You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Positive deviance: a new strategy for improving hand hygiene compliance.
Abstract 1:
OBJECTIVE To evaluate the effectiveness of a positive deviance strategy for the improvement of h and hygiene compliance in 2 adult step-down units . DESIGN A 9-month , controlled trial comparing the effect of positive deviance on compliance with h and hygiene . SETTING Two 20-bed step-down units at a tertiary care private hospital . METHODS The first phase of our study was a 3-month baseline period ( from April to June 2008 ) in which h and hygiene episodes were counted by use of electronic h and washing counters . From July to September 2008 ( ie , the second phase ) , a positive deviance strategy was implemented in the east unit ; the west unit was the control unit . During the period from October to December 2008 ( ie , the third phase ) , positive deviance was applied in both units . RESULTS During the first phase , there was no statistically significant difference between the 2 step-down units in the number of episodes of h and hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections ( HAIs ) per 1,000 patient-days . During the second phase , there were 62,000 h and hygiene episodes per 1,000 patient-days in the east unit and 33,570 h and hygiene episodes per 1,000 patient-days in the west unit ( P < .01 ) . The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit ( p = .04 ) . During the third phase , there was no statistically significant difference in h and hygiene episodes per 1,000 patient-days ( P = .16 ) or in incidence density of HAIs per 1,000 patient-days . CONCLUSION A positive deviance strategy yielded a significant improvement in h and hygiene , which was associated with a decrease in the overall incidence of HAIs


Title 2:
Reviewing studies with diverse designs: the development and evaluation of a new tool.
Abstract 2:
UNLABELLED RATIONALE , AIMS & OBJECTIVE : Tools for the assessment of the quality of research studies tend to be specific to a particular research design ( e.g. r and omized controlled trials , or qualitative interviews ) . This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches . The aim of this paper is to describe the development and preliminary evaluation of a  quality assessment tool that can be applied to a method ologically diverse set of research articles . METHODS The  16-item quality assessment tool ( QATSDD )  was assessed to determine its reliability and validity when used by health services research ers in the disciplines of psychology , sociology and nursing . Qualitative feedback was also gathered from mixed- methods health research ers regarding the comprehension , content , perceived value and usability of the tool . RESULTS Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of ' good research technique ' being assessed . Face validity was subsequently established through feedback from a sample of nine health research ers .  Inter-rater reliability was established through substantial agreement between three review ers when applying the tool to a set of three research papers ( κ = 71.5 % ) , and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability . CONCLUSIONS The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies , and may be an extremely useful tool for review ers to st and ardize and increase the rigour of their assessment s in review s of the published papers which include qualitative and quantitative work


Title 3:
Factors that enable nurse-patient communication in a family planning context: a positive deviance study.
Abstract 3:
BACKGROUND Family planning programmes in developing countries need a better underst and ing of nurse-patient communication in order to improve the quality of counselling . OBJECTIVES To identify factors in the clinic and in the community that enable nurses and patients to communicate effectively with one another . DESIGN The study explored the personal experiences of nurses and patients who communicate especially effectively during  family planning consultations  ( so-called " positive deviants " ) . SETTING Sixty-four r and omly selected public clinics located in East Java , Indonesia . PARTICIPANTS Seven positive deviant nurses and 32 positive deviant patients were identified from among 64 nurses and 768 patients who participated in an earlier patient coaching study . Flooding prevented 5 patients from participating in the study , reducing their number to 27 . METHODS Investigators conducted : ( 1 ) a content analysis of qualitative data collected by structured in-depth interviews and focus-group discussion s ( FGDs ) with positive deviant nurses and patients , and ( 2 ) analyses of variance ( ANOVA ) of quantitative data on clinic , nurse , and patient characteristics . RESULTS Positive deviant nurses identified four factors , listed in rough order of importance , that helped them communicate effectively : independent study to strengthen their knowledge and skills ; communication aids ; feedback from colleagues ; and motivation stemming from a desire to help people , patients ' appreciation , husb and 's support , and increased income . Positive deviant patients identified five enabling factors : motivation due to their need for a service ; confidence in their own communication skills ; positive feedback from nurses ; belief in patients ' right and responsibility to communicate with nurses ; and communication aids . CONCLUSIONS Insights from positive deviant nurses and patients suggest that efforts to improve nurse-patient communication should go beyond conventional communication skills training . Managers should consider a mix of clinic-based interventions ( such as peer feedback , communication aids , and better management of patient flow ) and community-based interventions ( such as patient education and mass media )


Title 4:
Information system support as a critical success factor for chronic disease management: Necessary but not sufficient
Abstract 4:
UNLABELLED Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practice s. Informatics tools are needed , yet implementing them remains challenging . OBJECTIVE To identify critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice . DESIGN A prospect i ve case study of positive deviants using key informant interviews , process observation , and document review . SETTING A chronic disease management ( CDM ) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline -based flow sheet . PARTICIPANTS Thirty community-based physician participants using predominantly paper records , plus a project management team including the physician lead , project manager , evaluator and support team . ANALYSIS A critical success factor ( CSF ) analysis of necessary and sufficient pathways to the translation of knowledge into clinical practice . RESULTS A web-based CDM ' toolkit ' was found to be a direct CSF that allowed this group of physicians to improve their practice by tracking patient care processes using evidence -based clinical practice guideline -based flow sheets . Moreover , the information and communication technology ' factor ' was sufficient for success only as part of a set of seven direct CSF components including : health delivery system enhancements , organizational partnerships , funding mechanisms , project management , practice models , and formal knowledge translation practice s. Indirect factors that orchestrated success through the direct factor components were also identified . A central insight of this analysis is that a comprehensive quality improvement model was the CSF that drew this set of factors into a functional framework for successful knowledge translation . CONCLUSIONS In complex primary care setting s environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions , successful implementation may require a set of interrelated system and technology factors
The positive deviance approach was most frequently applied within North America , in secondary care , and to address healthcare-associated infections .
Research predominantly identified positive deviants and generated hypotheses about how they succeeded .
Applications of positive deviance typically lacked staff and /or patient involvement , and the methods used often required extensive re sources .