Changing Practitioner Behavior

Gail D’Onofrio MD, MSProfessor and Chief

Section of Emergency Medicine Yale University School of

Medicine

Principles of Motivational Interventions

Create cognitive dissonance Lessen ambivalence by reflection on

conflicting motivations Negotiate strategies for change

Steps: Brief Intervention

Raise the subjectProvide Feedback Enhance MotivationNegotiate & Advise

NIDA: Principles of Drug Addiction Treatment

#10

Treatment does not need to be voluntary to be effective

Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase treatment entry, retention rates and success of interventions

Approaches to Quality Improvement and Their Assumptions on Improving Medical Care

Grol, R. Improving the quality of medical care: Building bridges among professional pride, payer profit and patient satisfaction JAMA. 2001:28:2578-86

Approach Assumption

Evidence-based Medicine

Clinical guidelines

Decision Aids

Provision of best evidence and convincing information leads to optimal decision making and optimal care

Approach Assumption

Professional education and development

Self-regulation

Recertification

Bottom up learning based on experiences in practice and individual learning needs leads to performance change

Approach Assumption

Assessment and accountability

Feedback

Accreditation

Public reporting

Providing feedback on performance relative to peers, and public reporting of performance data, motivate change in practice routines

Approach Assumption

Patient-centered care

Patient involvement

Shared decision making

Patient autonomy and control over disease and care processes lead to better care and outcomes

Approach Assumption

Total quality improvement

Restructuring processes

Quality systems

Improving care comes from changing the system, not from changes in individuals

Effects of Different Strategies to Improve Patient Care

Strategy Conclusions

Educational Materials Continuing education Interactive education

meetings Educational outreach

visits Use of opinion leaders Feedback on performance

Limited Limited Few studies, mostly

effective Affects prescribing and

prevention Mixed effects Mixed effects, effect on

test ordering

Strategy Conclusions

Reminders Substitution or delegation of

tasks Use of computer Total quality management

and CQI Patient-oriented

interventions Combined and multifaceted

interventions

Mostly effective Pharmacist: effect on

prescribing; Nurse: No Mostly effective Limited effects, weak

study design Mixed effects, reminding

pts good for prevention Very effective

Clinical Inertia

“Recognition of the problem, but

failure to act.”

Phillips LS, et al. Clinical inertia. Ann Intern Med. 2001;135:825-834

Clinical Inertia

Problem of the provider and system It is not related to patient adherence to

treatment regimens Result of:

– Overestimation of care– Use of “soft” reasons to avoid changes– Lack of training and practice structure needed to

attain goals

Strategies to approach practitioner behavioral change

Provide skills-based educational sessions Elicit opinion leaders Institute systems changes (forced computer

entry, reminders, multiple screeners etc.) Provide ongoing feedback to practitioners Provide incentives (positive or negative) Be creative