Changing Provider Behavior: Is It Really That Hard?Robert Greenberg, MDErin Harvey, MDSangeeta K. Schroeder, MD
Disclosure• We have no relevant financial relationships with the manufacturers(s) of
any commercial products(s) and/or provider of commercial services discussed in this CME activity.
• We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation
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Learning ObjectivesDiscuss and illustrate the challenges and barriers to changing provider
behavior– Meet others & discuss barriers to change– Discuss perspectives on change – Diffusion of Innovations Theory
Describe the key elements for leading change– Review a process for change– John Kotter: Leading change: Why transformation efforts fail• 8 steps for successful change initiatives from the individual to the organization
– Participate in a few exercises that highlight some challenging steps in change
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Leading Change• How many of you are involved in a project/process to implement a
change?• In groups of 3-4, take a few minutes to introduce yourself and to
share a project that you are working on at your organization. – *Include an example of a barrier your team has experienced.
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Examples of a
Project/Barriers
Example of a Project/Succe
ss
Meet Others Discuss Diffusion of Innovation
Barriers to Change
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Stakeholders• Interest• Traditions• Experiences• Perceived Danger
Setting• Timing• Cost• Process Barriers
Communication• Spread• Core Team v Lead
Team
“I don’t really have the time to do this”
“I don’t care about CLABSIs, I care about my oncology
patients”
“I get a lot of respiratory kids in the ED, I don’t have the
luxury of knowing which ones will be bronchiolitics”
“Such a great project…why didn’t
that catch on?”
“Did you know there was an order set for
that? I didn’t”
“What email?”“I’m working on another
change effort. I don’t have the time for this one right
now.”
“There isn’t a structure in place for this effort and I
don’t have the resources to do it right now”
Meet Others Discuss Diffusion of Innovation
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There are a few commonly held views amongst physicians that foster resistance
to change.
Meet Others Discuss Diffusion of Innovation
Change is … confusing
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Meet Others Discuss Diffusion of Innovation
Change is … confusing
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Meet Others Discuss Diffusion of Innovation
Established practices are frequently contradicted, fostering resistance behaviors
Change is … making my life harder
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• Most changes for physicians in the past decade have been external– Changes in payment/reimbursement– Worsened job satisfaction (particularly related to the EHR)
Meet Others Discuss Diffusion of Innovation
“Few professional groups have been so broadly incentivized to adopt such a new, not-yet-mature technology that changes their interface with almost
every aspect of their job.”
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Exercise #1
Diffusion of Innovation
• Take a minute to consider your own attitude towards change• How do you get your news?
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Newspaper
TV NewsNews App
Meet Others Discuss Diffusion of Innovation
Exercise #1 Key Concept
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Meet Others Discuss Diffusion of Innovation
An individual’s attitude towards change is specific to the subject matter.
Resistance patterns suggest a person’s attitude towards your specific change. Adjust your strategies accordingly
Diffusion of Innovation
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DenialResistanceExploration
Commit?
Meet Others Discuss Diffusion of Innovation
Diffusion of Innovation
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AwarenessResistanceExploration
Commit?
Denial
Meet Others Discuss Diffusion of Innovation
Goal for laggards: Move from denial to awareness
Diffusion of Innovation
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AwarenessInterestExploration
Commit?
Resistance Denial
Meet Others Discuss Diffusion of Innovation
Goal for late majority: Move from resistance to interest
Diffusion of Innovation
1616
AwarenessInterestEvaluationCommit?
Exploration
Resistance Denial
Meet Others Discuss Diffusion of Innovation
Goal for early majority: Move from exploration to evaluation
Diffusion of Innovation
1717
AwarenessInterestEvaluation Buy In!
Commit? Exploration
Resistance Denial
Meet Others Discuss Diffusion of Innovation
Goal for early adopters: Move from considering commitment to buy-in
Diffusion of Innovation
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Evaluation Buy In!
Interest
Meet Others Discuss Diffusion of Innovation
Focus change on the early majority and early adopters and others will follow.
Learning ObjectivesDiscuss and illustrate the challenges and barriers to changing provider
behavior– Meet others & discuss barriers to change– Discuss perspectives on change – Diffusion of Innovations Theory
Describe the key elements for leading change– Review a process for change– John Kotter: Leading change: Why transformation efforts fail• 8 steps for successful change initiatives from the individual to the organization
– Participate in a few exercises that highlight some challenging steps in change
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Exercise #2
Taking a Systematic Approach• Exercise
– 20 sticks of spaghetti– 1 roll of masking tape (you can use up to 1 yard of it)– 1 yard of string– 1 marshmallow
• Build the tallest, freestanding structure out of these elements.• The marshmallow has to be on top• Time Limit: 15 minutes
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Exercise #2 Key Concepts• How many tables successfully created a structure with the marshmallow
on top?– What worked well?– What hampered the progress?– Did you have people in the group that were disinterested?• If so, what did the group do?
– Ignore them or attempt to change their behavior?
• For the teams that did not create a structure…– What would have helped?
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Taking a Systematic Approach• Pick a Process for Leading Change
– DMAIC– Model for Improvement– Provider Behavior Change
• Common Pitfalls– Impatience– Sense that change is overdue
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To create even the smallest change, you must have a process. When the change involves provider behavior,
consider Kotter’s 8 Steps.
Establishing a Sense of Urgency• Strategies
– Listen• Find out what is urgent. The best idea is the one
you get someone else to say!– Problem focused (define the issue)– SWOT analyses (groupthink)– GAP analyses (groupthink)– Interviews (key stakeholders)
• Illustration– Harnessing the momentum of a crisis or
sentinel event
• Common Pitfalls– Falling in love with the solution
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Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Forming a Powerful Guiding Coalition• Strategies
– Lead team v Core team– Aim to mix junior and senior leaders– Find the right team• Early adopters (those ready to commit)• Early majority (those ready to explore)
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Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Forming a Powerful Guiding Coalition• Strategies
– Lead team v Core team– Aim to mix junior and senior leaders– Find the right team• Early adopters (those ready to commit)• Early majority (those ready to explore)
• Illustration – Stakeholder Analysis– Use prior interviews– Think about the Marshmallow Example
• Common Pitfalls– Time investment • If the problem is not compelling…no one
has the time 2626
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
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Exercise #3
The “Vision”• Standard Pig Exercise
• First DrawingPlease draw a pigYou have 1 minuteRaise up the pig when done
• Second DrawingWe need 2 volunteers Please draw a pig exactly following my
verbal directions I’m only going to read through it once
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Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
The “Vision”1. Draw a capital M, so the tip of the middle V of the M touches the intersection of the grid lines in the NW quadrant2. Draw a capital W, so the tip of the middle V of the W touches the intersection of the grid lines in the SW quadrant3. Draw a capital W, so the tip of the middle V of the W touches the intersection of the grid lines in the SE quadrant4. Go back to the M you drew in Step 1, and draw a slightly upwardly bowed line that runs from the most eastern point of the M, to the intersection of the grid lines in the NE quadrant.5. Continue that line from the intersection of the grid lines in the NE quadrant to the most easterly point of the W that you constructed in the 3rd step.6. Draw a downwardly bowed line from the most western point of the W in the SE quadrant, to the most easterly point of the W in the SW quadrant. 7. In the exact middle of the box between the NW quadrant and the SW quadrant, draw a circle the size of a dime. 8. Draw an inwardly bowed line from the most westerly point of the M created in Step 1, to the top of the circle you just drew in Step 7. 9. Draw an inwardly bowed line from the most westerly point of the W created in Step 2, to the bottom of the circle you drew in Step 7. 10. Draw a horizontal straight line about ½ inch in length starting from the middle of the line you created in Step 8. 11. Draw a horizontal straight line about 1/3 inch in length starting from the middle of the line you drew in step 9. 12. Draw a curly-cue about 1 inch in length starting at the upper third of the line you created in Step 5, extending in an easterly direction.13. Put two dots in middle of the circle you drew in Step 7, arranged horizontally, and about ¼ of an inch apart.
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Establishing a Sense
of Urgenc
y
Forming a
Powerful
Guiding
Coalition
Creating a
VisionCommunicating the Vision
Empowering
Others to Act on the Vision
Planning for & Creatin
g Short-term Wins
Consolidating Improvements
& Producing Still More
Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
The “Vision”• Standard Pig Exercise
• First DrawingPlease draw a pigYou have 1 minuteRaise up the pig when done
• Second DrawingWe need 2 volunteers Please draw a pig exactly following my
verbal directions I’m only going to read through it once
• Third Drawing 30303030
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
The “Vision”
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1. Please draw this pig. Hold up when complete. Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Exercise #3 Key Concepts• Which pig was the best for Attempt #1?
• What was helpful about Attempt #2?• What was detrimental about Attempt #2?
• What made Attempt #3 effective?
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The “Vision”• Strategies
– Creating = The 5 W’s– Communicating = Clearly delineate new
process• Use every method• One-on-one meetings are high-value
– Empowering Others• Hardwiring change in current process
• Illustration– Standard Pig
• Common Pitfalls– Not tying the vision to the problem– Lack of clarity– Ineffective communication 3333
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Early Wins & Improvements
• Strategies– Building Momentum – Quick response to early adopters
(refinement)– “Low hanging fruit”
• Illustration– Pilot your initiative– Implement in cycles
• Common Pitfalls– Overly focusing on laggards and late
adopters– Forcing change 3434
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
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Exercise #4
Institutionalizing New Approaches
• Change Exercise– Challenge: Recognizing change.– Select a partner. Face away from them and
change 3 things about yourself– Try to identify the changes
• How many changes could you identify?• Who changed something about their
appearance? Location in the room?• Who has already changed back something
from this exercise?
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Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New ApproachesKotte
r’s 8
Ste
ps
Exercise #4 Key Concept
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Even amongst early adopters, maintaining something that is “out of the ordinary” is
not easy
Institutionalizing New Approaches• Strategies
– Sustaining change requires time/effort– Tracking processes• Local Dashboards & Data• National Networks or Accreditation
Agencies– Vermont/Oxford Network (NICU)– Society for Pediatric Sedation– Solutions for Patient Safety
• Illustration– Change 3 things
• Common Pitfalls– Feeling like the work is done 3838
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Final Points
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• Know your audience and their assumptions• Focus your efforts on the early
adopters and early majority
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Final Points
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• Know your audience and their assumptions• Focus your efforts on the early
adopters and early majority• Know your own assumptions and
clearly state the problem before embarking on an initiative• Create a roadmap for success• Change can revert back to the
status quo without continuous cycles of improvement
Establishing a Sense of Urgency
Forming a Powerful Guiding Coalition
Creating a Vision
Communicating the Vision
Empowering Others to Act on the Vision
Planning for & Creating Short-term Wins
Consolidating Improvements & Producing Still More Change
Institutionalizing New Approaches
Kotte
r’s 8
Ste
ps
Thank You
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