Academic Pediatric Association

QUALITY

IMPROVEMENT TRAINING: Module #2

Improvement Cycles &Improvement Cycles &

the Psychology Of Change 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 SzilagyiCoordinators: Christina Albertin, Nui

Dhepyasuwan

Ed MarcusCindy RandJan Schriefer (QI

expert)Stanley SchafferJanet SerwintWilliam Stratbucker

Donna D'AlessandroWilliam AtkinsonPaul DardenSharon 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 project4. More tools to better understand the

system5. 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. 2nd Editionwww.josseybass.com

5 Key Ideas for Integrating Change

1. The differences in people2. Behavior is driven by motivation3. Fundamental attribution error4. Attracting people to the change5. 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)

ExampleWhat I sawThe story I made up about what I sawThe 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. 2nd Editionwww.josseybass.com

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. 2nd Editionwww.josseybass.com

123 - EasyABC - EasyQI - 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 stupidityB. 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 correctA. Tendency to attribute fundamental

errors to laziness and stupidityB. 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 MotivationAgent 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 MotivationMoral 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

AutonomyMastery 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 #2Ron 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 11-18 years of age this month.”

Which of the following is FALSE about Ron’s approach to the problem?A. It’s unlikely to be sustainableB. 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?

5 attributes to facilitate

change

Everett Rogers, The Diffusion of Innovations, 5th Edition

5 attributes facilitate change:

1.Relative advantage2.Compatibility3.Simplicity4.“Trial – ability”5.Observability

Relative AdvantageThe extent to which the innovation is better

than existing practicesA key indicator of adoptionBut not the only indicator…good ideas do not

sell themselves because "good" can be A matter of debateNot immediately evidentComplex to understandCircumvented by economic/business/political

circumstances Considered as morally abhorrentDifficult to implement

Compatibility

Innovations are easier to adopt if they are perceived as being consistent with:Existing valuesPast 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 #2of Module #2