Academic Pediatric Association QUALITY IMPROVEMENT TRAINING: Module #2 Improvement Cycles & the Psychology Of Change This work is supported by a grant from The Centers for Disease Control & Prevention.

National Partnership for Adolescent Immunization PI: Peter Szilagyi Coordinators: Christina Albertin, Nui Dhepyasuwan Ed Marcus Cindy Rand Jan Schriefer (QI expert) Stanley Schaffer Janet Serwint William Stratbucker Donna D'Alessandro William Atkinson Paul Darden Sharon Humiston (moderator) Keith Mann (QI expert) FACULTY & CONSULTANTS

This is part of the APA series on Quality Improvement. The examples focus on adolescent immunization, but the principles are widely applicable. The series includes: 1. Overview: The Model for Improvement and Deming’s System of Profound Knowledge 2. Improvement cycles and the psychology of change 3. Initiating a QI project 4. More tools to better understand the system 5. How will we know that a change is an improvement? An introduction to QI measurement 6. Changes we can make that will result in improvement

Module 2 Objectives After viewing this segment, you will be able to: 1. Describe 5 key ideas for integrating change 2. Contrast incentive types (intrinsic, extrinsic, and dis-incentives) 3. Explain Everett Rogers’ 5 attributes to facilitate change

5 key ideas for integrating change Based on The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley GJ, et al. 2 nd Edition

5 Key Ideas for Integrating Change 1. The differences in people 2. Behavior is driven by motivation 3. Fundamental attribution error 4. Attracting people to the change 5. Intrinsic, extrinsic, and dis-incentives

The Differences in People Individual preferences, aspirations, motivations, learning styles, levels of need, beliefs, values What appeals to one individual does not appeal to another No appeal  people unwilling to make the change

Behavior Is Driven by Motivation Observed behavior does not give us a clear window into motivation We see through our own “lens” (created by our assumptions) Example What I saw The story I made up about what I saw The truth Seek to understand the motivation underlying the behavior

“Understanding what is motivating someone rather than relying on the interpretation of the behavior can help us take appropriate actions to build commitment to change.” The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley GJ, et al. 2 nd Edition

Fundamental Attribution Error Tendency to place an undue emphasis on internal characteristics to explain someone else's behavior in a given situation, rather than thinking about external situational. Does not explain interpretations of one's own behavior—where situational factors are more easily recognized and can thus be taken into consideration. If the problem is the system, a pep talk is not the solution.

Attracting People to the Change There is more to change than the tangible and technical aspects. Workers may resist change if They do not feel included or They have not truly understood the change’s expected benefits to the organization or themselves Communication throughout the process “Make people part of the solution.” The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley GJ, et al. 2 nd Edition

123-Easy ABC - Easy QI- Not easy

Question #1: The fundamental attribution error is best described by which of the following? A. Tendency to attribute fundamental errors to laziness and stupidity B. Tendency to place an undue emphasis on internal characteristics to explain someone else's behavior C. Tendency to to place an undue emphasis on system problems to explain observed phenomenon D. Tendency to attribute QI quotes to Dr. Deming

Question #1: The fundamental attribution error is best described by which of the following? B is correct A. Tendency to attribute fundamental errors to laziness and stupidity B. Tendency to place an undue emphasis on internal characteristics to explain someone else's behavior C. Tendency to to place an undue emphasis on system problems to explain observed phenomenon D. Tendency to attribute QI quotes to Dr. Deming

Intrinsic incentives, extrinsic incentives, and disincentives

Disincentive A person can expect that the failure to act in a particular way will result in some form of punishment

Extrinsic Motivation Agent can expect some form of material reward – especially money – in exchange for acting in a particular way Often very effective at first Difficult to sustain

Intrinsic Motivation Moral incentives – “ the right thing to do” or a particularly admirable thing to do Natural incentives – E.g., curiosity, mental or physical exercise, admiration, joy, the pursuit of truth, or control (over oneself, others, things in the world)

3 Key Intrinsic Motivators Autonomy Mastery Purpose Too often, planned QI approaches diminish at least one of these. Drive, Daniel Pink

Usually intrinsic incentives are more sustainable than extrinsic incentives.

QUESTION #2 Ron despises anything associated with “quality improvement” so, when faced with his team’s low adolescent immunization rates he announces: “We are not doing any of that QI balderdash. I’ll fix this problem myself in one minute flat. Here is a $100 bill and it goes to the nurse who gives the most vaccines to patients years of age this month.”

Which of the following is FALSE about Ron’s approach to the problem? A. It’s unlikely to be sustainable B. It ignores some important potential “side effects” (e.g., adolescent patients being brought in from the waiting room preferentially, decrease in nursing staff morale, sabotaging other people’s efforts to vaccinate teens) C. It creates constancy of purpose for continual improvement at the clinic D. It relies primarily on extrinsic motivation

Which of the following is FALSE about Ron’s approach to the problem? A. It’s unlikely to be sustainable B. It ignores some important potential “side effects” (e.g., adolescent patients being brought in from the waiting room preferentially, decrease in nursing staff morale, sabotaging other people’s efforts to vaccinate teens) C. It creates constancy of purpose for continual improvement at the clinic FALSE D. It relies primarily on extrinsic motivation

5 attributes to facilitate change Everett Rogers, The Diffusion of Innovations, 5th Edition

5 attributes facilitate change: 1. Relative advantage 2. Compatibility 3. Simplicity 4. “Trial – ability” 5. Observability

Relative Advantage The extent to which the innovation is better than existing practices A key indicator of adoption But not the only indicator…good ideas do not sell themselves because "good" can be A matter of debate Not immediately evident Complex to understand Circumvented by economic/business/political circumstances Considered as morally abhorrent Difficult to implement

Compatibility Innovations are easier to adopt if they are perceived as being consistent with: Existing values Past experiences Needs of potential adopters

Simplicity Innovations are easier to adopt if the end user perceives the innovation as easy to understand and use

Trial-ability Innovations are easier to adopt if they can be tried out in part, on a temporary basis, or easily dispensed with after trial.

Observability Innovations are easier to adopt if we can easily observe relative advantages of the change.

Summary Key ideas for integrating change include: recognizing and responding to people’s different motivations (which are not always apparent); discerning when something is a system problem & when it is personnel problem; communicating with everyone involved in the change to make sure they feel included & understand the change’s expected benefits. Intrinsic incentives tend to be more long lasting than extrinsic incentives or disincentives. Innovations are easier to adopt if they are perceived as improvements; compatible with the existing values, past experiences, and needs of potential adopters; simple to understand and implement; easy to test; and have results that are easy to observe.

Your vision is at the heart of QI. Quality improvement is not for the faint of heart.

The End of Module #2