Applying Behavioral Economics to Implementation of a Shared Decision Making Demonstration
Anne 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
Research Objectives
Principal Findings
Conclusions
The clinical and administrative leadership of three large multi-specialty, feefor-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.
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 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.
Study Design
• 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.
Left: Care Coordinator explains
SDM to a patient using a
decision aid (DA)
Right: Video and booklet DAs
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.
Guide the Rider
Follow the bright
spots
Script the critical
moves
Point to the
destination
Implementers networked with other sites to learn how others overcame similar
challenges.
Implementers created and fine-tuned workflow process maps that designated
persons for each specific action.
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 Elephant
Hospital leaders and practice groups believed SDM was the right thing to do.
Find the feeling
Shrink the change New activities are less daunting when they align with the organization’s other
Grow the people
initiatives, such as patient satisfaction and medical homes.
All sites shared positive patient feedback to help providers and staff identify
with and “own” SDM.
Relevance to Delivery or Clinical Practice
Target Level Desired Behaviors
Health Care
System
1) Support SDM
Practice
Group
1) Support SDM
2) Incorporate SDM and DA
distribution into practice
work flow
Shape the Path
Tweak the
environment
Build habits
Rally the herd
One site put flyers and pamphlets in the exam rooms, both to encourage
patients to initiate SDM conversations and to remind providers.
One site taped a list of conditions to monitors in the exam rooms and flagged
patients’ charts during pre-visit review.
One site created a friendly competition between staff members to encourage
DA distribution and between providers to encourage SDM.
Providers
and Staff
Strategies to Encourage
Behavior Change
Limitations & Caveats
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.
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) Identify eligible patients 1) Implement different forms of
2) Initiate SDM
reminders.
conversations
2) Work with providers and staff to
3) Distribute and/or collect brainstorm reminder strategies.
DAs and surveys
3) Find champions among providers
4) Provide decision support and staff and encourage them to
engage others.
Funded by Foundation for Informed Medical
Decision Making & Health Dialog
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.
1) Inducing behavior change is
difficult, so it may take time and
many forms of reminders before
SDM and DA distribution
become habit.