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Exam (elaborations)
Positive Deviance and Hand Hygiene: More Questions than Answers
To the Editor—Optimizing adherence to hand hygiene rec 
ommendations has been problematic in many healthcare set 
tings. We read with interest the article by Marra et al1 relating 
their experience with a positive deviance (PD) approach to 
improving hand hygiene adherence. The authors should be 
commended for adding to our understanding of hand hygiene 
and the PD strategy for improving adherence, but a number 
of limitations should be noted and several questions should 
be addressed.