 And what a thrill it is to introduce our presenter today, Dr. Arvin Single is the Samuel Shirley and Edna Holt Marston Endowed Professor of Communications at the University of Texas in El Paso. Yeah, that's a mouthful. Samuel Shirley, Edna Holt Marston. But you see, I just called them Grandmama and Granddaddy. My mother and father are both graduates of UTEP. Back then it was called the Texas College of Mines. Mama majored in journalism and as a senior was editor of the school newspaper, The Prospector. Daddy went on to medical school to become a pathologist. My mom endowed this professorship in 2003 to honor her parents, Edna and Shirley Marston, for their unflagging belief that hard work and education would be keys to opportunity. It's a belief that runs strongly in my family even today. And it was a red letter day indeed when Dr. Single accepted the Marston professorship at UTEP but not only is he the endowed professor of communications but he is the director of the social justice initiative at UTEP and the William Jefferson Clinton Distinguished Fellow at the Clinton School of Public Service in Little Rock, Arkansas and the co-author or editor of at least a dozen books and numerous research papers. He is a communicator par excellence but he's a communicator with a heart with a heart for health, education, the alleviation of poverty and sustainable development across the globe. Positive deviance. Have you ever heard that phrase before? I know I hadn't but I have a feeling that it will flip the way you approach your work and your life. So with an open mind, prepare to enjoy a fresh way to look at complex problems but I guess that's exactly what Wesley nurses do every single day. Dr. Single. Good morning. I cannot recall a more joyous and a more sort of poignant from my perspective introduction as the one that Shirley Watkins just provided. Thank you. So I bear the name of Swatkins grandparents with deep honor. I am deeply honored that her mother would as a way of respect to her parents endowed a named professorship and I'm very pleased that the University of Texas would feel that at least on paper I was worthy of that title. You be the judge. My paths crossed with the Methodist healthcare ministries Shirley and with several other colleagues including Catalina, who is here, Catalina, where are you, you just entered. Here in San Antonio a few months ago in April when some of us were here at the University of Texas, San Antonio Health Sciences Center and they had put up a special one day conference on positive deviance. It was the first time that to my knowledge a university and I'm so happy a university in the state of Texas in your beautiful city had put up a conference on the topic of positive deviance and all this to say that this area of practice and work is relatively new. It's been around for some years, some decades, but its recognition, its manifestation in the realm of healthcare or in the realm of social services or social justice in the United States is fairly new. So I'm delighted to be back within a few months and we'll see through the participation of all those who are represented here, the Wesley Nurse Program, other colleagues, how it'll have legs in the important work that you do. So welcome. How many of you had, just a sort of a quick show of hands, how many of you had heard the term positive deviance prior to Catalina sending out the announcement that we're going to have somebody who's going to talk about positive deviance? Curious, raise your hand high up if you did. Okay. All right. Okay. This means that Ms. Watkins, I can get away with anything. Terrific. You know a little about asset mapping. You probably know a lot about asset mapping. I know you have done work through some things that Catalina sent me about ABCD, yes, and asset-based community development, and more importantly the work that you're doing in your community lends itself in my opinion, but you are to be the judge, to a way of thinking, which we know as the positive deviance approach, that may, perhaps, you will see be useful in the outcomes that you so desire. Okay. Just wanted to recognize all of you, but also in addition to all of you two colleagues who have joined us. So may I request Dr. Lucia Dura to just rise for a minute and be acknowledged. Dr. Dura is a professor in the Department of English at the University of Texas El Paso. She was here for the April meeting. She has a very strong connection with San Antonio. She went to San Mary's for her undergraduate education. She has a brother who lives in San Antonio, who's a lawyer, and so she doesn't miss an opportunity to come back. More importantly for me, she's been a colleague of mine for the last eight years, doing collaborative work in the area of positive deviance, even better than any of us can do individually. I also want to acknowledge Eleni, if you want to just rise. Eleni is a doctoral student wrapping up, so soon she'll have the title of doctor from Texas A&M College Station. My Pat's crossed with her four years ago for the first time when she was a first-year doctoral student. She heard about positive deviance, got a little engaged and interested in the topic, and then I was at Texas A&M as a keynote facilitator for the whole day last week. 870 students from 16 locations. The topic was positive deviance, and I had an opportunity to reconnect with Eleni, and when she heard that it was going to be here, she decided to drive in from Austin, not College Station, she lives in Austin. So thank you, Eleni, for being here as well. All right, let's see. I think I have a clicker somewhere in my pocket, perhaps. Yes, and it even works. Terrific. So together, we will have a journey. And I think I am an important part of your program today, so it's going to be a journey from now till about 3.30, I'm told, when we need to wrap up. And so these are some of the milestones, you can say, that we will get to. It's sort of a path of the journey that we'll take. Oh my, I don't even need to look back. I can look there. So if you're a professor of communication, you somehow like to look back, but here I can, and that's good because positive deviance is about a flipped way of looking. So now I can just be me. So we'll do a little bit of state setting. Maybe we've already done some of it. We'll talk about why the flip, the mental flip. We're going to talk about mental somersault. So today is a playful day, you know, you're going to play with ideas. You're going to play with stories. And then we'll get into the nitty gritty of what the positive deviance approach is. And we'll do it through, again, a case study of some work that was done in a community in Vietnam, even though it may seem very far away. But the principles that this case study exemplifies, I hope you will find, of some interest. And then we'll serve lunch, I think, and after that maybe we'll get into some PD servings, which are nothing but some examples of positive deviance as they've been applied in several communities, including, I'll give you some examples from our community of El Paso, Texas. And then all through the day, I create some moments for you to be thinking about, and not just thinking about, but sharing in certain configurations, perhaps in small groups. And you will also be rising a few times and talking to people, and I'll create the conditions for that. You will be thinking about how this approach may apply to the work that you do. So there'll be numerous opportunities for you to think about PD applications, as we call it, discussing how this approach can be useful to your work. And that's not going to happen at the end, even though we've, that's the destination, that'll happen as we go on. How does that agenda sound to you? Sounds okay? Yes, all right. Good. So let's set the stage, and when we say set the stage, we are talking about understanding the philosophical basis of positive deviance. And it's always good to begin with gratitude. So these are my teachers of positive deviance. Somebody that I, as you can see, this picture was taken some time ago. I had a lot more hair, and this was taken in 2004 at my home when I lived in Athens, Ohio. And these are Jerry and Monique Sternen. They were the founders of the positive deviance approach. And my world flipped upside down when I met them at a small, smaller meeting. And so for the last 11 years, I consider them as sort of my gurus, so gratitude to them. And I don't need to say this, this is a, you know, a faith-based initiative. Everything that I've seen and heard and read about the Wesley program, it's about the heart, it's about the spirit. It's clearly about the mind and the body as well. So the invitation to you is just be here fully to the extent that you can. I suggest you be unencumbered of technology, whatever that may mean. You may need at most a simple notebook, maybe a pen. But it's perfectly okay if you even don't have that. Because I'm gonna go ahead and send Catalina the entire slide deck. And so, you know, it's not like, oh, I missed the fourth bullet point on the 11th slide. Don't need to worry about that. And then just have faith and go with the flow. Because there may be some moments of discomfort, especially with our cherished ways of looking at things. It's like, oh no, this doesn't sound right. Or no, this is not the way it is. So if you encounter a moment such as that, just have faith. Even if it's temporarily. And go with the flow. Embrace it, at least for that moment. And we'll see, you probably, if you resist it, that's fine. You'll end up at a certain place. If you go with the flow, you'll perhaps end up at a different place. And so you make that choice. But that's the invitation to you. Go with the flow. Have faith. So our conversation frame is, again, positive deviance is one approach among many. There are plenty of approaches, A, B, C, D, acid-based community. There's that approach. There's other kinds of approaches with respect to social change. Positive deviance is one way. It's not the only way. It's one way. What positive deviance, I think, does uniquely is it expands the solution space. So if you're trying to solve a complex problem, as we are in the business of problem solving, no. We are trying to solve health problems or access problems or, you know, getting care to those who need it the most. We're trying people to get tested for diabetes. We are trying people to lose weight. We are trying, you know, the whole host of things that we are trying to solve. And what positive deviance can do fairly uniquely, in my opinion, is really expand the solution space. And you'll see why that's the case. And not only does it expand the solution space, it gives us new tools, new ways of coming at the same problem that we may have been trying to solve for a long period of time and, you know, hitting our heads against the wall and maybe not making too much progress. So it allows us to look at new ways of addressing the same problem. Now, this really is the first slide, the one that you see now of this presentation, of state setting. And what does it have on it? It's a blank slide. And that's the point. The Zen Buddhist philosophers say that a beginner's mind is an open mind. It's full of possibilities. The expert's mind, my mind, is one that is a closed mind. It doesn't have too many possibilities. Or maybe it just has one, the expert possibility. So the invitation to you or the challenge to you is to see if we can try to reset ourselves, even if it's temporarily to zero. Not possible, no, it's like just completely wipe out if you can. And the positive deviance approach invites you to do that. Blank slide, full of possibilities. So we'll be using a device, I'm going to put the microphone down. The Tingsha bells, Buddhist prayer bells, we will be ringing them a few times. And the Buddhist use the Tingsha bells not to get attention, which oftentimes bells are used for, but to drop attention. So much like beginner's mind, open mind. When you hear the Tingsha bells, the invitation to you is to drop attention from what you're doing presently, so that we can pick up your attention to move on to the next stage. So beginner's mind, open mind, full of possibilities. And this is the second important part of stage setting, setting the philosophical basis of the positive deviance approach. So anybody in this room who sees somebody whom they recognize, even though it's upside down, yes, Abraham Lincoln. And it's, we, you know, we should really give an applause for that because it's just little pixels, black and white on a screen turned upside down. But yet there is something in us which is phenomenal at recognizing patterns. So did all of you get the sense that this was turned upside down? You didn't have to really think too much about it, no? And what is it about us that does that? We are very good at recognizing patterns. And not only are we good at recognizing patterns, but in this upside down image, which you are able to even say, ah, that's Abraham Lincoln. And that is a phenomenal quality of the mind, you know, that it can make sense of patterns. So we are trying actually in some ways to invite you to go beyond the patterns that you see. And there's a reason why Abraham Lincoln is in this image because I want to begin with the Abraham Lincoln story with your permission. Yes? Your permission to tell a Lincoln story? All right. So the story is during the Civil War. And you know that the weight of the decisions that a presidency was responsible for weighed very heavily on Lincoln's shoulders. He was commander in chief. He was president. He was commanding the Union Army. And a good chunk, a good percent of the adult male population of what was the United States, whether it was the north or the south, was a casualty of the war. And you could not not be affected, even if you were not in a battlefield as a family member. And this was not for a day or two, but for many years as we know. So we know about his famous Gettysburg address, no? 272 words spoken where he's talking about those who've given the ultimate sacrifice so that a nation could live. And he also used to spend his time. And I'm very happy if somebody wants to come and join me closer here. We'll be moving around in a bit, but please. Great. Thank you. So Lincoln would spend a lot of time in battlefields and in hospitals. And so the story goes that he's in a hospital and he comes into a ward and he says, the sons, they were mostly sons, I'm going to come around and I'm going to shake your hand. And as I come and shake your hand, I'd like you to say your name out loud for me. And so he goes out and shaking hands and he's shaking hands and he comes to a bed. There's a soldier that's lying. He hears the footsteps of the president. He gets up. He clicks his heels. He salutes the commander in chief. He says, I'm petty sergeant, gives his name and extends his hand only to realize that his hand needed to be like this. Lincoln was a tall man. And so as he extends his hand and puts it out there, he says, oh, Mr. President, you're tall. How tall are you? And Lincoln, without batting an eyelid, says, son, like you, tall enough that my feet reach the sun, like you, tall enough that my feet reach the ground. So we tend to measure height in a certain way. Yeah? You don't even think about it. So may I ask how tall you are? Sixty-six inches. Yeah? You can say five feet, six inches, 66 inches. May I ask how tall you are, Jennifer? Five feet, four inches. Yeah? And we all know what that means. Sixty-six inches, five feet, four inches. If I were to ask this question in maybe a different country where they use a different system, the answer that you would get would be maybe in centimeters. I've never heard it in millimeters, but people may even say meters. No, they'd say, like, I'm 1.8 meters. And yet our mind processes this. Sixty-six inches, five feet, four, 1.8 meters, 174 centimeters. We process this very, and you get a sense of how high a person is. And that's terrific. That's great. That's how experts. Use language. Use a certain mental model to make sense of what the world is like. And that is beautiful, no? There's a shared common understanding. But then why are we sharing with you this Lincoln story? Sharing this Lincoln story with you is because Lincoln, who is very interested, by the way, in Euclidean geometry, he was an autodidact. He was self-taught. He had very little formal education. He was a country lawyer who studied law on his own and passed exams. So he was very interested in the notion of proof, evidence, and Euclid geometry. The geometry of straight lines really interested him because Euclidean geometry is all about theorems and proofs. What constitutes evidence? Yeah, you get the idea? Evidence. If you're a lawyer, are you interested in evidence? Can you prove? So Lincoln's notion of how he measured height were very strongly influenced by the notion of proof, by the notion of, I mean, there was a statement in Euclidean geometry, things that are equal to the same thing are equal to each other. It's a very important axiom in Euclidean geometry. And so when he answers the question, son, like you, tall enough that my feet reach the ground, it comes from a certain deep sensibility, which is not looking at height as, oh, tall or how short you are, but it comes from the sensibility of the common ground that we stand on. And then again, there's nothing right or wrong about that way of looking. It's a different way of looking. It's a flipped way of looking. And that flipped way of looking gets you to a different place, the place of a common ground. So even though you're president, commander in chief, you're talking to a petty soldier. And the petty soldiers asked you, Mr. President, how tall are you? And his response is, son, like you, tall enough that my feet reach the ground. Do you see what I'm saying? Get the idea? It's a flipped way of thinking. Takes you to a different place. Takes you to a different place relationally with the one that you are. And especially with expertise, if you're trying to serve this notion of the common ground thinking, which is deeply inherent, I know in each one of you, it needs to manifest. And it can manifest behaviorally, but clearly it can manifest in the way we think. So that's part of the state setting. So now maybe you want to see it the right way. And that's the whole point that you can see things in different ways. I'm going to try to see if I can play this video. No, I'll go to this image itself. So you see me. I had even more hair at that time. And this is a picture of my younger son, who's now a sophomore. I'll announce that to you at UT Austin. I'll see him tomorrow night, tomorrow evening. And I want to share, as part of the state setting, a story about his early days on what we call this planet earth. So he was born 19 years ago. And he's a rather special child, because when he was born, he was born at about 28 and 1 half weeks. And you know what that means. He was 648 grams. That was his birth weight. And his medical chart was very impressive. So I'm going to say a few, because there are people who know that lexicon. So he was male, Asian, 648 grams, SGA. And that means small for gestational age. He had BPD, bronchopulmonary dysplasia. His lungs were all messed up. That's what it means, because he was on a ventilator the first six weeks of his life. He was at a high risk for ROP for many months. ROP, retinopathy of prematurity, gone blind. He had GERD, that you know, gastro-usefagal reflux disease. For the first two years of his life, he was fed through an NJ tube, NG, NJ, nasal jujunum tube, which meant that the tube went past his stomach, because he had GERD, which means that there were 39 times that his tube came out in the two and a half years that he had the NJ tube. Because all you need to do is his hand just had to go like this, and the tube moves a little. And then it means that you have to be at children's hospital where under fluoroscopy, you've got to wiggle that tube past his stomach into his, you know, having how that goes, and so on. So as I said, he's doing great now. And his sophomore at UT, he's been through a bit. And through him, we learned a lot about health and healing, and thanks to all the wonderful nurses and doctors and medical professionals, many of whom are represented here. He's doing great, so we're very thankful. So this picture was taken August of 1998. So he's about two and a half years old. And he had had his, this major surgery, fundoplication, you know, what that is, where you basically fix his GERD. And he was fat enough as his doctor, or he was big enough. He was thriving enough that the surgery, now being reminded who I am. So there were thousands of people who took care of him, thousands. My wife and I once made a little calculation at the back of the end. You know, I mean, he spent so many days at the NICU and at the PQ and, you know, pulmonology and surgery and gastroenterology. You get the idea, you know, how many nurses, I mean, we could name a few hundred nurses who took care of him. And there are two incidents that I want to describe to you, which are still, even though it's been 19 years, are very indelibly sort of etched in our memory. One is about a way a certain neonatologist did his rounds. So he was, you know, teaching hospital, children's, Columbus, Ohio, many neonatologists. And they do the rounds the way they do the rounds, no? So a NICU may have 35, 40 beds. You have a team of doctors. Every morning they come in. They're wearing their white gowns. You know, their doctors and, you know, their interns and their residents and their fellows. And, you know, there's some nursing staff and they come. And as a parent, as a caregiver, we didn't miss the rounds. We were always there. And typically the way the rounds go, as you know, as they come, they, what do they do? They circle around. Yeah, it looks like a crowd. You want to say they crowd around, but they circle around. No, I mean, as Lincoln would say, circles are better than crowds, no? They circle around. And it takes about a couple of minutes for the chart to be read. And the chart is, you know, as I described it to you, Malaysian, 28 and a half weeks, SGA, BPD, GERD, at risk for ROP, blah, blah. You get the idea. That's the chart. And then very quickly some decisions are made, you know. And then what do they do? They move to the next. Where do you think the parents or the caregivers are in this? In the circle? They're out, no? And nothing wrong with it. I mean, you know, work needs to get done and so they're out. Now, do parents and caregivers, especially if you're a professor and my wife's an educator too, do they have questions? All parents have questions. And the question, believe it or not, is always the same. And what's the question when your child is, let's say, if he or she is at the NICU, they're sick. They're not there for fun. This is, so what's the question? How's my child doing? It's asked in different ways, but the sentiment, if you hear it, is the same. No matter whether you're describing it in centimeters or inches or feet or meters or millimeters, the question is pretty much the same. I heard it for many months. How's the child doing? And if you're lucky, you'll get, if they're stined, they'll give you an answer. If they hear you, you'll get an answer. You know, this was normative practice. And right now we are getting into setting the stage for what positive deviance is, okay? Nothing wrong with it? Yeah, I mean it's, they did, all the neonatologists were phenomenal neonatologists. The doctors who did rounds were phenomenal. They, you know, because our son did well. But when a particular doctor, Dr. Carter, I believe was his name, came, things were just a little different. So I want you to focus on the little differences. Dr. Carter and his team had a secret sauce. That secret sauce actually was made up of many small little ingredients, small little ingredients. The first thing that you saw was the same, no? Doctors, white coats coming around and in a circle around the bed, but they were carrying something in their hand. That's the first difference. Looked like an umbrella to me the first time I saw it. It was a stool from Walmart, you know, $4.99 is what it must have cost. I checked its price later. And what do you do with the stool? You open it. That's the secret sauce. You have a stool, you open it because you could just be carrying your stool, not open it, no? Some people do that. Oftentimes we carry a lot of things and we don't, you know, they open it and what do they do? Three things have happened. They've got a stool, they open it and in that moment they sit down. And what do you think happens when caregivers, doctors who are doing rounds with nurses and others sit down? What does that do? Absolutely, exactly all of the things that you've said. Time slows down, they're at the same level. It just, it changes, the dynamic changes. And then the next little thing was the lead doctor, the neonatologist would say, Mr. and Mrs. Singhal, would you please pull up your chairs and join the circle? Me, Moa, what does that do? Makes you feel, makes you feel a part of it. And Lincoln says, son, tall enough, tall enough that my feet, my son, tall enough like you that my feet reach the ground. It's like, ah, me too, gives you that feeling, no? And then, as I said, normative practice was, chart is read, decisions are made and you move on and if you get lucky and if you wanna ask a question you can ask. Here the conversation began by the doctor asking, Mr. and Mrs. Singhal, you've observed your child for the past 24 hours since we visited and you have been engaged in their care. From your perspective, how do you believe your child is done? The first question comes to you. I can guarantee you, our son had phenomenal clinical outcomes, especially when the pulmonologist and the gastroenterologist could not agree on what was going wrong with him because we were invited into such conversations. And you know it, I see a few nods about the importance of that. Okay, what's the point? I'm describing to you a fairly mundane, routine kind of an activity that happens in a NICU in NICUs and PICUs and ICUs all over the place. What was happening with this one doctor were multiple little things, small little things which didn't cost very much, which took the same amount of time because it's not that they were spending hours and hours. Somehow the conversation always would come down. The act of bringing a stool, the act of opening it, the act of sitting down, the act of inviting a parent, the act by name and the act of how do you think? The six or seven small little things that have happened didn't happen by accident and they made a difference. So here's a little introduction. Are you ready to positive deviance? And hopefully by the end of the next minute when I ask you how many of you've heard and know about positive deviance, you'll all say, okay, you know, I know enough that I can be dangerous in a cocktail party or something, especially if you're with a new natologist. What other doctors were doing were normative behaviors, the norm, the usual behaviors. What happened in this case was non-normative, a deviant behavior. Deviant not in the sociological sense of bad, deviant in a statistical sense of being non-normative. Like standard deviation. So deviance in the form of deviation from the norm. You get the idea? So positive deviance or deviation, if you want to, it's called deviance, but you know, you get the idea. Is a way of understanding things that are not normatively done, but yet which make a positive difference, which result in a positive outcome. Get the idea? It's sort of the secret behavioral sauce. Secret behavioral sauce with multiple ingredients. Not only is it a secret sauce, but it has multiple teeny tiny ingredients which to most people are invisible because Dr. Carter was the only doctor who had this practice. Get the idea? So far you're with me. Setting the stage, blank screen, flip thinking, Mr. Lincoln, experts, how they think, what becomes routine, how we ask for height, how we do our rounds. The importance of non-normativity, which is manifest in small little behaviors and how those can deliver outcomes that are very different from. You're with me so far? How's it going so far? Thank you, some nods. Should we speed it up a bit? No. Should we slow it down? You're okay? You're good, okay. So you want to see what my son looks like? This was taken on his 10th birthday. This was taken last year. And he's got his mother's good looks, as you can tell. Okay, one more story about his. He had multiple surgeries and I would contend, argue, profess, lay a claim that one of the most difficult times for parents is when your child is being wheeled into surgery. I don't understand that. And actually, what compounds this stress is what happens if you have a child and what happens during pre-op, especially with the anesthesiology team, who obviously all means well, they don't want your child to feel the hurt. But in order to not feel the hurt, they have to hold the baby down and, you know, puncture them, puncture their skin. That's the way I'll describe it. Well, find a spot where some needles could go in. And if your child is not asleep yet, they aren't because they're awake. The idea is to get some needles in them so that they could be put back to sleep. Then if there's no matter whether they're 648 grams or, you know, five kilos and 648 grams, they fight with all their body. Whatever little they have. And with all their lung capacity, even though our son's lung capacity at that time was like 20%, you know, they fight. And as a parent, you, it's very visceral, right? When they fight. And does the needle go in the first time? If yours doesn't, you know, there are no laser-guided missiles. And, you know, the child is moving. It takes a long time. You know, maybe at the seventh jab, maybe fifth, if you're good. Third, I mean, if you're like a genius, very skilled with fine motor skills. So, and that's normative practice. Our son went through numerous surgeries. We were part of numerous surgeries because, you know, you get, become friends with people and they're having surgery. You join them at pre-op and, you know, so the child, the anesthesiology team comes. They're very gracious. They explain what they're gonna do. They hold the baby and then some needles go in. Then, you know, all hell breaks loose. And it's very, it's a very difficult situation to put back together. And then it's time for them to be wheeled in. Except when this pediatric anesthesiologist came. You wanna know what was different? First thing she would do is she'd come, as we saw her, interact with others. She'd say, Mr. and Mrs. Smith, do I have permission to hold your baby? Could be Mr. and Mrs. Sengal, it could be, you know, whoever. Do I have permission to pick up and hold your baby? So, you know, your baby's got lots of tubes here and there and you can imagine. She's asked for permission if she can pick up and hold the baby, you know, like this. What does that do? It does something, you know? I don't know what it does. It does something. And as they are holding the baby and as this pediatric anesthesiologist, in her own words, administers what she calls verbal anesthesia. Something that you and I know as peekaboo. What's the purpose of anesthesia? What's the purpose of verbal anesthesia? What's the purpose of peekaboo? A little distraction, a little creator, you know, calming, smiling, fun, uh-huh. As she does verbal, as she administers verbal anesthesia. One of her staff in the moment has massaged the baby's, you know, thigh or leg or arm and found exactly the right spot. And the needle goes in, no twisting and turning and flailing bodies at the first. And by the time the child who's engaged in verbal anesthesia, peekaboo, realizes something's happened, you know, it's all strapped and, you know, secured. The needle's in place. And then there's Dr. Mama, you know, who's holding the child to comfort the child, you know? And the child may make a, you know, a face and then realizes that it's okay. Everything's fine. Is it normal? I didn't see that as being normative practice. So again, what was happening where a series, there was a secret sauce. The secret sauce was coming, asking for permission, lifting your child, holding the child close. Yeah, it's a series of things. Administering peekaboo, while that's happening, the child is distracted. Somebody finds the right spot. The needle goes in the first time. The needle is secured. The child is held, comforted. It's a very different outcome than what is normative. Get the idea? And then what does it do to parents when she asks for permission to walk your child to the operation theater? What's normative practice? It's not, nothing wrong with it. There's nothing wrong with wheeling a baby. The way it's always done. Maybe that's the only way it can be done. But she asks for permission. What does it do to you? It's more comforting. And what does it do to you if she sort of turns around as she's walking and looks at you and says, he'd be okay with me. You know, what does it do to you when somebody who's gonna put your child to sleep and hopefully bring them back up? Which all pediatric anesthesiologists who attended on our child did. They were great pediatric anesthesiologists, nothing. It's just that they did things the usual way, the normative way. And here was one who was doing things somewhat differently. She was a deviant in the sense that she was, what she was doing, what she was doing was not the norm. And what she was doing yielded and maybe you felt it, better outcomes. So she was a positive deviant. Doing things which were non, so you are beginning to understand grasp in the state setting what the positive deviance approaches. Clipped way of thinking, look at what's working. Yeah, what's working, what most others are not doing and what is yielding outcomes that, okay. So PD is about secret sauce. Secret behavioral sauces and usually made up of many ingredients. Small little things that people do. Small things that people do that most others do not do. That make a big difference. Get the idea? So now is, and I already see a friend who's stood up and is stretching and we are going to invite you to, each of you to put down whatever you're holding, your notebooks and to rise. And we'll be moving around, yeah, in this. We will be discovering some secret sauces. So here's the question that's posed to each one of you. What is your secret sauce? Now, you can answer this question in whichever way you wish. We are talking about something that you do that most others don't do, which you think yields a better outcome. And believe me, you've got, you may not be aware of it. Oftentimes we are not aware of our secret sauces. That's the reason why maybe they are secret, even from you. And this could be related to your profession, you know. This is one thing which I do. I sit down when, and I don't know what it is. You bring your own stool, I don't know. Maybe you administer a verbal anesthesia. So the question is what is your secret sauce? I'd like each one of you to think about it. So basically what is the small little thing you do that most other people do not do that you believe makes a difference. And it could be work related if you want to get into that mode, but it doesn't have to be. Now, if some of you are very modest and say, well, you know, I really don't have any secret sauces, if you ever find yourself in that situation because sometimes in a big group you say, oh, like, you know, I don't know what that, then you can talk about someone else's secret sauce. I don't think you can see it very well, but that's what it's saying. Yeah, get the idea? Okay, we'll do this in three rounds and there's only two simple rules. One is you'll have to stand in a way, position yourself in a way that you can look at most people, and find somebody whom you don't know very well. If you know all the 100 plus colleagues who are here, then walk up to somebody whom you believe you know the least, okay? And there's a reason why we are doing it. We don't want you to talk to somebody whom you know because they probably already know your secret sauce, okay? So that's one invitation. The second thing is that person has to be standing as far away as possible from you. I know, it's tough because it's so much easier to just say, oh yeah, I need to know your secret sauce, no, the one who is. So there's movement and these little things matter is what we are trying to show. How we give directions matters. How many rounds, talk to somebody whom you don't know, move, find somebody. Now, if somebody has a problem finding you, which can happen, no? It's like, gee, I mean, nobody's coming to me. I mean, you can certainly go find somebody. If nobody's coming to you and you need to be found, if you have that need, you can just raise your hand and say, I need to be found, you know. Okay, you get the idea? Three rounds and each round will be four minutes, which means that when you find somebody, you will spend a total of four minutes with them. You can spend two minutes. I'm not gonna time it, you know, spend a minute or two talking about your secret sauce and probe a little, no? Why do you do it? What results does it have? How do you know those kinds of things? And after four minutes, what will you hear? Ding, and when you hear the ding, what does it mean? Drop attention, drop attention from what you're doing. Shake the person's hand and find somebody else. Another four minutes and you'll hear the ding and then drop attention, find another person, share your secret sauce. So each of you will learn, not just a little more about your secret sauce, but about, you get the idea? So a total of 12 minutes. I encourage you to put yourself in a position, stand in a way that you can face most people. I don't know how you'll do it, but just do it. And I will ding the bell so that you can go with the first round in 30 seconds. So you can be thinking about your secret sauce for the next 30 seconds, okay? So go far away. Okay, go, go. So you may come back and sit down in your seats. All right. How was the act of rising and walking up to somebody and listening to their secret sauces? And all right. So I don't think we are going to harvest the secret sauce that each one of you shared multiple times, but I think we're gonna do at least three secret sauces. Each person heard their secret sauce and at least three others, no? So, but I think all of us need to hear about at least three more, yeah? So the invitation to you is the following. If you heard somebody talk about, if you heard, so it's not about what you said, it's about what you heard. So if you said something, it perhaps was heard, no? You get the idea? So the invitation is if you heard about somebody's secret sauce and you said like, wow, that needs to be shared here with this whole big group. Without naming them, you don't need to. You can just say, I heard. And then very briefly, in a few sentences, describe that secret sauce. We wanna invite three people based on what they heard and something that you think, well, this is something that ought to be shared with the larger group. So yes, terrific. I'm coming to you. The microphone comes to you. We'll get you to be a little louder than what you can. I met somebody who talked about their secret sauce is time that normally scheduled appointments are based on time constraints. And that kind of is where the system is moving currently. But by giving people time, it allows them to fully engage in the conversation without watching the clock. And then with that expansion on time, they're not feeling like they're being cut off in the middle of, they're just getting through something that means something to them. And thanks for getting to that point. We'll see you next week. They actually get to finish out where they are and that it's been very, very therapeutic. And I think time is a secret sauce all of us can apply. Thank you and your name? Oh, I'm Donnell. Donnell, thank you Donnell. All right, the microphone is ready to be shared with two more people. Yes, coming to you. I've actually kind of heard this from all three and it's like having a judgment-free zone in their office, being allowing their clients to be completely honest because they're not gonna have, they're established in their own mind not to have a preconceived notion or idea from whatever walk of life they come from, whether they are a professor or whether they are homeless, it's not having prejudgements or preconceived ideas about them. So I think that I thought that was very impacting. Thank you and your name? Perla, Perla, thank you. Gracias Perla. So the notion of parking your judgment, we all have judgments somewhere, even if it's temporarily, and creating a space that becomes different. Terrific, one more, this side of the room. Terrific, thank you. Coming to you. Be okay with discomfort. Just being okay to push yourself to be a little bit uncomfortable. Be okay speaking really loud into the mic. Be... To the point, I should listen to, I should listen intently to what I'm hearing. Be okay with discomfort. So push yourself to be a little bit uncomfortable so that you can be better for others. Thank you and your name? Stephanie, we met in San Antonio, I know. You even tweeted a picture of me while I was presenting. I was looking pretty darn good that morning. Thank you, Stephanie. Am I correct, you did tweet, didn't you? Stephanie, you did tweet. She... Stephanie, this side, you know, thank you, Stephanie. Being okay, whatever you would need to do, whatever you would need to do, whatever behavioral act you would need to do to be okay with discomfort is what you're saying. Okay, thank you. So far so good. We are in positive deviance, the gurus, Monique and Jerry Sternen, would always remind us that you go fast by going slow. That's another flip, you know? And it's interesting that we are talking about time. We are saying maybe you go fast by going slow, you know? You slow down time a little. So if for some of you it feels we are going slow, that's okay, that's part of the plan because we're going slow with the purpose because we want to internalize, we want to share, we want to have conversations as we go. So we've set the stage and this is milestone number two, the flip. And we've already given you some ideas about what a flip may look like from a linkin-esque perspective, but a few more flips. And I would say that the following three stories that you will hear, do you like hearing stories? The following three stories that you will hear give you the fundamental framework for understanding the basic elements of the positive deviance approach. So if you left this room at 3.30 or at four, remembering nothing else, but if you could remember the linkin story and a few other stories and if you could remember them at an appropriate time to do some mental flips, I think our purpose would be quite well-served in terms of forward movement, but maybe you'll do more. I know you'll do more in association with others. So the flip is a container you can say for us to understand the narrative elements which make up the positive deviance approach. All right, this is not flipped upside down, but let's see if you can recognize somebody, Mother Teresa. So that is Mother Teresa's handwriting and you see her name, no? And the letters dated 1979. So I was 16 at that time, it's April. And that's when I started a correspondence relationship with Mother Teresa. And it lasted for many years. This was the first letter that she responded to. Lived in New Delhi at that time. So I can tell you 100 stories about Mother Teresa. In fact, my dream one day is to teach a course on Mother Teresa, lessons from her life about life. So this is a mini module of that aspiration that I have. There are multiple stories about her. You've heard stories about her talking about whenever somebody would walk, and I've seen this, whenever somebody would walk up to her and say, oh, Mother Teresa, I'm so honored to be in your company. And until then she's okay. And then you say, oh, you're such a great person. If you said that in her company, she would stop you right there. And she would say, she'd hold your hand and she'd look into your eyes and she'd say, my child, remember, none of us can be great. None of us can do great things. But we can all, at every opportunity, do small things with great love. You'd always remind you. So greatness doesn't come from being a great person. As for Mother Teresa, none of us can be great. But everybody, each one of us, now, in the here, in the now, with whoever is in front of you, can do small things with great love. And so there are many stories about her, but this story in particular, the one that I'm sharing, happened here in the US. The year is 1974, and Mother Teresa arrived in Washington, D.C., Dallas Airport, Arrivals Hall. And as she arrived, she's on a personal visit. She sees the two sisters from the missionaries of charity. They're very recognizable, as you can see. White saris, blue bands, you can spot them from a distance. And she saw them, so she knows exactly where to go. She's been found or she's found them, right? And so she's walking. But there are about 1,000 people, seemed like 1,000 people to her, separating her and these two sisters. And they were all holding placards and they were cheering for her. Mother, we are so happy you're here. How did they find out? One doesn't know, but when you do small things with great love, people find out that you're there. And a representative of this group walked up to her and said, Mother, we are so happy you're here. Tomorrow we are having a march in Washington. And we would like for you to march with us. And she said, oh, that's very nice. My child, what is the march about? And I said, Mother, we are marching against the Vietnam War. And now there's silence. If there's silence with Mother Teresa, the answer is, could be no. So there's silence and so the representative. So Mother, we are having a march in Washington. You will march with us, right? And she says, my child, I am so sorry. And then there's somebody behind this representative. He said, what, did she say she's sorry? She's not gonna march with us. Why not? Why will she not march with us? We're having a march in Washington against the Vietnam War. We want her to march with us. And Mother holds the representative's hand and says, my child, if you're gonna have a march in Washington against the Vietnam War, I am so sorry, my child. But if you were to choose to have a march in Washington for peace, I will be happy to be the first to lead. So think about this for a moment. Was being against the Vietnam War and being for peace one and the same thing in Mother Teresa's mindset? Very different, no? For one, she says, I am so sorry, my child. But for the other, if you were to so choose, if you were to so choose, I would be the first to... Now, most of us who are problem solvers, and we are trained to be problem solvers, and there's nothing wrong with that, are trained to begin by asking the question, what's the problem? You begin, if you're a problem solver, you say, what's the problem? What are the gaps? What are the deficits? What is not working? Or in Mother Teresa's lexicon, what am I up against? So I'm against, you can say, teenage pregnancy. I'm against drug abuse. I'm against, we are against so many things, no? Nothing wrong with it. But as problem solvers, if you begin with, what's the problem? What are the deficits? What's not working? What am I up against? It takes you down a certain road. Takes you down a certain road. I, as an academic, I did a lot of work, the first 20 years of my academic life was studying gaps, and needs assessments, and what's wrong, and how, with my expertise, then I can fix it. What Mother Teresa is telling us is, perhaps, that it's okay to do that, but it's always a good idea. If you want to expand the solution space as a problem solver, is maybe to flip and ask, what are you for? Maybe to ask, what are the assets? What are the strengths? What is working? Get the idea? You know about ABCD, you know about asset mapping, but that's the thinking. Can I begin, whenever I get hit up, oh, this is a problem, can I begin and center and ask not what the problem is, and what the needs are, and what the gaps are, and what the deficits are, but can I ask what's working, and what's working where it shouldn't be working, and what are the strengths and assets? It'll take you down a different path, okay? Clear? So with the positive deviance approach, you're asking the question, what is working? What, with the pediatric anesthesiologist, there's something that is working. It's not about what other pediatric anesthesiologists are doing wrong. It's about what's working. What are you for? You're for better patient outcomes. You're for better caregiver outcomes. You're for better clinical outcomes, yeah? Get the idea? Clear? The story, okay. Ready for the next one? Yes. And then you'll have to string these stories together, and then you'll have the basic tenets of the positive deviance approach. And you can see there's some parallels already with asset-based mapping, but PD goes a little, it's a little different. I think it's, well, you decide. We'll see. You recognize Mr. Gandhi? And you may ask the question, what is he wearing? Not very much, no? He's got a loincloth, and who made that loincloth? He himself did, no? That was his notion of bread labor. Every morning, spinning his wheel. Spinning the wheel, so as to turn cotton into thread, and then spinning the thread to make his loincloth. And that was the daily discipline that he needed, physical discipline. Because if you're a soldier of non-violence, as he'd say, you need a lot of discipline. And where does that discipline come from? It comes from spinning the daily yarn. I was at Highlander Folk School in Tennessee two weeks ago. And so, you know, it was where the Rosa Parks and the Martin Luther King juniors and Miles Horton and other were spinning the yarn of discipline. Mr. Gandhi was trained as a lawyer in England, had a thriving law practice in South Africa for many years, and then became involved in human rights issues, rights of Indians living in South Africa, spent 20 years there, and at age 45 came to India and then spent the last 35 years, basically taking his country to independence. And he was never, he never held any political office. That's the interesting thing. He never commanded an army in the sense of a Julius Caesar or a Napoleon. No artistic gift wasn't a Pablo Picasso or a Michelangelo. No scientific achievement wasn't Einstein or a Niels Bohr. He wouldn't have won any beauty contest. His five foot four inches stall and weighed 110 pounds. And his skin, in his own words, was chocolate brown. And he lost his teeth when he was a fairly young man and his hair and you, yeah. And yet, and yet. And yet in India, when we were growing up and I'm the first generation of Indians to be born in a free India, independent India. My parents were both born and there was still a colony of the British. We knew him as Bapu, which means father, loving father. And he was affectionately called as Rashtrapita, the father of the Indian nation. And yet, the father of the Indian nation in this case is traveling by train. And he is traveling, as you can tell, from the left top corner. What class of service? Third class of service. So it was first class and there's second class and there's third class. Now, we know the Pope also travels in a fiat 500. That's beautiful when I saw him come into the White House lawns riding a fiat 500. It was like, wow, is traveling like Bapu? What's the name of the plane that the president, our beloved president travels? Air Force One. It's Air Force One, right? And there's first lady and first man. So our father of the Indian nation traveled third class and he only took as much space as that one seat would take. That was important. It wasn't just important to travel third class, but you travel and you use as much space as you would be allowed if you'd bought a third class ticket. And he always bought his third class ticket. Yes, father of the Indian nation bought his third class ticket. And this, of course, was somewhat disconcerting to some of his fellow. And they would say, Bapu, father, why do you travel third class? We as a country, we as a people can do better. You shouldn't be traveling third class. You should be second class. You should be first class. Now I know I do a fair amount of traveling, as I'm sure many of you do. And once in a while when you get bumped up from coach to business. I mean, the question I ask is, have you really traveled business if nobody else knows that you've traveled business? So, you know, you, you know, maybe tweet and you, you know, post a picture of the olives or something and say, oh, you know, oh, who enjoying these olives, you know, or whatever you may do, right? I mean, there are different ways of, you know, if a tree falls and nobody hears it, has it really fallen. If you've flown business class and nobody knows about you really. That's the sentiment. That's the mentality that is usually normative. Yeah, you identify with that? Nothing wrong with it. I mean, it's a terrific mentality. It, you know, keeps us on a path, you know, the notion of mobility, whether it's social or otherwise. A little different for Mr. Gandhi, you know, and he would say, if you want to find yourself, is this was a statement to young people. If you want to really find yourself, lose yourself in the service of others. And, you know, I'm, you know, that's something that you know. Part of the service metaphor, the service mandate, the service calling, which is very true of the work that you do. And what Gandhi is telling us is too often when we look at assets or even when we look at best practices, we often look at the best case scenario. What's working and what's working, you know, well for most people. What he's saying is, if you begin to ask the question from the perspective of the fourth class, I travel third class because there is no fourth class. And that is something which I know the Wesley Nurse Program does. And the little video clips that Catalina sent me were about, you know, we serve those who are of poor means. We serve those who are uninsured. We serve those who are hard to access. You are talking about those who don't travel first class. So what Gandhi is saying is if you in your way of thinking can look at things from the perspective of not your class, but from the perspective of those whom you wish to serve, like no judgment, then you will be at a different place. So now let's string Mother Teresa and Gandhi together. What Mother Teresa is saying is tremendous value in looking for what's working, what are you for? And what Gandhi is saying is yes, and look at what's working for the fourth class. Look at what's working for the poorest of the poor. Look at what's working for those who are the highest risk. And if you can find in the communities that you serve, some people who have secret sauces, who are doing things which few others are doing, which are working, which are yielding outcomes, positive outcomes, and if they are doing it even with the highest risk, there is tremendous value in finding out what is it that they are doing. Because if they can do it and achieve good outcomes, then the outcomes that they achieve should be accessible to all. A little more on this as we go forward, but are you with me so far? What's working as opposed to what's not and what am I up against? Mother Teresa, what am I for? And with Gandhi, what's working for those for whom it shouldn't be working? I'm putting on the hat. And now to the third story. Now this one is a fictional story, and no apologies for fiction, because fiction can take you places where reality cannot, right? That's the beauty of fiction. It can transport you to a place where a Mother Teresa or a Gandhi cannot, because you can spin. You can not just spin yarn to make your lion cloth, but you can spin the fictional yarn in whichever way you wish. And I know Dr. Dura teaches writing and she's a professor of spinning the yarn when it comes to ink and flows. So this story comes, how many of us have heard stories about Mullah Nasiruddin? Mullah Nasiruddin? Now he's, the stories are very popular in Central Asia and Central Europe. Originally he comes from Turkey and in the fictional part of the world. And there are hundreds of stories about Mullah Nasiruddin and each story has a message, a point of reflection as Mullah says. He's called Mullah, he's the learned one. Some people call him Hoja, which means professor. So his stories create a moment for reflection. So I'm gonna tell you a Mullah Nasiruddin story with your permission. And it's a very foundational, positive deviant story. And hopefully it'll create a moment of reflection if you're ready. You ready? Yes? Okay, we are ready. So in this story, Mullah Nasiruddin, the story begins by he going to the mountaintop. Let's say, well let's say to Mount Everest. And he announces to the world, he says, I am a smuggler. I am a smuggler. Catch me if you can. So the challenge is issued to, let's say those who are in the business of catching smugglers. And in Texas, of course, borders and so on, yeah. So every morning in this story, Mullah Nasiruddin riding a donkey with other donkeys loaded with stuff comes to the border checkpoint. And at the border checkpoint, there's a customs official and the customs official is like, I'm gonna nail you today Nasiruddin. What do you have? And Nasiruddin says, and so the customs official looks. And he looks this bag and looks in that bag and empties this and empties that and over and under and he finds nothing of interest. So what do you do if you find nothing of interest? You've got to let him go. Off he goes. And the next day he's back. He's riding his donkey with loads of other donkeys. Loaded with stuff, even more stuff. And the customs officials are saying what? I'm gonna nail you today, Mr. Nasiruddin, what do you have? And he says, and so what does the customs official do? He looks and this time he really looks now over and under and empties this and empties that and from this side and that side and here and there and everywhere and he finds absolutely nothing of interest. So what does he do? You've got to let him go. And off goes Nasiruddin. The next day he's back riding a donkey, loaded with more stuff. And the customs, I'm gonna nail you today, Nasiruddin, what do you have? And he says, and the customs official looks and this time he puts on his x-ray glasses and administers the sniffing test and does this and that and over and under and on this side and that side and finds absolutely absolutely nothing of interest. So what does he do? You've got to let him go and off goes Nasiruddin. And this happens day after day, week after week and month after month and year after year and even decade after decade. And the customs official comes to University of Texas San Antonio and gets a few, comes to St. Mary's and does a few more courses in customs checking and how to nail smugglers like Nasiruddin and then goes to that school in Cambridge, Harvard School of Customs Checking and gets the ultimate expertise diploma in, and is unable to catch Nasiruddin in an act of wrongdoing. And after 35 years of failure, fed up with his lack of ability to nail Nasiruddin in an act of wrongdoing, the customs official goes to the top of Mount Everest and says, I retire from customs checking and Nasiruddin follows him and he says, and I announce my retirement from smuggling. And then they happen to meet, let's say here in San Antonio in a Starbucks and the customs official says to Nasiruddin, Nasiruddin now that I'm an old man, now that I'm in no official capacity to do anything to you, Nasiruddin for all the nights that I've not slept, all the heartaches and ulcers that you've given me, please today in this coffee shop as I buy you a latte. Can you please tell me? Please, please, can you tell me? What is it that you were smuggling? Donkeys says Nasiruddin, really enjoyed this story, didn't it? I think it was that latte that I threw in which may have tilted the, all right. So the question is the following, you don't need to answer it, but you need, there should be a reflective pause. The question is why was the customs official unable to see what was there right in front of his eyes all the time? That's the question to be posed. How many times did I mention donkeys and more donkeys? But we are all looking at the stuff as was the customs official. The customs official was interested in his stuff. So some people study this, and they say that the customs official was a victim of his own trained incapacity. Some other people who are a little, or not as kind, call it occupational psychosis. And you know, some people more simply explain this phenomenon as, if you're a hammer, you look at the world as a, it's the folly of expertise. Beginner's mind, open mind, full of possibilities. You become an expert, the donkeys are coming and going and have been coming and going for 35 years and you don't see them. It's a foundational positive deviant story. That solutions to very, very complex problems almost always exist. But we, those who serve, those who have expertise often are unable to see them, even though they're right there. That's the fundamental premise of the positive deviance approach. That, you know, the pediatric anesthesiologists, they're there who are doing stuff. There are doctors who are caring stools and there are nurses among you who have secret sauces. The answers to the very, very complex problems that we are trying to solve are there. We have, we don't see it. They hide from us in plain sight. So must have the clicker somewhere. So here's the positive deviance premise. How's it going so far? As slow, okay, stories, you can, good, it's good. That's like a very vehement, it's good. Good, okay, good. So the positive deviance premise is the following. Solutions to problems exist. Whatever problem you're trying to solve, actually solutions to very complex problems exist. They stare us in the face. We do not see them. In fact, we are incapable of seeing them. Our training gets in the way, no? So by virtue of getting trained as a professor, as a nurse, as a doctor, we begin to see things in a certain way, which means we don't see things in a certain way. We don't even know where to look. Where do we find the donkeys? Because the donkeys is the solution to the problem that the customs official is trying to, but he doesn't know, he can't, he doesn't know where to look. And the territory of finding the donkeys is uncharted, especially if you're a trained. And the conventional maps that we use, and what are the conventional maps? The conventional maps are, if I'm interested in solving a problem, I begin with the problem. I begin with the gaps. I begin with the needs. I begin with the deficits. I begin with what I'm up against. That's the conventional problem solving map. We map all this. And those are not very helpful in seeing the donkeys. So you remember, we began by saying that positive deviance helps expand the solution space. It's saying that if you chose to focus on the Mother Teresa principle, what's working, what's working, and if you added Gandhi, what's working for those who face the highest risk, the fourth class, what's working for those for whom it shouldn't be working. If you begin to use those maps, then perhaps the solutions that you will find will be the donkeys that have been hiding from plain sight. Because if, I'm just gonna give this as an example. If somebody who is the poorest of the poor in the communities that you serve who has no medical insurance, who is, let's say, at high risk based on sociodemographic factors, which go beyond income for diabetes or for obesity, you will expect that this person with that profile in the Gandhian notion of being at the highest risk, the fourth class, would not be able to manage their sugar levels well. Right, and you run a regression equation who's at the highest risk if you have these and these characteristics, gee, you're in trouble, right? But we are asking the flipped question, is there somebody who belongs to a race ethnicity who's at the highest risk, who's in a certain age group that's the highest risk, that's poor, doesn't have medical insurance, yet for some strange reason, they not just monitor their sugar levels and manage their diabetes? Well, we are saying that if you want to find the donkeys, look there, because they, because they've solved the problem. They must be doing something, or something must be done to them. There is something that's happening which enables them against all odds to have solved the problem. And so that's where, you don't know what the donkeys are, but you know at least where to look. So the positive deviance map is look for what's working, what's working against all odds, and if you can figure out the secret sauce. Now by definition, given these people have no extra resources and face the highest odds, they must be doing something. It's not that they have resources. They must be doing something. There must be something that's being done to them which enables them to have these better outcomes. And if you can figure out what that secret sauce is, then you found the donkeys. And that solution has implications for a whole host of people because somebody in that community against all odds has figured out a way to solve the problem. And by paying attention to them, you can learn the secret sauce of what's making the difference. So far so good, are you with me? You're setting, yeah, we've set the stage, the flip thinking, what's working, what's working against all odds. Donkeys are there. We don't see them. We are incapable of seeing them. How do we see them? You need a map. The map has three principles look for. Mother Teresa, look for Gandhi, and look for where the donkeys may reside. How are we doing on time, Catalina, are you here? I'm doing fine. 10 more minutes? Yeah, yeah, and then we take a break. Is that good? We've already covered two out of the five things we want to do. So we're making good progress, I think. And then we come back and go on for another hour and a half or something before lunch. And then we have a few hours post lunch. You're stuck with me today. All right, okay, 10 minutes. So Einstein was once, I mean, here's somebody who thought very differently, no? And he was once asked a question. The question was, if your life depended, if your life depended on solving a problem, and you had one hour to solve that problem, what is it that you'd do? How would you approach it? And his response was the following. I would take the first 55 minutes formulating the problem, thinking about what is the problem, if my life depended on it. I would think about the question, because if I figured out what question I needed to ask, then I'll find the answer in five minutes. So one of the other things which positive deviance does, or this approach does, is it is asking us to be very mindful of the question we ask. Most of the questions we ask are, who's at the highest risk, what's not working, why isn't it working? We just spend all our time as researchers, no? Asking that kind of a question, and that's the reason why we don't make too much progress. With positive deviance, and you will do this as we get into application, you can be thinking about, what's the question that I need to ask? But if I ask the right question, and if that question is Mother Teresa and Gandhi, and allows me to see the donkeys, that is damn good. That's very good. It'll take you to a place where you've not been, because if you can formulate that question, in my life and the work that I do, what is that question that I haven't asked about the somebody who has found a way to solve a problem which they shouldn't have? And if I can ask that question of intrigue, and if I can have that map, maybe I will be a little closer to the answer. So we'll do this. Do we have 15 minutes? Can we do 15? No? Should we or no? Okay, so, okay, we'll do it 10. It's no problem. I mean, you know, we're flexible. Dr. Dura, may I invite you to come? And may I also invite our two colleagues to maybe the three of you to come? And can we just demonstrate a circle of five people? And as we do this demonstration, at this time, just watch the demonstration. And then you can get into groups of five, yeah? So there are five of us, yeah? So you will find yourself in groups of five, yeah? That's good. And basically, the question to you is the following. What implications do these foundational PD stories or positive deviant stories hold for re-scripting the way I work? So I is you, you know? The way I solve problems. And this is a very preliminary, this is just to get you started on this, and we'll do a few more rounds. So the way it works is we do four rounds, but we'll do three rounds only, okay? Because we are shooting for 10 minutes, okay? We can modify, I'll change the directions. The way it works is there's always a talking stick. We are doing a conversation cafe. I've got a microphone, this is a terrific talking stick, yeah? The tradition comes from the Navajo tradition. You can create your own talking stick, can be a pen, can be a, you know, whatever. Could be your watch, if it's an expensive one. The purpose of the talking stick is to bestow honor and respect on the one who is talking. That you are being recognized as somebody who's the holder of wisdom, and you are going to be talking. If you don't hold the talking stick, what does it mean? The other four are only there to honor the talk, to listen, to deeply listen. Get the idea? Straightforward directions? The directions are important. In a conversation cafe, you do three rounds. We will do three rounds, which means that I will talk, you can begin anywhere, and then the talking stick will move in a certain direction. Doesn't matter whether it's left or right, you can decide which way. You can pass it left or right. And everybody will speak. And you will complete a round when everybody's spoken. Clear? You with me so far? The first round is only a sentence. It's like a headline. So the question is what implications do these foundational positive deviant stories hold for me? And you will say a sentence and you will pass it on. Get the idea? Once you've completed the round, once the talking stick comes back to the one who started it, you go into a second round. In the second round, you get a short para. Two sentences. Get most three. And no long clauses, no colon, semicolons. Two or three sentences. You can either widen or deepen what you've said, or based on what you've heard, you can build on that. Get the idea? Second round is over. Then you get into the third round. In the third round, you get two more sentences. Five, okay? Somebody keep count. And again, you can widen, deepen, build on what you've said or what the other said. But this is your first opportunity to articulate what this means for your own work. So get into circles of five, pick a talking stick, three rounds, one sentence, two or three sentences, and then four or five sentences. And we should be done in 10 minutes. And I'll ding the bell after 10 minutes and we'll take a break. Terrific. So you all can join any circle you wish. Perfect. All right. And how about the amplification with this microphone? Much better. All right, terrific. With your permission, may I sit down? Here's a high stool. So, well, I know if I fall, there are lots of nurses here who are able to provide good care. We'll give ourselves another 30 seconds then. So in your conversation cafes, you heard some initial utterances about possibilities. And you also were able, not just to hear yourself, but you were also able to hear others. And I think that's the key, you know? That we learn not just from, oh, what is it that I'm getting out of this and what implications these stories hold for me, but I'm also hearing five others, you know? And that makes a bit of a difference. Okay, good. So carrying on with just to give you a sense of the ground we've covered, I'm gonna see if I can go back. So flow of the agenda and learning objectives. We've set the stage, understanding the PD philosophy, and of course the notion of the flip, the narrative flip, and the mother Teresa's and the Gandhi's and the Nasiruddin donkeys. And then you've had discussions amongst yourselves about secret sauce, secret sauces as also an initial conversation about what this means for, you know, your work. I'm actually gonna let this tool go and move around. So now we are gonna get into PD steps. So there's a certain method, a certain approach, and we will learn about the method and the approach by talking about an actual case study. And we will go back to the founders of the positive deviance approach, Jerry and Monique Sternen, because this case study is about the work that they did in Vietnam in the year 1990. Actually, they did this work in Vietnam for five years, between 1990 and 1995. And then through that experience, the positive deviance approach, the method, the steps were codified, systematized, and now have been applied in over 40 different countries. Came to the US for the first time, the positive deviance project that was implemented was in the year 2005. In hospital settings, looking at the problem of hospital-acquired infections, which as many of you may know, MRSA, C. diff, very, very big issues. And a four-year project on hospital-acquired infections in the six hospitals that were part of the pilot reduced infections by 73% in a study that was funded by the Robert Wood Johnson Foundation. So it's through that experience of positive deviance in US healthcare settings that within the US, this approach has begun to go places now. But still, we are very early on in the positive deviance movement, if you may. And I think your presence here and the kind of work that you do in a very distributed fashion within the communities that you live and work holds the seeds for tremendous potentiality going forward. If you think that this has meaning and value for the work that you do. So that's the hope, we'll see, okay? So PD Steps. It's a good summary of where we've been. Yep, yep, yep, yep, yep, yep, yep. Yep, yep, PD Steps. Okay, so internalizing through casework, the step-by-step PD methodology. So again, here's the story. Here's the Vietnam story. Solving the problem of malnutrition at a big scale in a country like Vietnam by finding the secret sauces, which were there, but they were hidden from plain view. So I'm gonna invite you to the rice fields of Vietnam. Vietnam is a country which you can, Mother Teresa was invited to march against the Vietnam War, depending on what point of view you have, where you're coming from, you'll have certain images, certain background about Vietnam, but Jerry and Monique Sternen, when they arrived in Vietnam in 1990, their purpose was very humanitarian. They were opening an office for an organization called Save the Children, you've heard of Save the Children. And the problem that they were asked to solve or help solve or address was the problem of malnutrition. Because research studies in the year 1990 had shown that 65% of the children under the age of five in the country of Vietnam were malnourished. And so even though Save the Children was a US-based organization, it was Save the Children USA, the Vietnamese government with the seizing of hostilities and given a decade had passed, had decided that it would be okay for a US-based organization to come and do this humanitarian work. Now Jerry and Monique Sternen prior to coming to Vietnam had worked in many different parts of the world. As I was sharing, Jerry was a Peace Corps volunteer. Then he became an assistant associate director of Peace Corps in five or six different countries. Very earthy, very good heart, had a good sensibility of service. As I know, your CEO also has a Peace Corps background. And so they went into Vietnam, not with no experiences in working, but they had gone into Vietnam with a lot of experience in actually addressing these social issues. So the story goes, and that's Jerry in Vietnam, in the early 1990s holding a child. The story goes that they arrive in Vietnam and the very next day, after they land in Hanoi, they are summoned, Jerry is summoned, summoned is the word, by an official in the Ministry of Foreign Affairs. And he's sitting behind a big desk as Jerry described it. Jerry arrives and he's asked to sit down, there's a wide gap with a big table in between, very officious looking gentleman who says, Mr. Sternen, welcome, we are happy you're here, you're happy you're gonna help us address this problem of malnutrition. And please know that you've got six months. Sort of slipped that in. Please know you've got, how much time? Six months. And Jerry's like six months. Said yes, you've got six months. He said, you know, there's very high suspicion of any American humanitarian organization, you know, we've got a history and we have agreed that we will allow you to be in this country, you know, as our guests for six months, but you've got to deliver results. You gotta show results in six months. Now, the work that they had done, and you know, given they'd lived as expatriates in overseas contexts a few times, six months clearly rattled the sensibilities of Jerry Sternen because he's telling himself, well, you know, you arrive in a country, you have to find a house, you've got to maybe hire some people, you've got to find an office location, you've got to get a connection for the fax machine, maybe you'll offer, you know, hire some staff, maybe you'll find a good Toyota, you know, land cruiser from, you know, so that you could do your field visits. You get the idea, I mean, it takes a little time to set things up and then you begin to make contact with the ministry, people in the field, you understand what's going on, you know, I mean, you're talking results in the second, the third year, maybe some minuscule ones. The official made it very clear, you've heard me six months is all you've got. So they knew that what they had done in the past was probably not a good option, even if you speeded it up in the context of Vietnam. And then, fortuitously, a person who was serving as their technical advisor, who actually was in San Antonio in the April meeting, if some of you were here, Kathalina, you were here, you may have met her, Gretchen Bergen, who was a technical advisor to Save the Children and was a technical advisor on this nutrition project. Her daughter, Ruth, now teaches at University of Texas, San Antonio, Ruth Bergen teaches. And she was the one who helped organize this April meeting that we are talking about. There's a connection, you know, I mean, things happen for a reason. So Ruth's mother, Gretchen, was a technical advisor to Save the Children. She arrived in Vietnam a month after Jerry and Monique had arrived when time was ticking and ticking fast. And along with her, as Jerry and Monique describe it, she brought along a Xeroxed or a Mimeographed copy of a book, it wasn't even published. Out of Tufts University, where Monique went to school, which has a phenomenal school of nutrition. And Tufts does a lot of work in terms of outreach in solving nutrition problems all over the world. So this book was written by a Tufts professor by the name of Mary Ann Zaitlin. She's a Facebook friend of mine. She lives in Senegal at the present moment. She's retired. And Mary Ann Zaitlin in this particular book that Gretchen brought for Jerry and Monique reviewed dozens of studies of nutrition projects in dozens of countries. And in the concluding chapter said the following. That maybe we, we nutritionists, professors, practitioners, scholars, implementers have done our nutrition work in a very limited way. In fact, she even says maybe we've done it quite wrong. And this is a humbling statement coming from an academic after being engaged in 30 years of work and doing a meta analysis, a review of all these studies. And she goes on to say that in every country, in every nutrition project where we've collected data, we have found data that we have purposely ignored. We have focused so much on what's the problem, what's not working, what are the needs, what are the gaps, what are the deficits and try to plug them that we have ignored data even though it was there. And she coins the term positive deviance. We ignored the positive deviance because in every country, in every project, in every nutrition program, they had data that showed that there were some poorest of the poor households in the most rural of remote settings, whether it was in Burkina Faso or Liberia or India or Bangladesh, there was data that showed that even among the poorest of the poor or in the Gandhian notion of the fourth class, there were some kids who were, well, they were a very few as a percent. They were a rounding error, a statistical rounding error, but the data was real because each child had been weighed and measured and their growth charts had been plotted and the circumference of their arm had been taken so you cannot question the veracity of the data. This is not a type one or a type two error that you make. The data is there which shows that these demographic profiles of the fourth class indeed have a few people who are very well nourished. So in this book that the technical advisor brings, Jerry and Monique Sternen become familiar with the notion of the positive deviance approach. They'd never heard of this before. This is not the way they were doing things and so they said, because they read the book, ah, maybe this is the way we will begin our work in Vietnam. So they began to make contacts with four communities. You can vary over period of time, know that there are about 3,000 kids under the age of five in these four communities, you can count. And they said, why don't we ask a question? Now I'm invoking Albert Einstein, yeah? Let's ask a question, an important question, a question whose answer will perhaps take us to a different place. A question that has some elements of Mother Teresa and some elements of Gandhi and which will allow us possibly to see where the donkeys reside. You see the connections here between what we've said? So this was the question that was posed in general. This is the Einsteinian question which usually is never asked. And what's that question? It's a very simple question. The question is, are there children in these four communities? Under the age of five, who come from the poorest of the poor families? So that was measured, you can have some measures of that. So the size of the land that they have, the number of milch animals that they have, do they have a kitchen garden? You can measure poor along multiple domains, whatever may be relevant. What's the size of the home that they live in? In El Paso County, you can often look at a zip code. You can say, okay, in 79901, you know that that is a very poor zip code. So there may be different ways of coming at it. In the case of Vietnam, in the four communities, they just ask this very simple question. Are there children under the age of five? Children, you can measure that. Under the age of five, you can measure that. Who come from poor households, poor defined in a certain way, is measurable. Who come from rural areas where you would think malnutrition is high, which was the case? You can measure that. And of course, the twist being, who are? That's a question that's usually not asked. Because we are asking who's at the highest risk? What's not working? What don't they know? Why aren't they favorably disposed? What don't they practice? The cap gaps? And then we as experts try to plug those gaps. Nothing wrong with it. It's a different way. Here, the simple Einsteinian question that was asked was the following. And when you ask a question like that in a community with 3,000 kids, you can measure, you can weigh these 3,000 kids, right? Which they did with the help of community members. They borrowed scales from UNICEF and this and that and five scales and took them four days to weigh all the 3,000 kids. And the Vietnamese kept good records so you could plot their growth charts and you measure the circumference. And you could tell, as you looked at the data, so the data gathering process sort of looked like this. The community was involved in collecting the data, in weighing the kids, and then in mapping. You know about mapping, you know about asset mapping, but this is visualization of what you see. And in positive deviance visualization is key. So that people can see what's happening. So think about this. So think about a map of these four communities, a physical map, you know, and each household in this community being represented with let's say a little rectangle, yeah? And inside this rectangle, one way of visually mapping it would be, let's say you have some dots. And the dots represent the number of kids under the age of. And if it's a green dot, what does it say? The child is well nourished based on their growth charts. And if it's a red dot, what does it say? Child is malnourished, simple enough. So you weigh the 3,000 kids, which is what they did in Vietnam, and then they plotted it visually. And actually these four communities approximated, 3,000 is not a small number, the national level data. So what do you see? Do you see more red dots or green dots? Red dots. So basically, if you're like, damn it, I mean, we've got a big problem, right? But if you're in the positive deviance approach, where do you begin? With the green dots. But really, you are beginning a process of eliminating, and I'm gonna underline this word. If there's one word that you need to write, it's the elimination of the green dots. You're saying really, what does that mean? I'm interested in the green dots. You are, if you are interested in positive deviance, you are interested in the green dots that should be, it's very important inside. So it's like, okay, we've got some green dots. Okay, let's look at the green dots. Whose green dots, well, who's household is this? Oh, this is the household of that dairy farmer. Oh, okay, how many, oh, he's got seven cows. Okay, lots of milk, oh yeah, there's beef. And you know, he also has some chickens, and they lay eggs. You would expect those green dots to be, you're not interested in this green dot, they're explainable. So you move on. Whose house is this? Oh, this is the village grocer. Oh, okay, you know, he's got a thriving business, and he's got plenty, his kids go to school. You would expect those dots to be green. Now, do you understand the notion of the fourth class? You are interested in the green dots that should be? Red, the unexplainable green dots. You're looking for donkeys, you don't have a roadmap. You don't know where to look. The only way you'll find where the wisdom resides is when it doesn't make sense based on data. So basically, what are they doing? Explainable, explainable, explainable, explainable, explainable, explainable, check, check, check, check. Whose household is this? It's got two green dots. Oh, this is that single mom who lost her husband during the war, who has the tiniest parcel of land, and while she has no animals, she, are you sure? Did we measure the kids? That's the starting point of a PD inquiry. Are you sure? This is not possible. And it answers that question, no? It basically answers this question, right? Because this woman, because of her poor status, her remote, rural, whatever, should not have kids who are well-nourished. Check, I am really interested in finding out the donkeys. Why? Because this woman and her kids have solved the problem already, but I didn't see them until I plotted the data, and until I, right? So now you know where to look for donkeys. You've got a roadmap, right? That's what we are describing, a roadmap, and you got to the roadmap because you asked this question, a question that's never asked. Einstein, if you formulate a good question, the answer will take you to a place where you don't know. So, in every community, they circled five or six households that were unexplainable, which means there were green dots that should have been. It's a data-driven inquiry. If you like data, it's data. Now, what percent of the 24 households that you've identified, 24 kids who are unexplainable, out of 3,000, that's a very small chunk. Or even if there are, let's say, 500 households, 3,000 kids, well, no, 3,000 kids under, let's say there are 1,000 households. You know, if you have 24, that's 2%. These are outliers. They're deviants, statistical deviants from the mean, and they have positive outcomes. So, you see why they're positive deviants? So, now, it's the who done it, right? So, bring in Agatha Christie, bring in Sherlock Holmes, you know, this is unexplainable. Do, if you like doing regression, it's all my colleagues here who like, that's the way I was trained. Lucia, you're not raising your hand. Eleni, you know? What does a regression equation do? The line of best fit, prediction and control. So, you would have predicted, you would have hypothesized that if these people had these characteristics, their kids would be malnourished. And most of the time, you'd be right. You get the idea? PD flips even that thinking, the deductive way in which we make inferences. So, now, you've got some children who are malnourished, who are unexplainable, based on the background of their parents. So, you are trying to discover what is happening, what's the secret sauce, right? Sauce is very secret, you still don't know. So, because the community was involved in the weighing of the kids, and because the community were the ones who could tell that no, no, this is unexplainable, the challenge was given to the community. You go and figure out, tell us what the heck is happening. So, the community members go out, they know where to go and to look, and they then come back and they report. You interested in what they report? I figured, okay. So, one group, one team, one Sherlock Holmes team comes back and they say, you wouldn't believe what these mothers are doing here. Really? What are they doing? If somebody begins to say, you wouldn't believe, you are on the PD path, because what is happening is unexplainable, and it's that little thing that's making a difference. It's like, you wouldn't believe what this pediatric anesthesiologist does as verbal anesthesia. Always little things. And she does a little more than peekable, right? There's strings of things. You wouldn't believe what this neonatologist does when he does rounds. His team carries a stool. So, you wouldn't believe what this mother does. What does this mother do? And you really shouldn't believe, because there's no reason why this child should be well nourished. This mother adds the greens, the shoots of sweet potato plants to the child's foe or rice. So, let's take a show of hands. How many of us have eaten sweet potato? Keep your hands up if you also ingest on a regular basis the greens of sweet potato. Get positive deviant. Do you get the idea? So, you label something as sweet potato, so you're interested in what? What, the tuber, no? That's under the ground. Who gives a damn about the greens, no? Well, most people don't. The normative behavior is, but what was this mother doing? She was adding the greens. Now, you will not die if you eat the greens. You can try it. In fact, if you do a nutritional analysis, if you're an expert, of sweet potato greens versus spinach, an ounce versus ounce comparison, sweet potato greens will win hands down. Why? Because what does sweet potato have? Beta carotene, the miracle vitamin for children. So, UNICEF and Save the Children are doing, they're doing vitamin A campaigns all over the world, going, creating a warehouse, having lines, putting two drops of vitamin A in a child's mouth every six months, because if you do vitamin A campaigns, it cuts infant mortality by 20%. What? This crazy mother, would you believe it? She's gotta be crazy, because she's a deviant, like the crazy anesthesiologist, like the crazy, is adding the greens off, sweet potato. So you ask the question, right, ma'am, how long have you been doing this? Oh, this is the way, you know, I've raised my four kids. The donkeys have been coming and going for, you just didn't have the eyes to see it, because you didn't even know where to look. Get the idea? How we connect, how you ask a question? Then, of course, there's like another group of people, you wouldn't believe what these mothers are doing. What are they doing? Wouldn't you believe it? This mother actively feeds her child as an expert. That's the folly of expertise, like what? What do others do? Oh, that's not normative practice. What's normative practice? The normative practice is when the child begins to sit, because the mother's busy. The norm is you try to make the child eat on their own. And so the child eats some, and drops some, and leaves some, and wastes some. Do you believe that this mother actively fed her child? Maybe a little less spillage, wastage. And what does she do when she has to work in the field? Oh, she lets one of the siblings know, too actively. How long have you been doing this, ma'am? Oh, I've been, you know, I've raised four kids, and my mother used to do this, and then our, but it's non-normative, it's not the norm. The donkeys have been coming and going. Didn't have the wisdom to solve the problem. The secret sauce to solve the problem has been there. You could only see it by asking a flipped question, by asking an improbable question. Using data, creating the conditions for you, at least to know where to look for donkeys, because the donkeys have been coming and going. Some people in every community, that's the contention of the positive deviance approach. In every community, in every community, there are individuals or groups who have, for some strange reason, unexplainably figured out a way to make sure they manage their diabetes, even though they're very, to make sure that they are walking, and they're doing stuff which others aren't. It's a different way of problem solving, right? You can keep solving the problem the old way, nothing wrong with it. You'll get somewhere, as you've gotten somewhere. PD approach, as we said, what does it do? It expands the solution space. It looks for what's working, and what's working within the context, and within the challenge of that environment. So the more challenging the environment, the more challenging the environment, as many of you work in very challenging environments, the more at risk the populations that you work with, I would contend the more value the PD approach can add to the work that you do. I cannot think of any, as we were talking, I cannot think of any other organization, actually, given the work that you do, who may actually, in some ways, be able, because you work in the conditions that you do, figure out, expand your solution space. Because the donkeys are there, they've been coming and going, you just don't have the eyes to see it, but you can develop the eyes to see it by asking questions that you've never asked before. Get the idea? Are we bringing it back together? Okay, on with the Vietnam story. Let's do at least one or two more you and beliefs. Yeah, you ready? So what have we done so far? Sweet potato greens, active feeding. Okay, here's another one related to active feeding, a little more subtle. You wouldn't believe what this mom does. What does she do? She feeds her child four times a day. And what does the expert say? Completely, this is completely. You don't see that, right? Like, okay, four times a day, you know. Yeah, I mean, every child should be fed four times a day, what's, oh, but that's not the norm. What's the norm? In Vietnam, a child is fed two and a half times a day. A big meal in the morning, a big meal in the evening, and maybe a little something. This mom feeds her child four times, but then you say, so the child is getting more food, more resources, right? Because with PD, you're thinking about no extra resources. Says, yeah, see, that's the funny thing. It's not more food. This mother takes the same amount of food, let's say you're giving a child 200 grams a day, as opposed to 75, 50, and 75, she breaks it up into 50, 50, 50, and 50. Why would she do that? We don't know, but she does it. Why would she add sweet potatoes? We don't know, but she does it. And you can nutritionally explain why sweet potato makes a difference, why active feeding removes wasted. You can now give your expert opinion that when you break a meal into four multiple smaller portions, what does that do? Better nourishment, more absorption, better assimilation, and this is not a one-time thing, right? Your little baby's body and metabolism is working, and what do we recommend for diabetic control? Go back now. Have smaller meals, more frequent. Heck, I mean, this is the other way around, no? You get the idea? This mom was already doing that. How long have you been doing this mom? Oh, this is the way I raised 11 of my kids. Yeah, I'm sorry, many of my kids, this is the way. I've been doing this, the donkeys have been coming and going. And now do you see the power of this discovery? Because it's not just one thing. By doing this discovery, by asking this question, you are on turbo charge. It's not just one little thing that you're doing. It's multiple things that are. The solutions are where they're there. You're picking up these little solutions. And imagine what that does now if you're somebody who's trying to intervene. You've got, you've expanded the solution space tremendously. And where did it come from? It came from here, the real context. So far so good. You wanna hear one more? Of you wouldn't believe. What time do we take our lunch? I'm just preparing ourselves for lunch. Wasn't it 11.45 on the schedule? Catalina, you're 12, is okay? Okay, 12. I thought the schedule said 11.45. We are flexible, okay. So 12, 12. I want you to completely internal, well, not inter, I want you to hear the Vietnam story, right? And the subtleties and the nuances. And then you can, you know, food for thought while you enjoy your food. So one more thing. You wouldn't believe what these two moms do. What do they do? Well, when they finish work in the rice fields, and Vietnam is a country of rice fields. Been there a few times. It's one of the few countries where you can grow three crops of rice a year. And rice has a cropping cycle of 120 days. And why can the country grow three crops of rice because it has a lot of water? You need a lot of water for rice growing. So the mighty Macong, and you know, trains a lot. The whole country is, you know, surrounded by an ocean. And when you have rice fields and a lot of waterlogged rice fields, well, so what was the premise again? You wouldn't believe what this mom does or these two mothers, what do they do? When they are ready to go back home after they finish work in the rice field, they spend an extra 30 seconds bending down playing with the rice field. How strange is that? Why would anybody do that? Let's go back. This is exactly what they do for an extra 30 seconds. The experts like, this makes no sense. Well, it makes sense because what they're doing is they're bending down and picking up what? The tiny, the teeniest of the tiniest shrimps and the teeniest of the tiniest crabs and the teeniest and the tiniest shellfish and their whole host of other crustaceans. It's organic matter. But the shrimps and crabs and the shellfish that the Vietnamese eat, where do they get it from? Ocean, river, they're not rice fields. That's chicken food or duck food. So every evening a farmer will bring their flog of chickens and you know, ducks and they will pick up these tiny shrimps. What do these mothers do? They pick up these teeny, tiny shrimps and crabs which are there for the taking, for the plenty. And they come home and they remove the crust. They wash it and they add it to there. How long have you been doing this, man? I mean, this is very strange practice. Oh, this is the way I raise my seven kids and this is the way my, it's non-normative practice. The donkeys have been coming and going for years. So the wisdom to solve the problem is where? The resources to solve the problem is here. So what do they do? What do you do? You're Jerry and Monique Sternen. What do you do? You try to replicate. You have found the difference that's making the difference. With PD, this is key. You're always looking for the difference that's making the difference. The difference is the secret sauce. The secret sauce is behavioral always. It has to be. It's not a resource-based because those people, poorest of the poor, have somehow figured out a way. So they must be doing something. Something must be done to them in order for them to have the results that they do. Get the idea? Resources are here. The wisdom is here. Somebody in this context is doing it and is making it work. So the notion of social proof, the discovery is made by the people. It's not an expert. The expert is clueless. What the expert is doing is just basically creating the conditions for this discovery to happen. So Lucia's done a lot of work with positive deviance and you go there and basically you say, I know nothing. You asked me to talk about to solve this problem of infection control. I don't know what MRSA is or who he is or she is. That's the way you begin. I know nothing. But I do know that in this particular hospital there is a patient who's figured out how to make sure that before he or she is touched, they are protected. Really a patient? Uh-huh. A patient. There's a chaplain who's figured out when they pass the Bible that they are passing a little more than the word of God because they have plastic covers and they use wipes when most others don't. There's some people who figure things out. But we are infection control coming from the 14th floor. Do this, do this, do this. This is what you need to do. Here are the guidelines. You get the idea? PD expands the solution space. There are thousand eyes and a thousand ears and a thousand hands if you have that sensibility. So replicate. How do we typically replicate? Telling people, right? I've got the gospel. Now I'm going to share it. I've identified what's making the difference. The difference that's making the difference. I'm going to tell you about it. And you are of course smart and you are a rational human being. And you will, you shouldn't do it, right? Wrong, completely wrong. But there can be other ways. So this is what they did. They tried to tell people. Look, right? They tried to show people. Look is Meera, no? See, see what they're doing. See what's happening. Yes, in the next few months by telling and by showing and pointing to what people were doing, you went from 65% of the dots being read to now, 55% of the dots being read. And you can pat yourself on the back, no? And say, yeah, I've made a difference because I have reduced malnutrition by a factor of, you know, I went from 35% of the kids being well-nourished to 45% of the kids being well-nourished, tremendous. Increase of 30% over the baseline, no. The problem is there. Of course, their visa got renewed. You remember six months? 10% percentage point, which is 30% over the base. Phew, you've done great. They realized that the more they told and the more they showed the telling and in the showing, even though this would make sense, it should make sense, there was a ceiling effect. And you try a little harder, you know, you become a little more creative and you employ this channel and you employ that channel and maybe you make another little dent, but there's a ceiling effect. And now you're saying, what's wrong with these people? The wisdoms here, the solutions are here, the resources are here, we have found the donkeys, we are telling them about the donkeys, we are showing them, but 55% of them are stuck. There's something about human nature, right? You know, you experience that, no? I know about me, right? I know about me. And then in one of the sessions, and this is how Jerry Sternen describes it, they were banging their heads, they were saying, what else can we do? What else can we do? You know, we've tried everything, I mean, it's good that we've made progress, but how come these people don't listen? You know, blah, blah. And there's a Vietnamese elder, there's a role for elders, no, always, who's listening to people, hitting their heads against the wall and saying, and the elder comes and stands and the way Jerry described it is, he says, or she says, when I was a little child and growing up, my elders used to tell me that a thousand hearings, hearings, not earrings, a thousand hearings is not worth one seeing, and a thousand seeing is not worth one, doing, and then the elder sort of wrapped their shawl and walked away, as elders do, creating a moment of pause and reflection. And the way Monique would describe this is, they had this encounter, the elder came, said something, it was like, wow, that sounds good. And Jerry and Monique are driving back home, and they were driven in a Russian car with a tractor engine. Why that was the case, I don't know, but this was Vietnam in early 1990s, and the tractor engine suddenly died, and so there was a moment of quiet, and there were a lot of fumes in the car, and so Jerry unrolled his window. There was quiet, and as he unrolled the window, he heard the voice of the elder. A thousand hearings is not worth one seeing, a thousand seeing is not worth one doing, and he said, my God, we are doing this upside down. What are we doing? We're trying to tell people, we're trying to have them here, we're trying to show people, we're trying to have them see, but they're not actually doing it. So he completely says, we need to flip this. As interventionists, we need to flip it. It's not about telling and showing, it's about doing. And then Jerry coins this statement, which Lucia knows very well, and the statement is the following. He says, what the elder is saying is, it comes to behavior change, and this is completely, runs contrary to what we learn in the cognitive processing of information model. Prochaska, stages of change, nothing wrong with it. It's a model, right? It's one way of looking at the world like height is in a certain way. I'm 66 inches or I'm six, I'm five feet. Basically, Jerry coins the statement, and the statement is, based on what the elder said, it is easier for us to act our way into a new way of thinking. Repeat it, it's an important statement. Your pen, if it wants to move, can move. If it so moves, then let it move. It is easier for us to act our way into a new way of thinking, than it is for us to think our way into a new way of almost all the work that we do. Education wise is information transfer. Think your way into a new way of acting. Nothing wrong with it, it's one way. All the models that we have, you go from psychology 101 to 501 to 1001, begin with stages of change, even going back to pre-contemplation. Pre-contemplation to knowledge, to contemplation, to comprehension, to intention, to attitude. And you ask the question, what stage of change are you? Or your client, right? Nothing wrong with it. It's a mental model, but it's a very cherished and dominant mental model. What Jerry is making sense, with respect to what the elder has said, is begin with doing. That's a very different place to start. So they asked a very simple question. The question was, how do we get people to do this? And when you ask a question like that, go back to Einstein. The question is not, how do we tell people? And how do we show them? The question is, how do we get them to do it? If you ask that question, the response would be very different. And then the answer emerged. Well, in Vietnam, women get together and cook. Oh, they do? Oh yeah, they do, as in any other part of the world. And guess what? If you're the host, somebody hosts, right? If you get together to cook. And if you're the host, then what privileges do you have? You can tell people what they can bring. In Vietnamese, the context, the custom, is called the price of admission. If you are the host, you can tell people what the price of admission is. It's a reasonable price of admission. Really? Okay, see, you've asked a different question. How do we have people do? So now you're saying, well, people actually do do this. They do cook. Oh yeah, they do cook. Okay, and the host has certain privileges. So now imagine you're the host and you have certain privileges. You invite some women to get together and cook. Whom do you invite? The ones who are still green or red? And what do you ask them? So what do you ask one of them? What should she bring? Greens of sweet potatoes. And she says, what? You aren't me. Would you please get me some greens, the freshest greens from your sweet potato? Really, yeah, uh-huh. So what do you have to do? You've got to go to the fields and you've got to bend and you've got to pluck the greens and she's also told you, wash them, put them in a bowl and cover it and bring it. You do it. You have acted your way, acted your way. And then what do you tell the others? What are you gonna bring? The teeniest, tinier shrimps. Really? From the fields? Yes. Can you do it? Yeah, well, I guess. So what do you do? You go. You bend. You pick them up. You remove the crust. You wash. You put them in a bowl. You cover it. You bring it. These are multiple acts. Doing, right? You pick up the kid. You ask for permission. You pick up the kid. You hold the kid. You administer verbal anesthesia. Somebody fine? They're multiple acts. And then you get together and you? Oh, some green leaves. Really? Yeah, throw some. Shrimps and crabs, no problem. They know what they are. They're just teeny. This would be the equivalent of you making beans. The teeniest, tiniest of beans that you're used to eating, right? You'd be okay with it. And then what do you do? You've cooked, acted your way again, right? Throw this. You throw this. You throw this. Now, you've got something. What do you do then? You active, you put your, you know, you say, well, children sit down. Yeah, sit them down. And you model that, right? It's not that you gotta stick, do it. No, it's like, let's, yeah. Before that, baseline, don't forget research, no? Have the mother's way, their kids. Plot it, right there. Today's date is, this is where my child is. Feed the child. Oh, my God, they eat most of them. You know, maybe 5% of them didn't. That's okay. Most of them like it. They're eating it. Oh, you know, it's not poison. They're eating it. And they've heard a little about this, anyway. And then they're encouraged when you go home, do this. See if you can have this, see your child. And the next cooking session is in two days and it's at your home. Ah, okay. And you're the host. What do you ask you to bring? Get the idea? You're asked to bring shrimps and crabs. What do you have to do? You've got to go and bend and act. 10 cooking sessions in three weeks. And in between. And every time you make, cook, feed your child, monitoring, you have the mother's way, their kids, and plot. What happens in two weeks, three weeks? Can you see it? You've done it? It's not a question of telling. You've done it. Get the idea? So, just before we, we've got a, time is 11.54, we've got five more minutes. Yeah, okay. So the process here that's important is self-discovery. That the community self-discovers what is uncommon. Because only the community knows what's uncommon. The expert may not know. So positive deviance is a process which engages the community to the extent possible. You can just do PD as research, as some of us do. But given the work that you're doing, active engagement of the community. This is one of the cooking sessions. And do you think you can locate Monique? Is she standing up and talking down at them? She is with them, no? In the blue with jeans. I've got a long story short. You can read more about this. I can send you. It was a special issue of the Food and Nutrition Bulletin which is a peer-reviewed top of the line nutrition journal came out of Emory University. 16 peer-reviewed articles on the Vietnam case. This was very well-studded. And it talked about how, using the positive deviance approach. This happened in Vietnam. Not overnight, not over six months, over years. Did the solutions vary from community to community? Yes. In some places there were more chickens that are using eggs. In some places there were eels, they were using that. Some places they were using spinach, you know. So the Vietnam case is a good segue into at least defining what we mean by the positive deviance approach. We haven't done that yet, although we have. But visually that's interesting. There's some people, ordinary people, or institutions. Who have found better solutions, even extraordinary solutions, to complex social problems against all odds. That's the deviation from the main. Their non-normative behaviors take them to a better place. If you're interested in data and you like normality, and we know that the normal curve is the holy grail of social science work and positive deviance flips it. It basically saying, well, you can look at normality, but a normal curve by its very definition and by its very manifestation privileges normality. Privileges, what is average, the more standard deviations away you are, you know, we even test our hypothesis, right? P less than equal to 0.01, less than equal to 0.05. We don't like outliers. PD is saying, well, love outliers, especially on one end of the tail. Especially if those outliers are collected, are there through your data gathering. It's a data-driven process. I've explained to you how it's a data-driven process. Red dots, green dots, begin with green dots, keep eliminating green dots, keep eliminating until you get a few that are unexplainable. Outliers. So we'll end here. Before we end, of course, here are the PD steps because that was the mandate, that was the milestone. You always begin at the bottom. What's the problem? A clear definition of the problem that I'm trying to solve. And a very specific, a very specific definition of the problem, 65% of the kids in Vietnam under the age of five are malnourished. It's a very clear definition of the problem. And you can further add, if you are the poorest of the poor, if you live in rural remote communities, 80% of the kids under the age of five are malnourished. You define the problem. Then what does PD do? It asks the Einstein question. Are there positive deviants? That's the determining question. Are there children under the age of five who come from blah, blah, blah, who blah, blah, blah? So the question has to have Mother Teresa in it. What's working? They are well-nourished, that's working. They face the highest odds. They are the fourth class. They shouldn't be where they are. Gandhi. Einstein is the determining question. That's the all-important question. It's the who-done-it question. It's an improbable question. It's a question that's never been asked. It's a question about what's working and what's working against all odds. And then if the answer is yes, you've got some families, those six dots in a community, those 24 dots that are unexplainable, then you come to discovery. What the heck is happening? That's making the difference. What's the secret sauce? What's the difference that's making the difference? Discovery. Self-discovery. Community-based discovery, to the extent possible, because they will know what's uncommon. You may not know. And then you design an intervention. But what's the principle of design? Is it tell? Is it show? Well, you can do telling and showing. It is to create the conditions for people to act there. Get the idea? And then it's discern. What is discern? Dissern is just making sure that there is monitoring. PD believes in the creation of tools. Visual mapping, red dots, green dots, rectangles, circles, the mothers weighing their kids, plotting. You are always creating the tools. The community is creating the tools so that they can discern their progress. So when we are doing work with hospitals, each unit had to, how many MRSA infections we had three months ago, that particular week, and how many did we have two months ago, that particular week, and how many did we have last week, and you see that, no? They are discerning the progress they're making. So if there is a red bar, it's like, oh my God, somebody here screwed up until it gets to zero. Discernment. So the monitoring is critical. And PD works with the community to create those metrics and measures and disseminate. And then it has a scaling dimension. How do you scale it? PD scales in a very different way. It's not like replicate, multiply. But we wouldn't talk about that because even before you get there, you've got to make something work. So once you make something work, we'll talk about scaling. Works in very different ways. So PD servings, food servings, yeah? So we'll save PD servings and PD application for post-lunch. But thank you all, you've been great. In the morning when we came in, I said, why do I have my vest? I'm so glad that I, and there's a reason I didn't wanna just sit on that stool. There's a reason why I want to. All right, so welcome back. Afternoon session. And Catalina, you're here someplace. I believe we go on until about 3.30 because I'm told that we need to be out of this room by four. So we'll try to finish by 3.25. How's that? And we'll go as far as we can without worrying about me, making sure that you've seen my 57th slide. And if that's okay with you, I mean, I can go and make sure that you see my 57th slide as well. But I think we've made good progress. We've done setting the stage, the philosophical underpinnings of PD, the blank page, the flip. And then where did we go? We talked about the narrative frame, the flip. Mother Teresa and Gandhi and Nasiruddin's donkeys and the question, the Einstein question. And then Vietnam, yeah? And was the Vietnam case helpful in seeing the connections and the steps? Now it's not that you would become, although you may become an expert in positive deviance with these stories and knowing these steps, but you at least have a sense of what the journey looked like or looks like in the positive deviance process. The expert who is so full of themselves here has to recognize that the wisdom, the solution, the answers really reside with the people. And so you are trying to guard against the folly of expertise, of finding problems, what's missing and creating the conditions for the wisdom that already exists to surface. Yeah, okay. As you can see, I'm just engaging in chatter while everybody settles down. I may be sounding very erudite, but okay. Now that pretty much everybody is in place. We'll go to some PD servings. So by servings, well, you know what servings are. So PD has been served or PD has served communities in different parts of the world and I thought I'll bring some examples to you. So we go beyond Vietnam. It's the classic case. Everything is not as neat or as neatly defined as or narrated as it was. So let's talk a little bit about some other experiences. And then depending on where we are at, so Catalina, we promised we'll finish at 325. Yeah, before 330. And are you sitting close to some resources, Catalina? So what Catalina is holding up are, so the social justice initiative that Dr. Lucia Dura and I direct at the University of Texas, El Paso. We have been at the forefront of, I think I can say at the forefront of systematizing and codifying the positive deviance work. And so we have some publications in collaboration with other publishers. And thank you, Catalina, you're doing a great, yes. And so there's some few of our publications that you can get from Amazon. That's probably easiest if you have Prime and so on. You know, you can order them. But if some of you get intrigued enough and you think you may want to pick up a publication or two, we use the funds that we generate from the publications for social justice activities and also the price that we are able to offer you at is at a 25% discount price than Amazon. So it's here. If you have an interest, it's available in the here and the now. And I think we say cash is good. We say checks are phenomenal. You can make them out to UTEP because the social justice initiative is part of UTEP so the money goes directly. And credit cards are also possible. And for that you'll need to be in touch with me because on my iPhone I can now be a vendor apparently. So it's all possible if you so choose to. All right, so PD servings, analyzing PD applications in community settings to address complex social problems, okay? So let's give you some examples. So as I think we've said, you know, the approach has been around 25 plus years. Conceptually it's been around even before that, you know, arguing that there are outliers, there are positive outliers and that it was operationalized at the field level in Vietnam, codified, systematized, studied, you know, brought to the attention of the world and it has gone on. It has had legs since then. But it's, but we've still scratched the surface. For those who may be interested, the positive deviance approach has about 200 peer-reviewed articles only. If you want to just think about how many peer-reviewed pieces there may be just on diabetes. And those who are at the highest risk for diabetes, you're probably talking thousands. So here we are talking about an approach that's applicable to solving complex social problems, going beyond obesity, diabetes to include. And it's, we are at a very early phase, which means any work that you think you may do with this approach, you will be pioneers, the first wave, really. The world will notice, I think. And there's mounting evidence of effectiveness under certain conditions. So there's some resources which are available. And we want to spend a little bit of time talking about, you know, an arena that many of you know a little about, healthcare. But it's in the context of something which seems very simple but isn't. You would think that hand hygiene, washing your hands before you touch a patient, gowning or gloving, wearing a gown and gloves, or putting patients in isolation if you're in a hospital would be simple kinds of things to do. But they really aren't if you look at the data because there's ample data to suggest that there are about three and a half million hospital acquired infections in this country, the United States. A year, no? Three and a half million. And you would guess that these infections are more preventable. They're three and a half million preventable infections. And they're about over 100,000 deaths. That's more deaths than breast cancer and road accidents and whatever else combined. It's under the radar. You go to the hospital to get better and then you hear always got an infection. And how did that infection happen? It happens because somebody did not follow hand hygiene protocols or gowning and gloving protocols or isolation. And these are very trained people. Do you know who the worst offenders are? If I were to just say physicians versus... And do you know among the doctors who are the worst offenders? Data, right? I'm not saying every surgeon, but we're talking in aggregate. That's what data does is it aggregates. So people die when they shouldn't because they're preventable. So this is your friends. These are your near and dear ones. 100,000 of them each year. And you would think that washing hands, I mean, what's the big deal, right? In a hospital, everybody should be doing it. But hand hygiene compliance rates. Do you know by hand hygiene compliance rates we mean how many out of 100 hand hygiene compliance situations? How many people actually follow the protocols as they should? Do you know how many? What's the number? It's about 40 in aggregate. 4-0. Which means that every time somebody in a hospital setting touches you, a healthcare provider touches you, there's risk. You're at very high risk. Two and a half times the bad kind of risk for that touch being a vector of infection transfer. And all these bad superbugs, MRSA, they transfer by touch. And they have a shelf life of six to eight weeks to months. So US hospitals, it's a very big issue. It's a political issue. It's an economic issue because which hospital would want to admit that they were responsible for the patient's infection? You know what the consequences are, right? And I guess some do. And it's very invisible too, right? Who can attribute this particular touch as, so there are lots of difficulties of pinning down where things went wrong, what made it possible for it to go wrong. And also, there's really no incentive to say, hey, I did wrong, I killed somebody. You know about liability and insurance and you're not gonna get paid for the extra stay that you get. So it continues. It's the MRSA rates in US hospitals are going up, continue to go up. In fact, 60% of all hospital acquired infections in the US are MRSA, methicillin resistant staph aureus. So in 2005, six hospitals who had sort of hit their heads and who cared and I think all hospitals care. Their CEOs basically said, they heard about positive deviants and it was like, is this something which we can use for infection control? Was the question that was posed. And Jerry's answer, Jerry's past now, he passed in 2008, but his answer was, I don't know. I don't know what MRSA is, but the people would know. And so we first began work at the VA in Pittsburgh. And I was sort of describe, I was writing the Pittsburgh story of what was happening and so on. And three years, three and a half years later, the answer from the six pilot hospitals was yes. You can reduce hospital acquired infections and MRSA infections by a whopping 70 plus percent by using the positive deviance approach. So that was sort of the first test of the positive deviance approach for a problem that was going like this and the trends had been like this in some places where it was applied. Now you'd say, well, this must have been gobbled up by other hospitals, right? You would think the VA actually did a pretty good job, but, and that's the nature of change. That's the nature of how things work. So some very simple questions were asked in these hospitals because positive deviance believes fundamentally that wisdom is distributed, right? Expertise is distributed, you know, with the mother who adds shrimps, the one who bends down, the one who, the solutions don't always, in fact, very rarely do reside with experts. The belief, fundamental belief, is that wisdom is distributed and it often lies in places that you least expect. That's where the donkeys are, right? They lie in places where the expert least expects, like the customs official who's looking everywhere but missing the donkeys. So the general question that was asked in these hospitals was, are there, does the wisdom reside with people from all walks of hospital life? Not just with the infectious disease specialists, okay? That is a big leap that you are now including and inviting and that's the reason why this book is titled Inviting Everyone. It's available here. Healing healthcare through positive because everybody was invited in these hospitals. Everybody, not just the infectious disease people, to see if there was hidden wisdom. And, you know, the story is very well documented. I'm not gonna go into the details but I'm gonna give you some simple examples so that you can see how, by posing a different question, is wisdom distributed among patients, among their family members, among their children, children, oh yeah, among chaplains, among transporters, among ambulance drivers, the people whom you ordinarily would never, the housekeepers because they are the ones who take their mop from one room to the other. You know what happens when, and some of them have certain practices which make sure by dipping their mop in a certain something every time, you would think that happens all the time, it doesn't. There's some who do it and who do it in a certain kind of a bleach or a certain kind of a this thing which, and you'd say, really? I mean, that makes a big difference. As I've told you, most chaplains don't but there's some chaplains we found who for some strange reason had a plastic cover on the Bible and used wipes before they, that was a normative practice. But they were doing it, the wisdom was there. We found Daryl, a patient at the VA, I'm gonna tell you Daryl's story. So Daryl made sure before any healthcare provider touched him, he was safe. How many patients can say that, that they can ensure that? Daryl pretty much had nailed it. And we found him because we asked a question, are there patients who are doing this? And the nurses said, oh God, try going into Daryl's room. They'd been there, right? So what happens when you enter Daryl's room? He, if he doesn't hear, you go for the wash basin or he doesn't hear the alcohol, dispenser goes squish. Daryl looks at you, invites you, smiles at you. Looks at you as you come in, he's very respectful. And then he very gently looks away. It's like looking at you, like hello, welcome, you're here, you're not going there, you should be. Wash your hands, you're not washing your hands. You're not doing that, so he'll smile and he'll look away. Now what does that do when you look away? It's like, and then he smiles of course as he's looking away, and then he'll look back at you. And now with a nod and a wink. And he doesn't say it, he doesn't use words. That's the genius of Daryl, that's the secret sauce. It's playful, it's manifest in making eye contact, welcoming you, and then the simple act of turning his face. And then keep smiling, look back. This is non-normative behavior. Patients, 98% of them don't even know the virology, or the bacteriology, or the epidemiology of infection. Somebody's there in the room, they're happy, maybe. Daryl knows, and because he knows, and because even though he's one of the few who know, even among those who know, he has figured out a way in a very polite, playful manner. So where does the wisdom lie? With the patient whom you least expect. And you can unearth this wisdom, and then what do you do? Okay, so once you, right? Once you've discovered, go back to the Vietnam steps. You've defined the problem, MRSA in this hospital, 65% of new infections are MRSA, and healthcare providers don't wash their hands. Are there some folks who, blah, blah, patients? You find Daryl. You've asked a determining question, you find Daryl. Now you discover what he does. You detail what he does. And now you, how are you gonna make it actionable? Are you gonna tell people? Show people? You can, there's nothing, you know. Yeah, so what did they do at the VA? They went for a little 50 cent laminated poster. And who came up with the idea, the patients did? They asked them, what should we do? We've unearthed this wisdom. How do we make it actionable? Okay, well, how about we make a little poster? Okay, what does the poster say? Patience, you have a right to clean hands. Please remind everyone, they said make it bold. To sanitize or wash their hands when entering and exiting your room. Because the normative practice was after, when they're exiting, they definitely wash their hands. What kind of a message does that send? These words came from them. They emerged out of the donkeys that were found when a certain question was asked. And based on this discovery, the patients, the community was asked, how do we make sure we protect you? How can you make sure they said, please make us a poster? Because it's very hard for us to tell people, wash your hands. What, the surgeon, I'm gonna be under a scalpel the next morning, but I'm gonna tell him, hey doc, wash your hands. Because he did wash them, and guess what? After he washed them, you know, maybe his wife called. And of course he's got to answer, no? And so he touched his beeper or his phone. All right, you've gotta go back to hand. You can't tell, hey doc, you washed your hands, but. So, and then they said, put it, put it up in a certain location. Oh, where? Well, if our beds are facing this way, it should be smack right in front, front wall. Okay, then you don't need to be a Daryl in terms of theatrics, right? You've removed, although if you still wish, you could do it, right? If you knew the Daryl story and how. So when patients are now, when patients were admitted at the VA, that's part of their check-in procedures. Patients, this is there. If a healthcare provider walks in and they're not washing hands, you just keep staring at that, no? And if you've been given the poster treatment one or two times as people had been given the Daryl treatment, you know, it's like, oh, shit. Sorry, that's like, let's see what happens. They're going into Daryl's room. Get the idea? Simple. You would never expect. We met Jas Papama, Albert Einstein. Hospital. Late, Jas Papama. Passed away in 2009. Jasper has a method named after him. It's called the Jas Papama method. The transporter. What does he do? Escort department. He escorts people. He moves them from one unit to the other. Worked there for 30 years. Jas Papama had a secret sauce which the donkeys had been coming and going for 30 years. We talk about the importance of gowning and gloving. So by very definition, you know, when you talk about sweet potatoes, you're not talking about the shoots, right? So when you say gowning and gloving, people pay a lot of attention to putting on the gown and putting on the glove. There's very little attention to de-gowning and de-gloving, right? Because it's about gowning and gloving. When do you really need to be careful when you're putting on the gown or once you're removing the gown? What's the purpose of the gown? Protection from what? Germs. And where do the germs get on? The gown and the glove. They don't get on as you wear it. This Jas Papama had a method for de-gowning and de-gloving. And you know, it's likes to dance and move. And I mean, this was an art form. So a year or two after this project ended during, a year or two into the project, we asked him if he would do a video of the Jas Papama method, which he did. And it doesn't bring out his personality, but you learn about de-gowning and de-gloving. Do you wanna see? Let's see if we can get it to play. And don't worry if you don't hear Jas Papama. He's very soft-spoken in this, although maybe we'll hear him. But if you don't, just watch him. But this is what he'll do as you see in the image. Hello. Hi. I'm Jas Papama. Hello. From the Albert Einstein Medical Center escort department. I'm here to show you a simple technique of disposing of isolation gowns after contact in an isolated room. It's a method that's very simple. Notice the gown has been inverted. Now, start to make a nice little ball. This prevent air from getting in and making it too hard to handle. Nice, slow roll over and over and observe the glove. Grasp in the middle. First one goes over the top and the second one goes over there. Creating a nice little ball that you can now dispose of in a trash can anywhere from 50 to 150 with no spillage. Thank you. Hello. Oh, Jas Papama. I'm Jas Papama. Oh, come on, Jas. From the Albert Einstein Medical Center. That's good. A little study, no? Quick and dirty with glow germs. If you use the Jas Papama method versus the traditional method, and you know what that looks like, but that's the normative way. Jas Papama method controls spillage by more than 80% relative to the normative method. And the Jas Papama method, how many did he say? You can now, this ball, you can dispose off from a 50 to 100, 150, depending on the size of the, how many times does that thing need to be cleaned and emptied if you're throwing gowns the traditional way? Hanging out and spilling and you get the idea, okay? Because we don't see it, it's there. So the point that we are making is this is the transport department. Mr. Papama, how long have you been disposing off your gowns like this? Oh, yeah, I've been doing this for 30 years. The donkeys have been coming and going. And the key is not, there's not one donkey, the multiple donkeys that have been coming and going. A thousand donkeys. You, we find a thousand people or a thousand practices, let's put it this way, that exist, which were previously completely unseen. And this is just for one issue, infection control. There are lots of other issues. So he knows how to move. And so we found a nurse who, her morning practice, this is at Billings Clinic in Montana, morning practice when she came in and she washed her hands and sanitized her hands. She would, so let me, a lot of you deal with gloves. When you pull out gloves, how many do you pull out? You're saying what kind of a strange question is that? A pair, right? Typically, I mean that's, I think that's normative practice. A pair. That seems to be the norm. This nurse, when she came to work, she would put her hand in and pull out as many pairs as she could. 15, 20. Oh my God, I mean what's wrong with her? Right? And she would put it in a sanitized. She's an ER, I mean she works emergencies. And let's say there's a code red. And what's happening? Blue, blue. Mix my colors. These are important colors not to mix. And you know, let's say there are people, and let's say the patient has an infectious agent. What does she do? She stands outside and gives them. This is non-normative practice. Why do you do that? I don't know, I just do it. Oh, okay. Because she has 20 pairs of gloves in her pocket, she can do it. So we find another nurse, she must have been from Texas because she carried something in a holster or what looked like a holster was prettier than a holster. And she carried a bottle of Purell. That was a normative practice. Her hand hygiene traveled with her and she could stand and give you a little shot. And she could discharge many shots at once. She could just keep going, bam, bam, bam, bam, bam, bam. This is a normative practice, is it? So then you ask, how can we, it's like, oh no, I don't want that holster thing, right? But the nurses decided, well, maybe we can have pendants, chains in which we can carry our Purell. Oh, okay. So you make it actionable, right? The wisdom is there, you find it. It surfaces and you figure out a way to make it actionable so that people are using it so that they're acting on it. Not tell them, carry your hand hygiene with you. You can read the hundreds of little things that came up just by asking a question, like a Mother Teresa question or a Gandhi question. And a question that in its very essence had a quest to look for the donkeys. There's some doctors, please, doctors are the good people. And yes, in aggregate, they may be worst offenders when it comes to, but look at Dr. Walt. He's got no white coat, no white coat. I mean, what kind of a doctor is he? No full sleeves, no jacket, no tie. He's an infectious disease specialist. He knows that the white coat, the full sleeves, the jacket, the tie, they're all vectors of infection transfer. He knows that, well, everybody knows that. But what's normative? I was at Texas A&M, I told you, and I love Texas A&M. And speaking to medical students, 869 had registered for this. And all the medical students were wearing pretty much white coats and ties, all of them who were in the room. There were 300 in the room and then they were, and of course I had to tell this story in great detail. By telling them that you're all good people, but you should know that there are doctors who don't wear this and they do it because like you, they want to serve their patients. And then I also talked about him in terms of, he sometimes, not sometimes, the stethoscope. If you're a doctor or a nurse, do you like Karen or stethoscope? I mean, bestows some prestige on you, right? It's an extension of your body and then what do you do with it if you're carrying it? I mean, you've got to use it, no? And so you use it, no? It's like unprotected, whatever, no? But there's some who would wipe it with an alcohol swab before they use it. That's not normative practice. Is that normative practice? Hopefully, good, good, good to know. Walt has a positively deviant way of doing rounds. And you're saying, what? Rounds are rounds, right? He's an infectious disease doctor. So some of his patients are in isolation. And when you're a doctor and you're doing rounds, he decides that he does his rounds in a certain way. Certain way, he charts the path to his rounds, really. Whom does he go to first? First, he goes to his non-infectious patients who are in non-isolation. Yes, because doctors can go wherever they want. They're God, right? Are you gonna tell them which patients to go to first? They bounce around the way they want to bounce around, right? And many do bounce around. He first visits his non-infected patients who are not in isolation. And only then later does he visit us. He says, this is non-normative. Is it normative? I don't know. I'm not a medical doctor, but you get the idea? So there are thousands of little things which can make a big difference as in people's lives, as in the quality of care outcomes that we also desire. If you want to use a certain way of looking at the common ground, I think we all want patient safety, quality of care. That's the common ground, even though we live in silos. Doctors, I'm a nurse, I'm a transporter. I'm this many feet high and you are so short, I mean we live in that world. That's the reason why the Lincoln way of thinking is important, I mean you come back to it. What's the common ground? The transporter who de-gowns and de-glubs in a certain way. And a medical doctor who does his rounds in a different way. Or a patient who's figured out a way to nudge and nod. They are all in essence standing on a certain common ground. Even though they are different. So PD embraces that sensibility of that common ground. You're saying the wisdom is not just with a certain expert in a particular silo, but it lies everywhere, it's distributed. And how do we create that norm of that common ground as being the driver of that wisdom being accessed and accessed? I had to somehow loop back to Lincoln because we've been looping back to Mother Teresa and to Gandhi and Donkeys, but a good idea to bring Lincoln back and the notion of the common ground, yeah? You like the fact that we knit these stories into data points and a way of thinking? Because if you were to only remember these notions, wisdom is distributed, lies with the common ground. Forget about silos, oh I'm this tall and you're that tall and I know inches and centimeters, if you get rid of all that, at least conceptually, thinking-wise, you will be at a different place. And then you add the Nasiruddin's, the Donkeys and the Mother Teresa's and the Gandhi's and you'll be at a very different place. So this is what happened in these six hospitals. And some hospitals have continued, in fact all the six have continued. And they've now, once you begin to think in a certain way and you begin to think in a certain way for infection control, you begin to say, well heck, I can apply this to pain management. Big issue, no? Is it? Very big issue. There's some nurses who are far more adept at calling a doctor at 1 a.m. in the morning to make sure that they can, on behalf of their patients, get some pain medication than most others are. You know, most are like, what, I'm crazy? I'm gonna call him or her at 1 a.m. in the morning? And they've figured out a way. Well, what do they do? They first call the pharmacist in the hospital. Why would you do that? Because the pharmacist knows the history of every individualized patient. The pharmacists have a very good idea about the range of pain medication that a particular doctor prescribes or has prescribed for their patients. So this nurse first has a conversation with the pharmacist. You know, I'm sitting here, I know the doctor prescribes a medication for her, you have the range order, whatever, and the patient needs more, is in deep pain. And what do you think? He says, oh, you know, I would think that this, she has an informant, she calls it a curbside conversation. It's not a formal conversation. Yeah, you know, it's on the side. Those are their terms, they aren't mine. They have a curbside conversation with the pharmacist. And once they know what's happening and what is possible, then they call the doctor. Even if it's at 1 a.m. And of course, they know that they've created the conditionality for some irritation because that phone is gonna ring and it'll be answered. And so they're very precise about the first phrase, the first sentence that comes out. This is Dr. I, I'm so sorry I have to call you but I know you care about your patient. It matters what that first sentence is. And it matters you've had a curbside conversation so that your second sentence says something like, it's Mrs. Smith and I've already spoken to the pharmacist and this is the present order. I think we can go up to this much if you'd say yes. Yes, it's a short official conversation. And they love these nurses. The doctors love these nurses because they are invested in the care and just like, oh my God, this nurse does her due diligence before she calls me. And guess what? The pharmacists love it. Why? Because they are so far detached from the actual care of their patients. They love to be consulted on Mrs. Smith. They have their records. They know what medication she's on. And it all came down to finding somebody who's figured out a way to focus on the patient's pain outcomes even though, gee, I can't call the doctor. She's figured out a way. You can learn a lot from her because what she does is completely non-normative including what her first sentence is which she practices a few times, taken several deep breaths as that phone is ringing, right? So deep breaths, taken deep breaths as part of that PD secret sauce. We pay no attention to these things. Secret sauce, small things that make a big difference. And if you do a lot of small things which involve a lot of people, the difference can be stupendous. That's what we are saying. Do you wanna hear a few more cases from outside? Danish prisons, big problem. Well, actually, they're one of the finest running prison systems as measured by recidivism. What is recidivism? Repeat offense. What's the purpose of a prison system if it's in part rehabilitation? Should be. I mean, what's the purpose of a hospital? Is it in part well-being? Okay, good. I'm glad we agree on a few things. Yeah, I mean, you know, so then why are they getting infected if that's the, yeah, or if they're in, okay, so, if they're in the prison and they're spending time while they're coming back, right? You get the idea, and you know, so fundamentally you've got to ask what are prisons, what's the common ground that we can all agree on? Okay, the task is rehabilitation. No repeat offense, no, that's recidivism. You know what the rates of recidivism, recidivism are here in this country? If you look at, you have to always count time, right? In how many years were they back? Five years, it's about 70%. Do you know what the recidivism rate is in Denmark? It's a little higher, it's about 15, which is great. 15%. But they have a big problem. The prison system, gee, I mean, you can say, phew, good job, five times better than the US. More, actually. But there's a problem. And this is the problem that they were trying to solve in Denmark. The problem is those who work in the prison system, if you're a prison guard, official, you are absent on average 35 days more. Get the idea? In a year than other government officials. You have three times the number of mental health prescriptions. You have very high rates of turnover and burnout. Average age of retirement for a Danish prison official is 48. Do you get the idea? They're 20 times more likely to attempt to kill themselves. So there's a prison system, and this is a wicked situation, a prison system that's, whoa, good, but then at a cost. It's a problem. Especially for the Danes, no? I mean, Scandinavia, right? Where you really take care of your people. You pay taxes too. But, and so they've been trying to fix this for a long time. And then they asked a very PD-like question against all odds. So where are the highest odds in a maximum security prison, right? Why do you think the odds are the highest in a maximum security prison when it comes to burnout or when it comes to stress? The nature of whom you're dealing with, right? And this would be like, you know, working only with the patients in the NICU. Right? And you know, or being in the emergency room with a stab wound and a gunshot and everything happening at once. Very high rates of stress because the job, you don't know, I mean, you're walking next to a murderer, you know you're walking next to a murderer or a rapist or whatever. So this case, nothing to sneeze about. This is a, could that go? I mean, I thought I'll make a try and see if some people would, oh, good, I'm getting good at this. So where will we? Okay. So if you're in a maximum security prison, you are at very high risk for all these things, huh? Yeah, exactly. Because stressful, right? There's a maximum security, there are locks after locks after locks and the people who are there need to be locked up after locked up after, you know, and so nothing to sneeze about, as I said. So you're looking at the worst case scenario, right? Gandhi, fourth class, I mean, you know, in this case, it's like I want to see if something's working in a situation which should be really bad. And then you ask the question, are there certain prison officials who work in maximum security prisons who are thriving? And you can measure that, right? How many days have they been absent, right? So I think the measure they used who's been absent no more than five days as opposed to 35, and you can, you know, you can say 10, even that's good. But you're looking at outliers, right? You're not looking at what's normal, what's average. The joy of looking at outliers. Those who, let's say, are in their 50s, no? I'm making this up, but you know, and those would be the kind of criteria you'd be. Those who've had the least number of mental health prescriptions written. So that's what makes them an outlier, that they're a prison official, working in a maximum security prison, very low absenteeism, and among those, very low mental health prescriptions. Among those, you know, it's like you're, all these variables are sieves, right? The answer is yes, there are some. Really, there are some. You know, it's like, who done it? I mean, these guys should be going crazy, right? Why aren't they? Why aren't they? And of course, the answer is, you won't believe. What they do, right? What the heck do they do? You wanna know? It is the who done it. You want to know. That's the joy of PD. That's the reason why researchers like Dr. Dura and I find it interesting. If you're a researcher, I want to know the unexplainable. I want to know what the explanation is because the explanation by definition should surprise you. It's given, it should surprise you. So what do they do? Well, some of the prison guards have just made an informal pact with themselves. And maybe with one or two other people that they will not read the dossier of the prisoner who comes in. How crazy. And the first thing you want to do is read, no? Who's here, right? Like oh, boy, impressive record, no? 11 murders and. Okay, so remember when we were harvesting the secret sauce, somebody said no judgment. What does it do to you if you have little idea of who is in your prison? Whereas what's normative is everybody knows who's in the prison now. What does it do to you in terms of how you behave with them? There's no judgment. You don't know who they are. So you treat everybody the same. But the point is what do they do to you in return, right? What do they do to you in return if you don't know? It's very relational, right? If you don't judge, they must sense it and they must not give you trouble, right? That's it. They don't read the dossier. That seems to be the difference. That's making the difference. That's the secret sauce. This is like Daryl, no? This is like, that's it. It's as simple. And in their own words, they say we, by killing our curiosity, we save our lives. These are their words. Like, well, there's some other people who are thriving, no? What, you know? What explains? You wouldn't believe what these people do. What do they do? There's some guards, very few, who, what's the normative practice? Normative practice is prisoner comes in, much like patient comes in. You fill out whatever, read their dossier, blah, blah. And then you check them in. And then what do you do? You put them in the cell. That's what they're, you know, that's what they're, you put them in the doctor's examining room, right? With prisoners, you don't put them in any exam room. You take them straight to the cell. Maybe you wash them, give them their clothes, and fumigate them, and whatever. Put them in the, I think it's done in some places. Why I don't know, but you know, it's done. So here, they do, the guards do everything as others do. Check them in, shake their hand, get them, and then they do take them to their cell. Except they give them a little detour. Why would you do that? I mean, this is a prison. They give them actually a tour of the prison. How crazy is that? You know, like, welcome to the maximum security. And let's walk through the gymnasium, and you know, we've got weights of different kind, and you know, there's a pool, and you know, you can dip yourself, and the water is at a temperature of, you know, whatever, and here's a jacuzzi, and you know, you get 15 minutes, and you know, the water is just right, and you can blow bubbles if you need. This is non-normative practice. This is crazy. What does that do? That's the question. With PD, you always ask, what is it that somebody is doing? What's the difference that's making the difference? But you also ask, how does what they are doing make the difference? It's not just the what. It's getting a little more deep into PD. How is what that they do make the difference? How does the adding of the, it's not what they do. Oh, I add sweet potato shoots. How does what they do make the difference? Oh, it's rich in vitamin A. It's rich in, oh, when you break the meal, you get the idea? So the question to you is, I've told you what they do. How does what they do make the difference? What else happens? What does it do in terms of the prisoner's orientation towards you? If you've been given a tour, whereas most others haven't been. It's a very humane thing to do. They love these guards who give them tours. I was like, did you get a tour? No, I got a tour. I'm making this up. But, you know, I mean, that's what it is. That's the reason why those who get a tour, it's almost like, hey, don't you mess with that guard? Don't give him a hard time. It's a good guard. The prisoners protect you. The ones who've gotten a tour. You're just giving them a tour. You have no idea that it's protecting you. You're thriving because every, you know, it's like, and when you see that prisoner again, does that make a difference? Does it make a difference when you say, well, gee, I wish we had that nurse. Gee, I mean, you wouldn't believe we, you know, we had that prison guard who welcomed me. Do you talk about those things? Yes, word gets around. That's what they're doing. It's that simple? Oh yeah, how long have you been given tour? Oh, you know, that's, it's been my normative practice. Donkeys have been coming and going. Then a few prisoners were interviewed. Who are the guards whom you really, you know, like don't give a hard time to? Because the stress comes from the hard time. Incidents of violence and so on. They say, oh, we love the guards who respond when we ring the buzzer right away. So think about this. Spanish maximum security prisons don't have a toilet within the cell. You know, there's plumbing and so on and maximum security and, you know, we know about some cases recently, right? Plumbing can, so you've got to ring a buzzer and be ushered into, you know, the toilet area and the guard allows you to do so, right? So guards, what kind of a life do they lead? And what are you doing when, you know, you're close to the maximum security cells? You know, you're just sitting there. You're, you know, you're swatting flies. If they're any flies, they probably aren't in Denmark. You're, you know, playing cards, watching TV and then the buzzer rings. And, you know, this is the scum of the earth, right? Their words, not mine. So what do you do with the buzzer rings? You know, let's do two more rounds of poker before I respond, right? Let's finish this. There's no hurry, right? I mean, you know, and they can wait. Let them squirm a little, no? Even if it's a little. There's some who respond right away. And the guards would say, not only do they respond right away, but as they walk, they jingle their keys. So we know they're coming. And guess what? Unlike most guards who just shove the key in and open the door, because that's their privilege, because they have the, they actually wait outside and knock. I'm here, are you ready? What does that do? How would you like it if somebody just barged into your home because they had a key or into your room just because they could enter? I'm coming. First of all, you've called me, I'm coming. Letting you know I'm coming. And then I even pause and I say, I'm here. You ready? Small thing, big difference. Small thing, big difference. How long have you been doing this? I respond when there's a buzzer and I like to jingle my keys. I like to let them know I'm coming and I like to knock, sir. Is he helping just the guard? Is he just helping the prisoner go to the toilet or is it a little more? He's protecting himself. He probably doesn't even know he's protecting himself that way. But it's that small thing which is making the big difference because we are all connected. So many of the positive deviants, I wasn't using a microphone, but you could still hear me. So many of the positive deviants' behaviors, not all, some. Many are relational. Act of sitting down. You're invited. What do you think? Holding a baby, turning back. That's the reason why they cost nothing extra. And they're there. There's some people who just figured out a way to do things. Oh, but this would blow your. Mind. Is that a good expression, blow your mind? Sometimes I'm not sure. I wasn't born and raised in this country. Blow your what? Always look at Dr. Dura who's my English expert. Nothing to sneeze about. So that I got. Blow your mind. I've heard the expression blow your horn. I don't know what that means, but. Toot your horn. Anybody here who's been to India? If you are following a truck, and there are trucks everywhere, right? And if it's a Tata truck made by the company Tata, at the back in big bold letters is written, blow your horn, which basically means, you know, just keep blowing your horn as you go. Anyway, I don't think we're talking about blow your mind. So this will blow your mind. So we've talked about what we've talked about opening the door, right? If you think announcing your presence and opening the door matters, how you close the door matters even more. So the prisoners were saying, I love this guard. What does he do? Oh, and he begins to talk. When you enter a prison, and if you're in a maximum security prison, what do you hear all the time? Locks, closing, afterlock. Locks, closing, afterlocks. Locks within locks. That's what you hear, right? So the prisoners talking about what does it do to you if you're the prisoner standing like that in a cage? That is what cells look like. They do. You know why cages are made, right? Whom we put in cages. You think these things don't matter? They matter. What happens if you are, when you hear the last click, you go through many clicks, many clicks, and then you hear the last click. It's like, gee, I'm here. I'm in my cage. I've been put in my place. In a very visceral, palpable manner, somebody has clicked the last door shut for you. So that's what they're talking about. He says, what's normative practice? Shove the men, lock the door, right? Whether they're coming from the toilet or whether they're coming from outside. Shove them in, lock the door. That's normative practice. That's where they belong. Lock them up. There's some guards who, before the last click, say, okay, I'm gonna close the door now. Be well, good night. You think we give those guards a hard time? We love them. Again, you see small things, secret sauces. What's working? What's working when it shouldn't be working? The wisdom is here. The donkeys have been coming and going for years. We didn't even know them. And the Denmark study, it's very well documented. By taking this, amplifying it, they did a lot of simulations so that people could practice, acting your way, not telling people what to do. See if you can lock the door in a certain way. I mean, you have your own sign-offs, your signature. You're not gonna control that. But be mindful. So I was talking to a physician friend of mine because my wife had a dizzy spell. She was diagnosed with benign positional vertigo, which is a good thing, no? As opposed to, gee, she's got a cerebellum stroke, right? So we had to rule that out by getting a CAT scan, so on. So I was texting a physician friend of mine who was my physician 15 years ago. And in this texting, I was talking about my wife. He said, Arvind, I learned one lesson from you 15 years ago when you were my patient. I got this text from a few days ago. Really? You've been so helpful to me as, you learned a lesson from me? He said, yeah. Every time I would do a procedure on you, including putting my stethoscope, you would say, hey, Mahesh, that was his name. Would you tell me what is it that you're doing? As you do it, would you tell me what is it that you're doing? And I do this of my current physician, too. Would you tell me what you're doing and what is it that you're finding out and the decisions that you're making as you are doing them? It's the same thing, no? I said, gee. And he said, now I follow that practice with every single patient of mine. Whoa, I didn't even know I was being a PD patient. But he's a much-loved, admired doctor. His parents love him, too. His patients love him. Why? Because he just explains what he's doing. Okay, I'm gonna put this stethoscope and I'm gonna listen to your lungs. I hear some deep breaths. Oh, good, good lung movement, whatever. He's just talking. Does it make a difference? I mean, half the time, you have half. 95% of the time, you have no clue what's going on. Or we are gonna do a CAT scan. Why are you gonna, what's gonna happen in a CAT scan? You know what? You have no clue. Just the end. Simple, small little things, which can make a very big difference in terms of, so hospitals, educational institutions, prisons are very hierarchical, just by their very nature. Power differentials. So relational issues make a very big difference when it comes to the common ground, as you've seen in these examples. Catalina, we're doing okay on time. You're good? It's 2.20, so we have an hour. Do we need a break? Are you all okay? A little break? Five minutes? Will you stick to five minutes? Will you stick to four minutes and 45 seconds? Okay, go. All right, so welcome to my prison. We've got another 55 minutes to go. So I would suggest do a couple more stories, including two from El Paso, one dealing with teenage pregnancy, and one dealing with diabetes. And both of these were actually small little research projects that came out of the University of Texas, and Dr. Lucia Dura was involved as well as advisor on them. And then maybe the last 30 minutes or so, we'll do a little activity, so you can at least ask the question, what does this mean for my work in terms of the next step? Would that be a good place to end? Yeah, Catalina, you're okay with that? Yeah, so we get into PD applications a little, okay? So, oh, the text is, you don't need to worry if you can't read it. You'll get the slide and I'll read it for you. So I have a colleague who now works at Planned Parenthood in Houston, who actually came for the April conference here in San Antonio. I mean, all paths read to San Antonio, it seems, when it comes to positive deviance. The name is Alejandra Diaz. Alejandra Diaz was a master's student at UTEP, and she one day came to my office and said, Prof, would you agree to be my MA advisor? And I said, well, that's very gracious and very honoring. Alejandra, what is it that you have in mind in terms of what you wanna do? And she said, I'm very interested in the issue of teenage pregnancy. I said, okay, yes, that's an important topic. And she said, I'm very interested in looking at it from this lens of positive deviance that you've been talking about in your classes and I've taken a few with you. And she worked quite closely with both Lucy and I on the social justice initiative. So I said, yes, yes, yes, of course. And then of course you always ask, why teenage pregnancy? Why is this an issue? It's a good question. I've discovered as an advisor, when somebody says I want to do this, like, why? I mean, not because you're questioning their judgment, but why because there must be something deep behind perhaps the statement that they've made. And she said, well, I grew up in this border community. I grew up and I know how difficult it was given what was happening around me for me to stay pregnancy-free. That's a deeply personal statement. And then she said, and I have two younger sisters. Oh, okay, and they're both in high school. And I had actually met her younger sisters because one day she brought them to my office, maybe even to a class. And she said, well, I see that several of their friends, people whom I've known for a long period of time are pregnant. So I really worry about my two younger sisters, deeply personal, no? Anyway, so we, I say yes, we proceed, she does a study. And remember, I told you the question is key. What you're seeing, and I'll read it, was Alejandra's Emma Thies' question. And basically it says what enables because there must be something that they must be doing or something that must be done to them which enables them to find a better outcome. Now in this case with respect to teenage pregnancy. So the question was asked by Alejandra and you'll see Mother Teresa in it, you'll see Gandhi in it, you'll see the notion of the donkeys, that the answers are there, I don't see it, the who done it part of it. And the question, which she took a few months actually because you've got to review the literature, you've got to look at who's at the highest risk because then among those you find who somehow are achieving extraordinary outcomes. So a question was the following, what enables some young age is a measurable variable, no? Latina, ethnicity, you can measure that. What enables some young Latina women, women, yeah, you can, man, woman, who are previously, who are presently enrolled in college which means they, because one of the problems is if you become pregnant when you're in high school you don't finish college, you don't finish high school. You don't go to college. So this is a positive variable that they're presently enrolled in college, no? So are the young Latina women who are presently enrolled in college who come from a poor socioeconomic status background, that's measurable, you would, the literature will show you that they're at the highest risk, whose mother became pregnant, mother or a sister became pregnant when they were a teenager, that's shown to be socialization an important factor. Who are presently in a relationship, I mean, you know, that's got to be the case, you're talking about pregnancy, boyfriend or, you know, have been in one or in several, and who, as per their own reporting, have been pregnancy free. These are all measurable variables. Are the young Latina women who come from a low socioeconomic status, who have a mother or a sister who became pregnant when they were young, who are in a relationship and who, for some strange reason, strange, of course that's not part of the research question, but you know you're asking, who for some reason are pregnancy free and guess what, they're in college. Two variables, no, in terms of what's working for them. You see Mother Teresa, do you see Gandhi, do you see, it's a question that's not asked because you would say, you would hypothesize that if you are young Latina woman who are socioeconomic status, mother or sister who became pregnant when they were a teenager, in a relationship, what would you hypothesize? Very high risk for pregnancy, right? Flip it, no, flip, focus on the question, make sure the question is specific, make sure the question is measurable, because you can do that, you know, if your research are doing studies. So she has a question, her committee approves it, proceed, see if you can find any. So she's defined the problem, go back to the PD steps. Teenage pregnancy rates among young Latina women and El Paso County are high. I don't think this says El Paso County, but that was part of it. That's also a measurable variable. You can even say zip code this, that's a measurable, you know, and you can decide where to set the limit. So committee says approved, go ahead. So now it's like, how do I operationalize this? That's part of this thing. And she operationalized it quite simply. She basically interviewed about, I think it was 764. Oh, don't worry, it wasn't really that much. You're saying, oh, poor thing, no. How many years did she spend getting her, she graduated in a semester after she started. Because there was clarity in terms of the question. She decided that she would collect data from students at the University of Texas, El Paso, who were women. Does that take care of a few variables already too? You're in college and you're a woman, right? And she had to go to 760. Well, she went to a few classes and she had a six item questionnaire. No happy faces and sad faces, no liquored scales, no, you know, just a simple binary dichotomous variable, yes, no. So two variables are taken care of, the rest are, ye or nay? Check, no. And age is a continuous variable, what's your age, blah, blah. What if you had all six ye's? That yes, I'm young, Latina woman, I'm blah, blah, blah, blah, and I've been pregnancy free and blah. You are a, what if you don't have, what if you have three ye's or four ye's? I'm not interested in talking to you. She is, but she wants to look at the ones who are at the highest risk who've made it work. You see, it's a very simple process. It's an operationalization, and you can operationalize it in a thousand different ways. But this is the simple way in which she operationalizes it. University students, women, and I'm gonna ask them six questions, you just say check, yes, no, yes, no, whatever. And if you've got all ye's, then there's a little thing that says, if you wouldn't mind, if you've got all ye's, would you be willing to be interviewed in form consent, right? So I don't know exactly what the numbers were, but I think she had like 35 ye's, all ye's. So what percent is that, if you're dealing with about 800? 35 out of 800, four percent, four and a half percent. Of the four and a half percent who had all ye's, eight didn't want to be interviewed. So she's down to what? 27, yeah, 26, whatever. And then off those 26, she realizes that three or four have parents or family members who work with Planned Parenthood. They have access to extra resources, right? They're explainables, no? Are you interested in the explainables? Remember, elimination. You're only interested in the improbable, the unexplainable ones. So she's left with 22 who are willing to be interviewed and she interviews them. Do you know what she finds? How do you think I should begin? Would you believe? Well, she found a few things. And she presented this in San Antonio a few months ago. One of the things she found is that the mothers of these 22 young women rarely, if any, had ever had a conversation with their daughters about the issue of sexual responsibility. What would the expert think? I mean, you know, the moms are chatting up. You know, just every moment they're talking about, don't have sex, don't have sex. Stay away from that good-looking guy who's wanting to take you out dancing and so on. Apparently, her research seemed to suggest that the conversations were not in that domain of like, don't do this. But the conversations were more in the domain of finished school. The conversations were not about don't have sex, don't go out dancing. Conversations were about do whatever you need to do, finish school. You've got to finish school. Look what happened to me. You've got to finish school. And that conversation happened multiple times a day. So there was no conversation about don't do this. A few, not every day, but multiple times a day. Remember, mehita, whatever you do. Look what happened to me, I had you. Got to finish school. You got to finish school. You know, this is like the nurse who calls the doctor and says, I know you care about your patient. The wording, what is said, how is it said? Is it don't do this versus do this, finish this? And not just finish school, you have my full support. I'm working hard so that you can go to school, that you can finish school. And that support is also manifested, palpable. So these are not empty words, finished schools. You know, you mean it, you convey that meaning. You affirm it, you validate it, you repeat it. And you engage in behaviors that are supportive. Right, and these are. And what do teenage pregnancy campaigns do? Typically, whom do they target? Young women, don't do this, not good. Why, because that's the problem, right? The problem is teenage pregnancy, so the solution is don't do teenage pregnancy. That's the way we think. What don't they know? Why aren't they favorably disposed? What intentions don't they have? What behaviors don't they practice? You just go down that path. Nothing wrong with that, it's one path. PD takes you to another path. Can take you to another path. Through a systematic data-driven inquiry. Get the idea? So what implications does it have? If you were to say, well, Alejandra's thesis expands the solution space, you know, what implications does it have if you are a interventionist, if you want to design? Basically, it's really not about don't have sex. Yeah? It's about be in school, finish school, have supportive parents, have mothers who affirm that, who validate that, do it repeatedly. Which means any program for teenage pregnancy should include mothers. That's what it seems to suggest, maybe. It's like, really? I mean, why? But they're not the problem. Well, you see, you're looking at the solution, you're finding the solution, and then you see what works. And she found another thing. Another thing, you wouldn't believe. Right? Most of these young women have a man in their life. They all have men. I mean, you know, they had to have a partner. They had to be, yeah, but it's not that man. Not that man? Yes, not that man. There's another man. Who's this man? It's actually not a father, usually. No, it's somebody whom they respect. And whom they've respected for a long period of time. Could be an uncle, could be an elder brother, could be a cousin, could be a neighbor. Somebody who's been there for them and who has affirmed and validated them at different stages in their life. Who have given them a sense of self-worth, self-esteem. You go, you're a good girl. We believe in you. Really, what difference does that make? In their words, they're saying that having that affirmation, that support, that male role model, gives me a sense of self-worth. That my identity is not tied to me given my body away to. Okay, wow, that's insightful. So if you are an interventionist, if you're designing a program, what does this say? Is it just about the girl, the problem? Don't have sex? Well, maybe there's some value in having mentoring relationships. Maybe? Get the idea? So I'm just giving you this as an example. And Dr. Dura has done quite a few studies using, so one of your studies was with medical students. Just give a little one minute. Yeah? Maybe invite her. So can you refresh my memory, Arvind, because I was completely in a different zone? I just, it's new, it's not that I don't remember, I just was thinking about Alejandra's thesis for some reason. Okay, so yes, at UTEP, we are, you could say we're a positive deviant school in that we send a lot of Hispanic students to medical school. So only out of all medical school applicants in a given year, only 8% of them are Hispanic. And the problem with that is that it's not reflective of the actual Hispanic population. And the number is even lower for African Americans. So we decided that even though UTEP is almost 80% Hispanic and is pretty successful or on par with the national average at sending students to medical school, we wondered if there was anything that we could do at UTEP or that we were already doing to improve those rates further. So we were wondering if there maybe are any professors who are doing anything special or any advisors or any groups or any students. So we did a very small pilot study and I wish we had interviewed 800 students like Alejandra but we found emails of alumni who had already gotten into medical school. So the question became, are there any UTEP students who have already been accepted into medical school and who are Hispanic, but you want to add to that more odds, come from a low socioeconomic background and whose parents are not doctors and even better if their parents are blue collar workers. Because one of the questions we had is a lot of times when being a doctor is part of your dinner table conversation growing up, then it's in your world and you think it's possible but many of us don't become doctors or medical professionals at that because we don't think it's possible. It's not in our purview. We think, well my dad was a factory worker so I'm probably gonna be a factory worker too or we tend to follow those paths. So anybody who wasn't supposed to dream big but did, that's who we were looking for and we found that a lot of students, a lot of people did make it into medical school who had graduated from UTEP since the 60s and we thought this is great but we need these practices and behaviors that we obtained to be relevant to our population so we looked at only students who had gotten into medical school since 2007. Out of about 300 names and emails we had a hundred and some complete the survey and from those we found eight positive deviants one of whom did not want to be interviewed. So we interviewed seven and one of the most interesting I think behaviors or practices that came about was by a girl's mother so I don't know how it is here or how you grew up. I went to St. Mary's so I stayed at the dorms so studying was very easy for me. I just, I had a desk and yes I had a roommate that brought a Rottweiler in one time to live with us and a few things that were sort of unexpected that made studying hard but I always had a place to go. This one positive deviant student from El Paso she lives about 40 minutes away from the university so her commute without traffic is 40 minutes and parking, et cetera, if she wants to go to the library it's gonna be an hour of her time so in order for her to study at home she lives with her family, her extended family in a small house so you can imagine that there's always somebody coming and going and there's a lot of distractions and for the MCAT her mom decided to help her so she supported her and she not only put posters up of the different things that she was studying so she helped her kind of decorate their house with visuals for the test but she also put up a curtain in the living room and when it was time for this girl to study the mom drew the curtain or she drew the curtain and everybody else who was living with them knew that this was her time to study and that they had to be quiet just for that particular time so for me that was wonderful because it's a very small thing, the curtain, not expensive and yet it made a big difference it gave her that time and that space and it showed as Irvin was saying how, right? So not just the what but how, what does this do? It gave her the support that she needed it showed that her family encouraged her to pursue this very challenging dream so we had, I can't remember, I can't think clearly I'm having like a memory lapse but there was another student who said that he was a hustler and I said okay, so how does that help you because I said what do you do differently? What do you think you do that makes you a successful student when we interviewed him? He said well I hustle, I hustle, I grew up in a neighborhood where there were a lot of drug dealers and a lot of just crime around us so I would see people hustling and I decided to change in my mind what a hustler was so I would be a hustler of a different kind I was, you know drug dealers and criminals who are very successful he said are there all the time they're working, they have their eye on the next target they're quick on their feet and so he said I take those things I'm quick on my feet, I know where I need to go and so what, I thought okay so how exactly does this play out with you as a student and he said well I go into a classroom and I try to identify the smartest person in the room and I'm gonna sit next to that person so I got, it reminded me of my mom telling me when I was in eighth grade and I was sort of misbehaving that I could use my leadership she called them leadership skills for good not for bad so as a leader you can lead in one direction or in another so she encouraged me so when he was talking about hustling in that way finding the smartest person in the room or finding a study group from the very beginning of your career as a student and sticking with that study group for the next four years deciding what I'm gonna do with my time so everybody who succeeded in this study had one of those I guess not a trapper keeper a day runner of some form whether it was electronic or not but everything was scheduled even family time, even play, even and so everything, Arvin calls this whatever you do you can only measure it against the alternative so what I mean by that is everything was a decision either I'm going to be with my family or I'm gonna study or I'm gonna have a drink and if I have a drink I might feel sick the next day so making decisions based on priorities so the way that they made decisions so yes everybody had a calendar and everything was scheduled but the way that they prioritized those elements on their list was unique so I think we're now at the intervention stage and we're trying to find ways to disseminate these practices or to amplify the study and make it UTEP-wide so I would love to see UTEP has some of the lower graduation rates in the state and part of that has to do with our culture I mean we're not, and I mean culture not in the Hispanic culture but I'm saying we're not in a hurry to graduate in some ways, we have full-time jobs we have full-time families we're not a college town that you go and move to and finish your education quickly so we haven't been in a hurry but it would behoove us in some ways to save money and to do things a little bit more quickly so that we are sure we finish so my question to UTEP students would be are there any students who do graduate on time on time according to Texas standards so four to five years and who are they and what are they doing differently so those are some of the implications of this kind of work in education and you could probably see that in medical education as we've done with the pre-med study so thank you for letting me talk she's so quick on our feet as you could tell my feet needed to rest so it's like all right, thank you Lucia so the point is the following there are lots of different areas in which you can fundamentally apply this approach so what's the problem as long as you can define it it's a tough one it's not a problem of others darkness so it shouldn't be a technical solution yeah I'm gonna flip on the light and you don't need PD if you need to flip on the light if it's a complex problem then such as graduation such as who's entering medical school or who's not what is it that they are doing doing differently what's the difference that's making the difference the kind of things that Lucia was talking about so you get an idea that there's a community of scholars, practitioners who have been dabbling who've been working with the area of positive deviance it's still in its infancy really except for some of the cases that I've discussed here Lucia should I talk about Claudia's work so a very recent graduate of ours, Claudia who's a diabetic type two did a study again asking a very similar question like Alejandra in this case she was interested in you know are there diabetics in El Paso County again looking at all the high risk factors which are not listed here who for some strange reason that wasn't part of the question but who for some reason have controlled their diabetes looking at their what are they H1AC A1AC their A1AC measures over a period of time because that which means they've been tested and so on and so forth and with no or low medication so I think her threshold was 500 milligrams metformin bare minimum you know only take that and so on and she actually did find a few she worked with the El Paso Diabetic Foundation and she was able to find some people you know who were the highest of high risks and who really shouldn't have been managing their diabetes well but for some reason they were so what were they doing you wouldn't believe what Claudia found first thing that she found if you want to control your diabetes the best thing you can do is to disclose that you're diabetic to everybody really that's what her study showed so the best prescription that a doctor can write you really is disclose and he's a really what does that do now he's saying what happened how does what happened make a difference what happens when you disclose when your son knows or when your daughter knows or your grandson or your granddaughter knows when your granddaughter says you're already everybody is engaged in your care that's the simple thing that she found you want to take care of diabetes disclose it to everybody or at least that's what the positive deviants are doing no stigma in fact by disclosing they're saying here I am take care of me I need help you know help me as opposed to not disclosing and then you end up at a friend's place and they've cooked your feast and you are eating and you don't want to and now the friend is watching and saying hey you had a little too much of that let's go for a walk so by disclosure what are you doing you're creating an ethic of care with others that didn't exist you're creating a connection a care everybody's taken care of you best thing you can do it's not metformin or it's not glucophage or you know whatever else it's not disclose because that'll make possible all the other things it's like going to the mountaintop I have diabetes that's the way it is take care of me okay gee that's what we're finding disclose a few other things hand recording what? hand recording of what? your sugar levels you record in your own hand with a date what your sugar levels are what does that do? I don't know what that does they talked about gee when I am recording by hand I'm looking at what the numbers were before so I have begun to I've lost a little bit of weight some people say like 10 or 12 pounds and it may not look as if I've thrown my weight around but I have and one of the things I've begun to do Lucia knows about this as do many of my family members is this heart app so today I have walked 1,767 steps which means I should walk a little more and if I know in real time how many steps I've walked I can walk a little more as I'm doing now if I record things in my own hand I know what my sugar levels are it's like gee I mean you know where have they been? that makes a difference it's like read in the dossier that makes a difference seems to if you record in if you get into the habit of recording in your own hand recording your what's it A1 A1C levels every 3 months oh my god I was at 9. this and then I was at 8.7 and now look I'm 7.3 I need to get to 6.4 basically it's feedback in real time which gives you at every moment it's like the daughters knowing every moment finish school knowing every moment dance move we're just sharing with you some findings one more thing what else they have their glucometers and their diabetic supplies lying all over lying all over what does that mean they are there in plain view it's not hidden in a closet it's there on the kitchen counter what does that do if you have your supplies for testing right there what does it do it's there we have our toothbrush and toothpaste and whatever there and reminds us we have soap there imagine if you had to bring the soap out every time you needed to use it these were the small little things that she found okay now I'm not saying this is going to change the world of diabetes but these are really good insights because they're non-normative disclosure is non-normative recording by hand I don't know and maybe people do it some people do it those who shouldn't be doing it to do it we're talking about those right we're not talking about those who should manage their diabetes well we're talking about those who shouldn't be managing their diabetes but who for some strange reason are doing what they do they disclose when most others don't they record by hand and they leave the supplies you've got twenty minutes so we get into PD application and now is your opportunity to take some steps with me so please rise and we'll end with this so before I end and Kathalina knows about this if you're going to be applying positive deviance to your own work there's a wonderful resource guide everything we've said and more and Kathalina we can send the link out to everybody okay so it's called the basic field guide to the positive deviance approach so what should you do next if you're interested see if you can access this and it provides some ideas on it's a very and Kathalina you liked it step by step it describes all these processes and you know how to get the community engaged and so on so it may have some relevance but what we're going to focus on is this that's the question to you and I want each one of you to think about this question so it's an initial exploration you know in the conversation cafe you had some even more preliminary exploration what is the one complex challenge or challenges that you're trying to solve for which you believe based on what you've heard that the positive deviance approach can be useful for your work let's say for your work and we'll do this in three rounds well actually four rounds maybe three yeah see that's the advantage maybe four we'll see the process is called a one two four all so the first step of the process is one which is self-reflection you're the one you are self-reflecting on this question you'll get two minutes but they haven't started now let me walk you through the process once you've spent two minutes reflecting once I give you the go-ahead you after two minutes the bell will ring and you will pair up with somebody and when you pair up with somebody the same two rules apply find somebody whom you don't know or don't know as well and the person who's standing as far away as possible from you not the person next to you simple you will be in a pair and you will have how much time six minutes we may cut it down to four we'll cut it to four I'm looking at you you're saying now four is enough you've done so much talking so two minutes for self-reflection four minutes in a pair which means you can share with the other person which means you get to hear one more person at least talk about what challenge they're thinking and then the bell will ring and you will get into a four so two pairs join together so your pair finds another pair and we'll remove that ten minutes and make it six, how's that? I'll change the numbers there see, it's a flexible plan two minutes for self-reflection four minutes for pairs and then you get into a group of four and in the group of four something changes in the group of four you don't talk about what you have already said in a pair you narrate what you have heard oh my god you've got to be awake in that pair conversation yes so what will happen is you will have heard not just you yourself articulate how you can apply PD but you would have heard three other people's ideas you'll go home with at least four ideas and then if we have time we may not so two four that's six and six twelve yeah we may have time we may harvest one or two you know we may say okay in this group we may ask what was one idea that you think everybody wants to hear if we have time get the idea okay so your self-reflection two minutes begins now think about this when you hear the bell get into a pair and I'll change the timing here two minutes have begun so for the final wrap up in the next five minutes for the final wrap up in the next five minutes we encourage you to please take your seats as you have so we are not going to harvest what ideas there were but at least each person uh... was privy to you know four ideas their own and three more and so this is sort of a time to bring uh... our session together our day together as uh... it has progressed uh... to a close and uh... I will just close it uh... with uh... as they say always close with Robert Frost sort of makes you look good now ride the shoulders of uh... Mr. Frost so uh... Frost uh... these are his words we dance around the ring and suppose especially if you're an expert we dance around the ring and suppose and the truth sits in the middle and okay thank you thank you if you were to rise and to applaud the way you applauded you must have brought so much of you into this conversation so I thank each one of you to close we always close with you uh... and applause is a good way to close uh... I for me but uh... uh... we will close by me randomly not in any random but actually maybe in some order I'm gonna walk up to five people and they'll have a sentence they're closing sentence for what the day may have meant for them and if I walk up to you we will end with five sentences all right so let's go here first what resonates with me is it's about relationships Jennifer uh... for me what I took from today is it's really about looking at things in a different way and reframing what has been taken into our heads over and over and over again and seeing it from a completely different perspective and not the negative aspect but the positive thank you, your name Heather Jo, thank you I think what I hear is that it's a good thing to take off in the direction that your heart leads the direction that your heart needs and the name is Vanessa, thank you be an outlier be an outlier and the closing word to my friend who was born in Vietnam for me it's paradigm shift all right, thank you, we closed it