Changing Provider Behavior: Is It Really That Hard?

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”


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There are a few commonly held views amongst physicians that foster resistance

to change.


Change is … confusing

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Change is … confusing

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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)


“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?

1111

Newspaper

TV NewsNews App

Facebook

Twitter


Exercise #1 Key Concept

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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


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DenialResistanceExploration

Commit?



1414

AwarenessResistanceExploration

Commit?

Denial


Goal for laggards: Move from denial to awareness


1515

AwarenessInterestExploration

Commit?

Resistance Denial


Goal for late majority: Move from resistance to interest


1616

AwarenessInterestEvaluationCommit?

Exploration

Resistance Denial


Goal for early majority: Move from exploration to evaluation


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AwarenessInterestEvaluation Buy In!

Commit? Exploration

Resistance Denial


Goal for early adopters: Move from considering commitment to buy-in


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Evaluation Buy In!

Interest


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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Creating a Vision






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



Creating a Vision






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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Creating a Vision






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


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



Creating a Vision






Kotte

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Ste

ps

The “Vision”

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1. Please draw this pig. Hold up when complete. Establishing a Sense of Urgency


Creating a Vision






Kotte

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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



Creating a Vision






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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



Creating a Vision






Kotte

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ps

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Exercise #4


• 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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Creating a Vision





Institutionalizing New ApproachesKotte

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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



Creating a Vision






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Final Points

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• Know your audience and their assumptions• Focus your efforts on the early

adopters and early majority



Creating a Vision






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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



Creating a Vision






Kotte

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Ste

ps

Thank You

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Documents

Changing Provider Behavior: Is It Really That Hard?