Study Design

Principal Findings Conclusions

Relevance to Delivery or Clinical Practice

Research Objectives

Applying Behavioral Economics to Implementation of a Shared Decision Making DemonstrationAnne D. Renz, MPH 1; Judy M. Chang, JD 1; Douglas A. Conrad, PhD, MBA, MHA 1; Megan A. Morris, PhC, CCC-SLP 1, 2; Carolyn A. Watts, PhD 1, 3

1) Department of Health Services, University of Washington; 2) Department of Rehabilitation Medicine, University of Washington; 3) Department of Health Administration, Virginia Commonwealth University

The clinical and administrative leadership of three large multi-specialty, fee-for-service group practices in western Washington State decided to pilot the implementation of shared decision making (SDM) and the use of patient decision aids (DAs). The research team at the University of Washington Department of Health Services facilitated this demonstration.

The research objective was to facilitate and document an SDM demonstration in the three sites using a framework grounded in behavioral economics (Switch: How to Change Things When Change is Hard, Heath & Heath, 2010). The framework includes:

• Planning and direction (what Heath & Heath term “guiding the rider”)• Engaging stakeholders (“motivating the elephant”)• Organizing the work environment (“shaping the path”)

This framework was used to document the demonstration’s progress and to work through issues that arose. This particular study focused on identifying the barriers and facilitators in implementation that are based on the behavior of providers and staff.

• Semi-structured key informant interviews were conducted with relevant stakeholders who were directly involved in implementing SDM (health system leaders, health care providers, and project managers).

• Interviews were conducted twice, in Autumn 2009 and Spring 2011.• Interview transcripts were coded for themes and qualitatively analyzed.• The themes related to behavioral barriers were further analyzed using a

behavioral economics framework.

Each provider organization implemented SDM to varying degrees based on various facilitators and barriers. Three overarching processes were critical in organizational and individual change-making:

• Signaling the organizational commitment of senior clinical and administrative leadership to implement and sustain SDM over time

• Motivating behavioral change through improving the efficiency and satisfaction of provider-patient interactions

• Standardizing and organizing work routines to facilitate consistency and integrate SDM within daily clinical and administrative practice

Examples of how the Switch framework’s subsections have been applied are listed below:

SDM implementation requires significant organizational and cultural change. Efforts may stall even when financial and staff resources are sufficient and training is provided. Leaders of SDM implementation initiatives can apply behavioral economics principles to accelerate and deepen organizational adoption of SDM. The Switch framework encourages three approaches: engage the minds of providers and staff, appeal to their emotions, and streamline the organization’s environment.

The Switch framework is helpful in developing effective strategies at the outset of SDM program implementation. It may also be used to work through issues that arise during implementation and to evaluate areas in which the SDM project could be improved.

Left: Care Coordinator explains SDM to a patient using a decision aid (DA)

Right: Video and booklet DAs Funded by Foundation for Informed Medical Decision Making & Health Dialog

Target Level Desired Behaviors Strategies to Encourage Behavior Change

Limitations & Caveats

Health Care System

1) Support SDM 1) Embed or fit SDM into organizational goals and frameworks.2) Launch a marketing campaign.3) Link SDM to existing organizational initiatives and activities.

1) Support from the top is necessary but not sufficient for successful implementation.2) Enthusiasm does not necessarily translate to activity.

Practice Group

1) Support SDM2) Incorporate SDM and DA distribution into practice work flow

1) Frame SDM in a way that appeals to the specific practice group.2) Provide education sessions and DA viewing opportunities.3) Work with the practice group to develop a work flow process map. 4) Provide ongoing support and feedback.

1) Engagement of the group does not necessarily translate to day-to-day behavior change to incorporate SDM.2) Placing blame is counterproductive.3) Turnover can affect implementation progress.

Providers and Staff

1) Identify eligible patients2) Initiate SDM conversations3) Distribute and/or collect DAs and surveys4) Provide decision support

1) Implement different forms of reminders.2) Work with providers and staff to brainstorm reminder strategies.3) Find champions among providers and staff and encourage them to engage others.

1) Inducing behavior change is difficult, so it may take time and many forms of reminders before SDM and DA distribution become habit.

Guide the RiderFollow the bright spots

Implementers networked with other sites to learn how others overcame similar challenges.

Script the critical moves

Implementers created and fine-tuned workflow process maps that designated persons for each specific action.

Point to the destination

Patients were waiting 3-6 months for surgery; SDM was promoted as a way to increase access and reduce the wait time by reducing the number of appointments with inappropriate or uninterested patients.

Motivate the ElephantFind the feeling Hospital leaders and practice groups believed SDM was the right thing to do.

Shrink the change New activities are less daunting when they align with the organization’s other initiatives, such as patient satisfaction and medical homes.

Grow the people All sites shared positive patient feedback to help providers and staff identify with and “own” SDM.

Shape the PathTweak the environment

One site put flyers and pamphlets in the exam rooms, both to encourage patients to initiate SDM conversations and to remind providers.

Build habits One site taped a list of conditions to monitors in the exam rooms and flagged patients’ charts during pre-visit review.

Rally the herd One site created a friendly competition between staff members to encourage DA distribution and between providers to encourage SDM.