The Power of Positive Deviance

Rachel Salaman: Right, so what are the roots of this idea, where did it start?

Richard Pascale: Its origins occurred in Vietnam in the 90s when the two folks that sort of stumbled upon this idea, Jerry Sternin and Monique Sternin, and were invited by the government of Vietnam as the I think sixth and seventh Americans to gain visas to Vietnam after the war, to assist them in dealing with what was regarded as an intractable problem, namely that something like 65% or 75% of all rural children were malnourished and serious malnutrition is not just a cause of crying and chronic illness and sometimes death, but even when children survive it, usually their bodies and their minds are severely debilitated by this condition in childhood. The Vietnamese had tried to throw resources at this through donors that would come in and provide food, but as soon as those resources were no longer available, the children would revert to their malnourished status, so they were looking for something that was sustainable. And they had more complexity of the problem since there was quite a debate in Vietnam about whether to have any Americans in the country doing anything, and Jerry and Monique were told they only had six months to prove their value. So as they entered these pilot hamlets, the idea occurred to them that they could engage the mothers in first weighing their children and seeing how they were doing against their norms for their age and their sex, and based on whether there were any exceptions, that is poor families who had healthy children notwithstanding that they had no economic means to have a different outcome than others; that that might be something to pique the curiosity of the village to actually investigate what was happening. So they weighed the children in one of these traditional devices that you weigh rice or chickens with, they placed their names crudely scratched up on a piece of black wood with soft rock on a board, they asked the village to identify the economic status of these various children and the categories were poor, very poor and very, very poor, and then as they looked down the list they circled the exceptions, that is the children of variously poor families who somehow were well nourished. From this they engaged the villagers in going out and actually visiting these families and figuring out what they were doing, and as it turned out they were providing freely available, it sounds exotic, shrimps, crabs and greens and this would be the equivalent of a westerner feeding their child worms, earthworms and snails and weeds. And so these families were providing these extra nutrients to their children and also feeding them more often and over the course of the day using siblings to do this. And the result was their kids were doing fine and as a consequence the villagers themselves learned from people just like them living in the same community with the same ecology what could be done that was indeed sustainable. That was the origin of the idea.

Rachel Salaman: And, what is gained do you think by identifying this as a phenomenon, positive deviance?

Richard Pascale: Well I think what's gained, again given the precondition that as intractable problems are ones where you've tried everything and nothing works and then it's accepted as just the way it is, what's gained is the upending discovery that in those seemingly impossible situations whether they occur, in this case, in Vietnam, or in hospitals where a very high percentage of people contract, in the case of the United States it's about 20,000 a year die of something called MRSA hospital infection or in between neonatal mortality and Afghanistan the trafficking of girls and Indonesia where the dropout rates and Argentina in these various settings where people are resigned to a condition that's just the way it is, the idea that you look for the exceptions and then engage the community in discovering what those exceptions are doing is a pretty big breakthrough. Again I use the word upending because I think that's its effect, we call it the somersault effect where something that you've thought about as incurable is suddenly something where you realize that there are a few people who somehow manage to do something differently.

Rachel Salaman: You mentioned a few different types of settings there. Are there any kinds of environments where a positive deviance approach won't work, or anywhere it will particularly work well?

Richard Pascale: I think a tougher road to travel is more traditional command and control settings like corporations; if you think about a continuum with loosely coupled organizations like communities on one end and most tightly coupled organizations which are very rigorously managed, like companies on the other end with maybe government agencies closer to the corporate end and NGOs closer to the looser community end, I think it's harder as you get more people in power who are highly reliant on top down directives. We've actually had success in companies, almost despite themselves we had an extraordinary result with the sales force of Merck in Mexico where a set of conditions caused the country manager of Mexico to be desperate enough and under enough pressure from corporate to do something and as a last resort turned to this idea of positive deviance and got his sales force engaged in discovering what the exceptions were actually doing to sell a great deal of a drug that was quite important, but a drug in which Mexico ranked the very bottom of the 42 countries in Latin America. And the result of course, as you know as is the case when a community discovers someone just like me is doing better, is that the likelihood of them actually adopting that practice, as opposed to resisting it, is not invented here, it's much higher. So the good news is it works brilliantly in Mexico and actually it's worked brilliantly at Goldman Sachs. But in the case of Merck Mexico, the sad thing was that even though there were extraordinary results in one location, there was absolutely no scaling of that idea beyond the boundaries of Mexico to other countries owing to the strong tradition of top down command control and the hesitance to really look to the people themselves for the solutions.

Rachel Salaman: Can you tell us a little bit more about your experience with Merck, I know that's one of the case studies in the book, how did they go about the whole process of starting the positive deviance approach?

Richard Pascale: Well you begin with a sponsor who in this case was the gentleman who was in charge of the pharmaceutical business in Mexico, and the sponsor needs to really buy into the idea that the community actually has to be first presented with the idea of positive deviance and be give the invitation to opt in to giving it a try or not, and that's like in any real invitation, it's not coercive, it's really an open offer and in the case of Mexico about half of the managers who were initially exposed to this agreed to give it a shot and the other half it made no sense. The second part is after exposing them to the concept and telling stories about things like Vietnam, you engage the community in identifying the problem that they, not the authority figure here, want to solve.

Now often it's pretty obvious to everybody what the problem is, so in Vietnam the community would clearly have agreed that malnutrition of children would be very high on the list because they cry all the time, they get sick, they die, it was a really pressing, poignant, tragic issue in rural Vietnam, so it wasn't a big stretch to go to the Ministry of Health that thought there was a problem to a community in the hamlets themselves who believed this as well. And in Mexico the issue was a particular drug for osteoporosis called Fosamax which is sort of a wonder drug for addressing that condition, which had sold well elsewhere in Latin America but was doing terribly for some reason in Mexico, and everyone in the sales force was aware that that was the one place where they had got a lot of undesired corporate attention for poor performance, and so while the sponsor thought that was the problem, he did leave it to the community to decide and they happily decided that was the problem as well, but that is something the community has to have their fingerprints on.

Finally you get the community to go out and engage lots and lots of folks in the question of what are the common approaches we're taking to selling Fosamax, and as they do that they are listening for the occasional sounds of what might be an exception to the normal practices. And then subsequently they go back and really drill in on those possible exceptions to determine if they're actually doing things that are available to everyone, and sometimes there are things we discover that are what we call true but useless. So in Vietnam if you had a rich uncle living in a neighboring village that was sending your kid food, you might have a healthy child and still be very poor but that doesn't mean anybody in the village has access to that uncle. So you've got to find the things that are freely available to everyone, not just one unique circumstance that gives some particular person an advantage that's not scalable. So that's the process.

Rachel Salaman: But then there's the important process I suppose of taking the learning from that and disseminating it.

Richard Pascale: Yes actually that's a great question and in effect the big discovery in the work was in Vietnam when it was discovered in the first pilots that these shrimps, crabs and greens were the so called answer and more frequent feedings, that it would seem just like the silver bullet, let's just tell everybody to do that and one of the older women in the hamlet said there is a Vietnamese saying to the effect that a thousand things is worth one seeing and a thousand seeings is worth one doing. And the point of that of course was if you are actually thinking that you're much more likely to adopt something when you actually practice it, so the village not the outsiders said the way to get this done is to invite people to, we call it a workshop but basically to a villager's home, Save the Children who were the sponsor of this offered a bribe of providing egg or tofu to the children that came, and these two week long workshops required that the parents show up with a handful of greens and a handful of shrimps and crabs, and get their children to eat those things while they were also getting the tofu or the egg.

The result of this over a two week period is people got in the habit of collecting those things and of course you weigh the children going in and weigh them coming out and see how they're progressing. And after a two week workshop and then two weeks of people doing this on their own, there was a second weighing and about three quarters of the kids that had gone through this had graduated by virtue of being nursed again, and more importantly their parents and the whole family were now in the habit of doing these things. We sustained these workshops for the people who hadn't graduated a second time to get almost everybody in the village into a well-nourished status, that is the children in the village. But the important discovery, in answer to your question, is that the community now has to discover what is occurring that is giving some people with the same resources the ability to cope with a problem seen as intractable, but they also have a major role to play in how those ideas are disseminated.

Rachel Salaman: So in a corporate setting like Merck, how does that happen?

Richard Pascale: In a corporate setting the entire sales force in Mexico, about 220 folks were invited to Mexico City on a couple of occasions to look at the data, to identify the common practices, to start to get interested in some of the exceptional results that were occurring in certain places to then be involved in, discovering what those folks were doing and then, in this case, just simply meeting with fellow salespeople from around the region in small groups discussing what they would want to try differently, given that it was working in several other people's territories quite effectively and it was simply by syndicating and socializing those ideas that they were taken on board, they stuck and the good thing about Mexico was that in that short period they went from being the very bottom to the very top of Latin America and have remained in the top decile ever since.

Rachel Salaman: You said that the success wasn't sustained as well in Merck as it was in your Goldman Sachs example, is that right?

Richard Pascale: Well it was sustained in Mexico, the problem is it wasn't scaled, so what occurred in Mexico remained in Mexico, but in the other 42 countries of Latin America where there are clearly situations where some particular product is not performing well and where arguably there are, I am sure, positive deviance out there doing things that the balance of the sales force might learn from, the bottom up approach was not adopted. Rather the management just felt it was more efficient, in quotes, to just try to figure it out themselves and identify the best practices and then tell people what to do. So it wasn't that it was not sustained where it had been discovered, but rather that it wasn't scaled beyond the place that had really given it a try.

Rachel Salaman: You mentioned best practice there and in your book you point out the difference between positive deviance and best practice, and why it's important to acknowledge that difference. Perhaps you could talk a bit about that now.

Richard Pascale: Yes, the concept obviously of what a positive deviant is doing that is successful could be described as a best practice, but it isn't just the terminology, it's the whole overlay of process that surrounds it in the way in which best practices are imposed. So in a traditional environment, when something good is working in one place and is seen to be the best way to do it, it's usually picked up, codified by consultants, experts or sometimes senior management, and imposed as the way to do it on everyone else, with the usual exceptionalism and not invented here, that's the defense response of the other sub-cultures around an organization that resist it, and that's what really had happened in Mexico when the rest of the 42 countries resisted this oddball idea that was happening in Mexico.

Now when you engage the community itself in discovering, in first opting into being curious about something that's been accepted as just the way it is, and secondly to going out and figuring out what the common practices are and then whether there are exceptions that are somehow doing better, that discovery process creates this equilibrium within the social system and it also kind of provokes folks to be starting to think anew about something they've just been inured to. And that's a very different way of going about discovering and then internalizing the solution than a top down, here's the way it is and this is the way you've got to do it approach which typifies best practices in most settings.

Rachel Salaman: The other corporate example in your book is about the investment bank Goldman Sachs as you mentioned, could you tell us how they used a positive deviance approach?

Richard Pascale: Yes, at Goldman in the private wealth management group there had been a long tradition of New York headquarters trying to instruct its 330 private wealth advisors around the country to do things in a certain way, and these are by the way extremely independent very well educated, very gifted characters who build a clientele of high net worth people, and who by virtue of their advice on the preservation of wealth and the management of wealth were these individuals and families have a really strong franchise and a very strong power base with their clients. Indeed when these individuals leave they often take their clients with them, so it was an ironic situation that New York was trying to impose solutions on a sales force, if you want to call them that, of advisors who were really about as independent as you could possibly get from headquarters in that they had effectively their own franchise with their clientele. And after this years and years of this not working very well, they stumbled on the idea of actually seeing if they could interest the advisors in whether they might learn something from others elsewhere in the country who were having exceptional results with certain products or certain ways of identifying new prospects or closing sales and so forth, and instead of it coming from New York, they just got lots of these folks quite actively visiting others in other regions, identifying in effect the positive deviance that were doing exceptional things and found very clever ways to manage their teams or gain access to the marketplace, and then by virtue of again this whole community of 330 people getting very active in the process of discovery and going out and visiting and syndicating these ideas, the spread of the virus of good approaches was rapidly increased and continues to this day.

Rachel Salaman: So what conclusions did you draw when you compared those two companies' experiences?

Richard Pascale: I think the difference was that the folks at Goldman Sachs in private wealth had the wisdom to realize that command and control of this particular sales force or advisory force was really an illusion, owning to the reasons I described, and I think the stickiness of the approach and its continuation since is really the ongoing wisdom of senior management, that the way learning takes place within the community is by the advisors being basically motivated to learn from one another. That isn't as classic a situation as what you have at Merck at more traditional organizations where the sales force is on a salary and a bonus and is pretty much under the thumb of management, and so the temptation in those more traditional companies to default to the top down, this is the answer now go do it, that consultants are experts or senior management discover, it's just hard to resist. I always call positive deviance the remedy of a last resort, it's only when people are absolutely desperate, particularly in more traditional organizations, that they give it a try, even though it would probably work in many situations short of total desperation, but it's only then that they tend to turn to it.

Rachel Salaman: In your book you draw together what are the essential ingredients of a positive deviance approach, and you've mentioned a few of them just by talking us through those examples. I wonder if you could summarize now what you consider to be those essential ingredients.

Richard Pascale: Yes, first you need a community that is tackling or is inflicted with some kind of a problem that is regarded as intractable and has reached the stage of resignation and kind of just accepting that this unfortunate condition is just the way it is. You need a sponsor who says let's try something different and a sponsor with enough convening authority and legitimacy who can bring folks together to be introduced to this concept, which takes an hour or two to describe and tell a few stories about Vietnam and so forth. At which point this community of people, often usually in the order of 100 or so, are given the honest option of whether they want to accept the invitation to sign up to see if they can use this tool in some way or not. And that invitation has to be an honest one where you're not coerced into doing it but you only do it if you say what the heck, why not, it could be interesting.

So you end up with some subset of that community as step three saying alright, let's go and see what we can learn and they begin by going out and talking to lots of people in focus groups to determine what the common practices are that seem not to be effective in dealing with the condition with an eye towards listening for the occasional exception that might be mentioned under someone's breath. It's very important to do two things in that third stage, one is to get beyond the usual suspects, because there's often a natural group of people you talk to, and it's increasingly apparent in this work that the outliers that you wouldn't necessarily include as the central players, like the orderlies and cleaning people and bus drivers and physical therapy operators in a hospital, turned out to be hugely important in curtailing the spread of this disease, who were not normally part of the doctor and nurse crowd that you would normally turn to.

The second thing is you talk to far more people than you need to, to get the information, clearly there is an 80/20 rule where you've talked to enough folks in a focus group environment where you start to say I've heard this again and again and again, and I'm not learning anything new. But that's not the point, the point is you continue doing this because the more people you talk to, the more people you get engaged in the question. So that leads to step four where you start to home in on the potential positive deviance, then learn what their practices are. And then finally you engage the folks that are driving this process who are usually now communicating a lot of excitement and interest with many others who do what they're talking about. And how in the world are you going to get others now that you've learned a few things to start engaging in these practices themselves and each community has their own unique solutions to that, but needless to say they're not standing up in an auditorium with PowerPoint's there, usually finding ingenious ways to help people do role plays and engage in somehow zapping away into a new way of thinking, and doing things that enable the community to actually practice the new behaviors so that they start to become part of their new reality.

Rachel Salaman: Is it possible to estimate what resources a positive deviance process like you've just described will absorb in terms of time and money?

Richard Pascale: It's underwhelmingly cheap, in fact an ironic and somewhat sad story is when we tackled the very high dropout rates in one in the northernmost province of Argentina, we were extraordinarily successful in getting teachers that were completely resigned to having 50 percent or 60 percent of their rural kids dropping out by the sixth grade, to discover why some schools had 100 percent retention and learning from those schools to alter what they were doing. We were surprised when the World Bank that had sponsored this decided not to take the idea further in Argentina and we enquired why and the answer came back, there are two reasons.

First of all at the World Bank our productivity is measured by the amount of money we can get invested in work in a given quarter or a year, and this $20,000 project in Argentina is so trivial in terms of really moving money and it takes this much money for me to manage this project as it would any others, so I'd rather do a $3m or $4m building project instead of a $20,000 project that actually gets kids to stay in the building. The second reason in Argentina was that that large flow of money into communities gives lots of transaction points for the local officials to gain personal advantage, so there was absolutely zero interest among the hierarchy within the Ministry of Education to pursue this because the $20,000 project wouldn't give the chance to rake off a little money at the top and was not interesting to the folks that were looking for automobiles and ways to employ their relatives.

So it's a very inexpensive process in economic terms, it takes time, albeit it's one of these ironies where you go slow to go fast, so at the end of the day I think the guy at Merck in Mexico would say my gosh we spent years and years messing around with this thing with no result, and in six months we had an incredible result, so while it seems time consuming to get all these people involved and their participation seems unusual for top down organizations, it achieves a lot. I think the hospitals were probably the most severe tests where time in hospitals, where there are huge productivity pressures, is confined to maybe 45 or 60 minutes and they figured out ways to run this process in these very short daily meetings in which the ideas of how they might proceed to curtail MRSA were floated and discovered and syndicated and socialized, and that particular set of ideas has spread around the United States in both the veterans in administration and to other hospitals as well. So it's time consuming, on the face of it the bottom line is it's not the economic cost in dollars or pounds or yen, it's the cost in time that appears to be the biggest concern albeit one that seems to be much less consequential when you realize what's been gained.

Rachel Salaman: So in your view, how important is this idea for organizations who are trying to change for the better or solve that seemingly unsolvable problem?

Richard Pascale: It is a method that I think deserves its place among important ways that we have in our arrows we have in our quiver to deal with difficult things. It's obviously not the only solution but it's a very good one and as we've said repeatedly, particularly when you've tried everything else, and it usually works.

Rachel Salaman: Richard Pascale, thanks very much for joining us.

Richard Pascale: Glad to be here.

Rachel Salaman: The name of Richard's book again is "The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems," and it's co-written with Jerry and Monique Sternin who carried out that groundbreaking study in Vietnam that Richard talked about. There's more about Richard's book at www.thepowerofpositivedeviance.com and more about the idea, how it works and what it can achieve at www.positivedeviance.org.

I will be back in a few weeks with another expert interview, until then goodbye.