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

Begin with the End in Mind

A Better Block Letter

What is a Nudge?

What is a Nudge?

What is a Nudge?

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?

Are Surgeons Unique Humans?

They eat food!

They Are !?!

They’re arrogant!

Theyhateto lose!

Two Kinds of Thinking

Gut ReactionThe Automatic System

Conscious ThoughtThe Reflective System

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

Decades of Research

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.

In Practice– Unused Minutes

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.

In Practice– Monthly Letters

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.

In Practice– Highlight Patterns

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.

In Practice– Volume Drives Everything

Tuesday4 Cases

Thursday10 Cases

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.”.

In Practice– No Loss Language

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.

In Practice– Highlight Streaks

On-Time Starts

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

What is Framing?

Oppose Obamacare

Oppose Affordable Care

Act

46% 37%

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

Framing with Metaphors

Strict Father Model

vs.

Nurturant Parent Model

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.”

Framing – Drop the Struggle

corrective action observation period probation

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.”

The Power of Vision

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

Best Fit for Block?

Should Both Flip?

Practical Resources

Best Practice – Fitbit

Best Practice – Nest Thermostat

Best Practice – Nest Thermostat + Reliant Energy

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!