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Beyond Fame and Shame:
Nudging Your Surgeons to Better Performance
Kevin O’HaraSyús, Inc.
© Syús, Inc. 2015. All Rights Reserved. US Patents 7860728, 8380534.
1. Discuss the latest findings in cognitive and behavior science on improvement efforts.
2. Identify what surgeons really want and how to best engage them in getting it.
3. Learn how to use your existing data to identify detailed, specific improvement pathways.
4. Determine the best approach to communicating with surgeons to “nudge” them toward better performance.
Learning Objectives
What is a Nudge?
A nudge is any aspect of the design of a choice that alters people’s behavior in a predictable way, without forbidding any options or significantly altering their economic incentives.
1. Bring cases to your OR . . . or not
2. Schedule cases in block . . . or not
3. Minimize elective add-ons . . . or not
4. Show up on time . . . or not
5. Use on-contract implants . . . or not
6. Participate in time out . . . or not
7. Come to you before the CEO . . . or not
Choices Surgeons Make
The Challenge
Can we design choices that alter surgeons’ behavior in a predictably positive way, without forbidding any safe options or significantly altering their economic incentives?
1. A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost? ___ cents
2. If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets? ___ minutes
3. In a lake, there is a patch of lily pads. Every day the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake? ____ days
Fast and Slow Questions
1. A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost? 5 cents
2. If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets? 5 minutes
3. In a lake, there is a patch of lily pads. Every day the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake? 47 days
Fast and Slow Questions
1. Anchoring
2. Availability
3. Representativeness
4. Unrealistic Optimism
5. Loss Aversion
6. Status Quo Bias
Predictable Mental Biases
Bias Judo
“In short, resisting a more powerful opponent will result in your defeat, while adjusting to and evading your opponent’s attack will cause him to lose his balance, his power will be reduced and you will defeat him.”
Anchoring
A bias toward the initial piece of information we are given, with all other judgments made only by adjusting away from that “anchor” and a bias toward interpreting other information around the “anchor”.
Anchoring in the OR
Observations
Eight hour blocks Late start grace period Focus on trending –
improvement instead of attainment
Incremental changes Others?
Anchoring Nudge
Let surgeons drop a new anchor
1. Change an existing measure or add a new one tied closely to desired performance.
2. Prepare background data on the new measure and share with individual surgeons without setting a firm target.
3. Have surgeons set their own target or goal with a process and promise to revisit as necessary.
4. Focus on goal attainment and not trending.
Availability
A tendency to overestimate the likelihood of events with greater “availability” in memory, driven by recency, uniqueness or emotional weight.
Availability in the OR
Observations
One time not getting case on turns into “I can never get cases on”
Need another late team because yesterday we needed another late team
Need to expand – can’t add any more cases
Surgeon belief they are always getting bumped
One time staff late becomes focus versus all surgeon lates
Others?
Availability Nudge
Increase availability of key information
1. Provide regular and consistent distribution of updated and current key information.
2. Regularly highlight information that may challenge established beliefs, e.g., Did You Know?
3. Regularly present information on probabilities of certain events and simplify them, e.g. 4 out of 5 dentists surveyed.
4. Be attentive to outliers, but don’t feed attention.
Representativeness
A tendency to believe something is more likely because it is representative of a group or characteristics of a population or seemingly a pattern.
Representativeness in the OR
Observations
Stereotypes about surgeons and specific specialties
Stereotypes about age, career stage, gender
Stereotypes based on roles Belief in historical patterns of
volume, utilization, etc. Others?
Representativeness Nudge
Promote positive patterns
1. Identify a pattern or two among your performance information, e.g. best days, times of day, surgeons, specialties, etc.
2. Investigate to understand nature of pattern so can explain and develop into teachable best practice.
3. Promote pattern to stakeholders with data, stories and impact.
4. Minimize connection or causation with group characteristics and instead focus on behavior.
Unrealistic Optimism
A tendency to believe you are more likely to experience a positive event or have positive characteristics or less likely to experience a negative event or have negative characteristics.
Unrealistic Optimism in the OR
Observations
Underestimating case time Overestimating current volume Overestimating potential
volume growth Mis-estimating scheduling
horizon Overestimating flip need Others?
Unrealistic Optimism Nudge
Focus optimism where action drives results
1. Encourage and support optimistic goals for measures related to volume.
2. Measures related to volume are impacted directly by action and effort which can be bolstered by optimism and energy.
3. Measures related to timing are impacted more by judgment, which is notoriously bad in light of optimism.
4. Challenging judgment challenges ego and is best avoided.
Loss Aversion
A tendency to strongly prefer – by a factor of at least two to one –avoiding losses to acquiring gains.
Loss Aversion in the OR
Observations
Strong negative response to threat of losing block
Overuse of threat or negative language about block
Focus on loss and negative consequences
Disruptive behavior by surgeons fueled by fear of “losing it all” after years of investment
Others?
Loss Aversion Nudge
Let loss loom lightly
1. Use positive language instead of negative language when discussing block scheduling.
2. Never mention loss of block as potential threat –the risk is already known and will be shown in practice.
3. Emphasize the community of surgeons, staff and administration working together.
4. Acknowledge mistakes when they occur and focus on positive remediation and not putting individuals “of the island.”.
Status Quo Bias
A strong preference for the current state of affairs, which is viewed as a reference point, change from which is perceived as a loss.
Status Quo Bias in the OR
Observations
Block scheduling Staff favorites or specialists, e.g.
my team Tray setup, room setup Room preferences Equipment, supply & implant
preferences Industry reps Attire, superstitions, music, etc. Others?
Status Quo Bias Nudge
Identify and support streaks
1. Pick a measure or focus where a streak is possible and probable, or best, already occurring, e.g. on-time starts.
2. Make the individual(s) aware of the streak and engage them in pursuing it.
3. Promote the streak casually to others at first, then more formally as it grows.
4. Provide additional support to ensure the streak continues.
Six Starter Nudges
1. Surgeons drop new anchor
2. Make key information available
3. Promote positive patterns
4. Focus optimism where energy drives results
5. Let loss loom lightly
6. Identify and support streaks
The Reigning Political Champ
Frank Luntz
Contract with America
“Death tax”
“Climate change”
“Energy exploration”
“Government takeover”
corrective action
our block time
must be maintained
to qualify
is required to maintain your block privileges
your block time will be reduced
right size
educate you
inform you
remind you
not count against you
does not meet criteria
observation period
probation
to remain in good standing
what could happen to your block
continue to have difficulty
Language from Actual Block Letters
Strict Father
Model
Nurturant Parent
Model
• People generally good, need to
be encouraged to grow and
achieve potential
• Focus on guidance to change
behavior
• Two-way, multi-level
conversation
• Consensus
• Fairness
Which Describes Your OR?
• People generally bad, need to
be taught right from wrong and
controlled
• Focus on punishment to
change behavior
• One-way, top-down
communication
• Right and wrong
• Survival of the fittest
“Tart words make no friends; a spoonful of honey will catch more flies than a gallon of vinegar.”
“Make yourself sheep and the wolves will eat you.”
Which is it, Ben?
Intrinsic Motivation
Information and Quality when Motivation is Intrinsic: Evidence from Surgeon Report Cards
“Information on performance that was new to surgeons and unrelated to patient demand led to an intrinsic response four times larger than surgeon response to profit incentives.”
A Purpose to Believe In
If people in an organization believe in the story or overall purpose for a change initiative, they will change their individual behavior to serve that purpose – in part to avoid cognitive dissonance or the state when beliefs are inconsistent with actions. Not all stories work, and those that are most often used focus primarily on the company. People are split between five motivating themes.
Five Most Motivating Themes
1. Impact on Society2. Impact on Customer3. Impact on the Company4. Impact on the Working Team5. Impact on Me
Reframe the Purpose
As always, our primary goal is to assist you in making the best use of this allocated time to ensure your patients experience relief and improvement as soon as possible and you may practice efficiently and effectively. We have this shared goal for all patients and surgeons we serve. To that end, in this update we will share with you any opportunities we’ve identified to positively impact your patients, your practice, or other patients and practices we serve.
To promote optimal use of OR time.
OR
To promote optimal use of available OR time and to ensure that surgeons who are consistent users of the facility have regular access to available OR time.
OR
To allow for surgical procedure growth of 5%.
Numerical Framing
Fair or Not Fair? The Effects of Numerical Framing on the Perceived Justice of Outcomes
“People generally tend to see a bigger difference in the performance between the self versus another person when their performance components are presented in frames associated with small numbers (e.g. absence rate of 3% vs. 9%) than when they are presented in frames associated with large numbers (e.g. attendance rate of 97% vs. 91%). Despite the same objective performance difference (e.g. 6% in the above example), people expected different fair shares of rewards and evaluated justice of a given outcome differently across the two frames.”
What was observed by us is the nature or
matter of the milky way itself, which, with the aid
of the spyglass, may be observed so well that all
the disputes that for so many generations have
vexed philosophers are destroyed by visible
certainty, and we are liberated from wordy
arguments.
Galileo Galilei
A Picture is Worth 1,000 Words
Join Our Study
• Three batches of monthly block
updates to half of holders of
surgeon blocks
• Pre and post surgeon surveys
• Virtual focus group
• Full report on results of study
• No cost
• Priority for full free opportunity
assessment
Looking for up to 10 additional facilities
Contact Us
Kevin O’Hara – kevin.ohara@syus.com – 615-469-6701Robert Schoy – robert.schoy@syus.com – 615-469-6705
www.syus.com
Thank You!
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