utilizing a consensus method for mitigation of discrepancies was used to improve methodological rigor, but also required more time and resources. Ultimately machine learning algorithmic approaches set within Learning Health System structures could be considered to process narrative data to enable feedback capability to simultaneously inform improvement and research activities targeting PE at scale. Finally, it should be noted that although the authors describe an approach for informing improvement using PD approaches and narrative data, their assessment is not an evaluation of improvement interventions or related outcomes. This would be worthy of subsequent study.

Conclusion

In the developing future, the worlds of care experience and QI in health care will intertwine. The areas of PE, care experience, and human experience, which overlap considerably with patient-centeredness and coproduction, will increasingly need to demonstrate value in driving health care quality outcomes. Similarly, the field of health care QI is increasingly recognizing that its efforts must evolve to equitably and inclusively be more patient centric. The application of approaches like those the authors have described here, which leverage patient-centered experience information to inform intelligent improvement actions, are likely early examples of efforts to inform “experience-based improvement” in health care. Additionally, by augmenting the current landscape of a predominantly deficiency-based improvement by adding PD approaches, the future of experience and improvement could become much richer and more balanced between the positive and negative aspects, providing a fuller picture focused on the shared benefit of patients, families, and workforce together. Finally, thinking forward, if approaches such as these were to be nested within active learning health system structures, they could contribute to informing and motivating greater coproduction capability within them, and drive related improvement, implementation and research activities with far greater scale, pace, and impact than we can currently realize in our current state of the art.

Acknowledgments

The authors would like to acknowledge and thank the patients and families who contributed compliments that were included in this study.

Author Contributions: Kolu S Baysah Clark, DNP, MS, MPH, APRN, contributed to every aspect of the research, including data sorting, data coding/analysis, and manuscript writing/editing. Nivethitha Manohar, MD, MPH, was involved in formulating the codebook, data coding/analysis, and assisting with manuscript writing/editing. Jabeen Ahmad, PhD, MPH, helped with the initial codebook formulation, early coding stages, and manuscript editing. Brant J Oliver, PhD, MS, MPH, FNP-BC, PMHNP-BC, provided expert guidance on all aspects of the project.

Conflict of Interest: None declared

Funding: None declared

Data-Sharing Statement: Data are available from Dartmouth Health upon request. Readers may contact Dr Brant J Oliver at brant.j.oliver@dartmouth.edu or Dr Jabeen Ahmed at Jabeen.Ahmad@hitchcock.org.
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