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Survival After Acute Myocardial Infarction (SAMI) Study: The Design and Implementation of a Positive Deviance Study

The Issue

"Positive deviance" studies identify the best clinical practices of exceptionally high-performing organizations—outliers whose successful strategies could be disseminated and potentially replicated by other organizations. The authors of this Commonwealth Fund–supported study identify the steps necessary to undertake a positive deviance study and then describe how this work led them to discover hospital strategies associated with lower mortality following acute myocardial infarction, or heart attack. 

What the Study Found

There are four stages to a positive deviance study:

  1. Identifying positive deviants using widely endorsed and accessible performance measures.
  2. Generating hypotheses about what accounts for the exceptional performance, often through interviews with key stakeholders.
  3. Testing the hypotheses by analyzing whether and how certain strategies and organizational characteristics are statistically associated with clinical performance.
  4. Disseminating the resulting information to enhance adoption by other organizations.

In their ongoing study of survival after acute myocardial infarction (AMI), the authors first identified substantial variation among hospitals in 30-day risk-standardized mortality rates; such variation in performance is a necessary condition for a positive deviance study. Then, to generate hypotheses, they selected hospitals that ranked in the top and bottom 5 percent of performance and interviewed staff closely involved with AMI care at these hospitals. This work enabled the researchers to identify six domains linked to high performance: hospital protocols and processes for AMI care, organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning.

In the next phase of their work, the researchers will survey hospitals to test their hypotheses.


There is a growing imperative in health care to identify strategies that can promote exceptional outcomes. The authors' work identifying hospitals with high survival rates after heart attacks—along with other strategies gleaned from positive deviance studies—can help hospitals throughout the country make improvements and reduce mortality.

Publication Details



H. M. Krumholz, L. A. Curry, and E. H. Bradley, "Survival After Acute Myocardial Infarction (SAMI) Study: The Design and Implementation of a Positive Deviance Study," American Heart Journal, Dec. 2011 162(6):981–987.e9.