Incentives & Behavior Modification Systems

“Weneedtodomorethangiveanesthesia!”–

Howdoyouincentivizecolleaguestodonewactivities?

AmrAbouleish,MD,MBA

UniversityofTexasMedicalBranch

[email protected]

Incentives&

BehaviorModificationSystems

Disclosure

•

ECGConsultants

•

TechnicalAdvisor

•

FocusonStaffingModels

Incentives

•

Incentives vs.VariablePay

•

Whatisanincentive?

•

BehaviorModificationPrinciples

•

PinpointRelevantBehavior

•

Charting Behavior

•

Choosing aContingentReinforcement

•

Reassess

•

Worked, MaintainSystem

•

Not Worked,ReassessBehavior

•

Examples

Incentivevs.VariablePaySystems

Incentive

•

Onlyactivitiesdon’twanttodo&the

groupneedstodotobesuccessful!

•

BaseSalary

mostactivities/behavior

•

Basesalary+incentive(20%)

•

Simple

•

Easiertounderstandandadministrate

•

Feedbackimmediate

VariablePay

•

Allproductiveactivities

•

Basesalary coversverylittle

•

Smallbase+largevariable(75%)

•

Complex

•

Informationsystemneeded

•

Feedbacknotimmediate

Anesth Analg 107:1765-7, 2008

Incentivevs.VariablePaySystems

Incentive

•

Onlyactivitiesdon’twanttodo&the

groupneedstodotobesuccessful!

•

BaseSalary

mostactivities/behavior

•

Basesalary+incentive(20%)

•

Simple

•

Easiertounderstandandadministrate

•

Feedbackimmediate

VariablePay

•

Allproductiveactivities

•

Basesalary coversverylittle

•

Smallbase+largevariable(75%)

•

Complex

•

Informationsystemneeded

•

Feedbacknotimmediate

Anesth Analg 107:1765-7, 2008

Understandability

Believability

Fairness

Complexity

IncentiveSystem

“90‐10”rule

VariablePaySystem

Incentivevs.VariablePaySystems

Incentive

•

Onlyactivitiesdon’twanttodo&the

groupneedstodotobesuccessful!

•

BaseSalary

mostactivities/behavior

•

Basesalary+incentive(20%)

•

Simple

•

Easiertounderstandandadministrate

•

Feedbackimmediate

VariablePay

•

Allproductiveactivities

•

Basesalary coversverylittle

•

Smallbase+largevariable(75%)

•

Complex

•

Informationsystemneeded

•

Feedbacknotimmediate

Anesth Analg 107:1765-7, 2008

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

WhatisanIncentive?

•

Ifallthingswereequal,howdoyoudecidewhattodoeachday?

•

Todosomethingthatisatoddstoyourpersonalpreference,you

needanincentive(thatoutweighspersonalsatisfaction)!

•

Whygetupandgotowork?

•

Whysitinthislectureratherthaninthehottub?

•

Whynothavethatdessert(orextradessert)?

•

Whystayinacademics?(non‐financialincentives)

•

Therefore,incentivesarereally…

•

BehaviorModificationSystems

Anesth Analg 2005;100:490

BehaviorModification:

JustGoalSetting?

Manager

and

Employee

SetGoal

Does

Employee

meetGoal?

Managerissilentor

reprimandsemployee

Managercompliments

(rewards)employee

foraccomplishment

Yes

Antecedent

Employee

Task

Behavior

Consequence

Contingent

Reinforcement

BehaviorModification



MorethanGoalSetting,butChangingBehavior

AdaptedfromFigure4.6,OrganizationalTheory8

ed.,Hellriegel D,etal.

BehaviorModification



MorethanGoalSetting,butChangingBehavior

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

AdaptedfromFigure4.6,OrganizationalTheory8

ed.,Hellriegel D,etal.

BehaviorModificationPrinciples

•

Thebiggestchallenge.

•

Whatbehaviorswillhelpyourgroupsucceed?Orfail?

•

WhatNEWbehaviors/activitiesdoyouneedyourpartnerstofocuson?

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModificationPrinciples

•

Cautioninchoosingwhattoincentivizeorreward!

•

TheenemyofGoodisBetter.Ifitain’t Broke…:Don’tsimplysetupincentivesifnoneneeded

•

TheFollyofRewardingA,HopingforB.

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

FollyofRewardingA,HopingforB

•Multipleexamples.

•Importanttounderstand

whatameasurementvaluesordevalues.

•ExamplesfromORmanagement:

•

B=BetterORthroughput,A=firstcasestartson‐timeincentive

•

B=BetterROIofORtime,A=utilizationtodetermineblocktime

AcademyofManagementExecutive1995;9:7‐14

BehaviorModificationPrinciples

•

Thebiggestchallenge.

•

Whatbehaviorswillhelpyourgroupsucceed?Orfail?

•

WhatNEWbehaviors/activitiesdoyouneedyourpartnerstofocuson?

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModificationPrinciples

•

Developsbuy‐in

•

Timingisimportant:thecloserthereinforcementistobehaviorbettersuccess

•

ObserverEffect(Heisenberg’sPrinciple)isveryeffective

•

CanbePostiveorNegativeReinforcement

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModificationPrinciples

•ContinengentReinforcement

•

Responseiscontigentonthebehavior

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModificationPrinciples

•ContingentReinforcement

•

Responseiscontigentonthebehavior

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcemen

Negative

Reinforcemen

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

Contingent Reinforcement:

PositiveReinforcement

•

Goal:IncreaseFrequencyofBehavior

•

MostEffectiveReinforcement

•

Rewardisnotnecessarilysameasreinforcement

•

ARewardisaReinforcer ifrewardincreases thebehavior

•

Reward–aneventthatpersonfindsdesirableorpleasing

•

Dependsontheperson–ifnotviewedasa“reward”,thennochangeinbehavior

•

Timingisveryimportant.Aconnectiontobehaviorandreward.

•

“Secondaryreactions”–mayleadtodecreasingbehaviorratherthanincreasing

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

Contingent Reinforcement:

PositiveReinforcement

•

Mostcommonone–moneyorcompensation

•

Mosteffectivemaynotbemoney.WhyLeadershipmatters.

•

Verbalapproval

•

Assignmenttodesiredtasks

•

Titles,promotions

•

Extratimeoff

•

Inputtaken,ownershipofworkflow,moreindependence

•

Jobsatisfaction:Highestwhen paidmarketcompensationandhavea

rewardingworkenvironment

MoneyisNottheONLYMotivator

•

HaifaDayCareCentersclosedat4pm.

•

Mostparentspickedupkidsby4pm.

•

Iftheywerelate,theyreliedongenerosityofoneteacher.

•

Beinglatemeantfacingthatsameteacherandapologizingtoher

•

Experiment.

•

Randomlychose6of10daycares,smallfineforshowingupmorethan10minlate

•

Results:parentsimmediatelyshowinguplateat2Xinitialrate

•

Removedfines,and…

•

…ratedidnotgobacktobaseline

•

Implication:non‐financialincentives:“Social”norm,contract,guilt.

•

Ifyoumonetizeanactivity,thenyoumaydevaluetheactivity

http://freakonomics.com/2013/10/23/what‐makes‐people‐do‐what‐they‐do/

JLegalStudies2000;29:1‐17

https://hbr.org/2009/03/when‐economic‐incentives‐backfire

Contingent Reinforcement:

NegativeReinforcement

•

Goal:IncreaseFrequencyofBehavior

•

Notsameaspunishment(usedtodecreasefrequency)

•

EscapeLearning:unpleasanteventoccursuntilpersonperformsa

behavior ,orescaperesponse,toterminateit

•

Alarmsonthemonitors,Saturationlowertone

•

AvoidanceLearning:personpreventsunpleasanteventfrom

occurringbycompletingtheproperbehavior

•

Publishinglisteachdayofdelayedfirstcasestartsorlongturnoversbyanesthesiologist

•

Publishingpatientsatisfactionscoresbyanesthesiologist

Contingent Reinforcement:

Omission

•

Goal:DecreaseFrequencyofBehavior

•

Omission:Removalofallreinforcingbehavior

•

3Steps:

Identifyingthebehaviortobereducedoreliminated

Identifyingthereinforcerthatmaintainsthebehavior , and

Stoppingthereinforcer

•

Examples:

•

Meetingstartingtime.Startmeetingatthetimescheduled.Don’twaitforeveryone.Ifsomeonecomesin

late,justignoreit.

•

Inappropriatejokes.Stoplaughingatthem

•

Careful– Omissioncanbedonebyaccident

•

Omission=failuretoreinforceabehavior.

•

Mistakeiswhenonedoesn’treinforcedesirablebehavior decreaseinfrequencythroughomission

Contingent Reinforcement:

Punishment

•

Goal:DecreaseFrequencyof(undesired)Behavior

•

Shouldbereservedonlyincases ofseriousbehaviorproblems

•

Tobeeffective

•

Needstobelinkeddirectlytoundesiredbehavior

•

Immediatefeedback

•

Size–shouldfittheissue

•

NegativeEffectsofPunishmentarenumerous

•

Althoughshort‐termmaywork,long‐termundesiredbehaviorcanoccur

•

Apathy,highturnoverorabsenteeism,aggressiveordisruptivebehavior

•

Learnedhelplessness&Pygmalioneffect

•

Remember:Punishmentcanbeinterpersonal–bothverbalandnonverbal

1Anesthesiology2010;112:1067‐9

BehaviorModificationPrinciples

•ContinengentReinforcement

•Moneyisnottheonlykind

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcemen

Negative

Reinforcemen

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

BehaviorModificationPrinciples

•

Reassessmentisessential

•

Ifworking:maintainingsystemtillbehaviorislearnedandpartoftheculture

•

OnlywayaQIprogramwillhavelong‐termresults

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModificationPrinciples

•

Ifnotworking:

•

Isthereinforementmeaningfultopeople?,Isthefeedbacktimely?,Issystem

understandable?

•

FollyofrewardingA,hopingforB

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

BehaviorModification



IncentivizeBehaviorthatisNOTbeingdone.

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

•

Reinforcement–mayusemultipleonesandreassess

•

Examples

SampleGroupPerformanceMetrics

•

ClinicalProcessMetrics

•

SCIP,SCORE,HEDIS

•

SurgicalProcessandEfficiencyMetrics

•

Improvefirstcaseon‐timestarts

•

ImproveORToTcompliancewithgoals

•

ReduceAnesthesiaidentifiedcauses

•

QualityMetrics

•

Complicationsandpatientsafety

metrics

•

Reintubation Rates

•

Reduceinpatientmortalityindex

•

Reducereadmissionswithin30days

relatedtoanesthesia

•

PatientSatisfactionPressGaney

•

Howwellyourpainwascontrolled

•

Howwelldidyourphysiciankeepyou

informed

•

Howlikelyareyoutorecommendthe

hospital

•

PayerSatisfactionMetrics

•

SurgeonSatisfaction Metrics

•

CompliancewithHospital

Documentation

•

Post‐anesthesiaevaluation(COP)

•

E‐signaturewithintimeframe

•

Date,Time,Witness(esp.ifonpaper)

AdaptedfromDr.StanleyStead

BehaviorModification



Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

•

GroupGoal:SurgicalProcessand EfficiencyMetrics

•

Improvefirstcaseon‐timestarts

•

ImproveORToTcompliancewithgoals

•

ReduceAnesthesiaidentifiedcauses

GROUPBehaviorModification



Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

•

GroupGoal:SurgicalProcessandEfficiencyMetrics

•

Improvefirstcaseon‐timestarts

•

ImproveORToTcompliancewithgoals

•

ReduceAnesthesiaidentifiedcauses

GroupReport

Daily&Weekly

GroupIncentive

Payments

Quarterly for

eachmonthmet

Reassess

Quarterly

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

INDIVIDUALBehaviorModification



Notallunderindividual’scontrol,butmuchunderindividual’sinfluence

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

•

GroupGoal:SurgicalProcessand EfficiencyMetrics

•

Improvefirstcaseon‐timestarts

•

ImproveORToTcompliancewithgoals

•

ReduceAnesthesiaidentifiedcauses

GroupReport

Daily&Weekly

GroupIncentive

Payments

Quarterly for

eachmonthmet

Reassess

Quarterly

WITHINDIVIDUALNAMES

andWhy?

Reporttoindividualand

publishtowholegroup

PublishListDaily

(timely)

“Idon’twantto

beonthelist!”

1.Individual

counseling

2.“Areyoutherightpersonfor

us?”Paiddayofftothinkaboutit.

(positivereinforcement)–remind

thattheirjobisinjeopardy

3.Punishment:nolongerhavejob

•

ClinicalProcessMetrics

•

SCIP,SCORE,HEDIS

•

SurgicalProcessandEfficiencyMetrics

•

Improvefirstcaseon‐timestarts

•

ImproveORToTcompliancewithgoals

•

ReduceAnesthesiaidentifiedcauses

•

QualityMetrics

•

Complicationsandpatientsafety

metrics

•

Reintubation Rates

•

Reduceinpatientmortalityindex

•

Reducereadmissionswithin30days

relatedtoanesthesia

SampleGroupPerformanceMetrics

•

PatientSatisfactionPressGaney

•

Howwellyourpainwascontrolled

•

Howwelldidyourphysiciankeepyou

informed

•

Howlikelyareyoutorecommendthe

hospital

•

PayerSatisfactionMetrics

•

SurgeonSatisfaction Metrics

•

CompliancewithHospital

Documentation

•

Post‐anesthesiaevaluation(COP)

•

E‐signaturewithintimeframe

•

Date,Time,Witness(esp.ifonpaper)

AdaptedfromDr.StanleyStead

Becarefulof

monetizing

behaviorthatis

bettervaluedin

ethicalandsocial

“guilt”.

Similarprocessfor

othermetrics.Groupis

atrisk.Challengeis

timely feedbacktothe

physician.

Thoseunder

individualcontrol

–considerdirect

positive

reinforcement

with$sharedto

meetgoals.

Quality:OPPE

OngoingPhysicianPracticeEvaluation

•

Areas

•

PatientCare

•

Professionalism

•

InterpersonalandCommunicationSkills(includes360feedback)

•

MedicalandClinicalKnowledge

•

PracticeBasedlearningandimprovement

•

SystemBased Practice

•

Developmenthowyouwillmeasureandoutcomes

•

Chartascomparedtocolleagues

•

Timely:6monthsforreport– difficulttodopositivereinforcementto

changebehavior

•

Simple“negativereinforcement”maybeenoughformost

•

PositiveReinforcement:Participateingrouppaymentsforhigh

qualityprovider(createdforthosefewwhoneedtochangebehavior)

•

Punishmentforsevereundesirablebehavior;TIMING

AdaptedfromDr.JohnAllyn

(seeRCLandAQM)

QualityMetrics:ShowingValue

AQIWebsiteResources

•

QualityProgramisessential.

•

Newbehaviorswouldbetoimprovequality.

•

Howtomeasure?

•

ToolsandMeasurementsfromAQIwebsite

•

Fromthisdefinetoyourgroupmembers

whichbehaviorsaredesirableand

undesirable(whatwillbemeasured)

•

Chartmeasurements

•

Negativereinforcement– publishby

provideroutcomes

•

Positivereinforcement –sharingingroup

payment

•

Punishment–lastresort

Incent

vesNee

toC

ange

ecause



NewBehaviorsareNeeded

Identify

Relevant

Behavior(s)

Charting

Behavior

Isthe

Behavior

Desirable?

Maintainor

Increase

Frequencyof

Behavior

Decreaseor

Eliminate

Frequencyof

Behavior

Positive

Reinforcement

Negative

Reinforcement

Omission

Punishment

Problem

Solved?

Maintain

Reinforcement

Change

Reinforcement

Reidentify

Desired

Behavior

Desirable

Undesirable

Yes

WhatBehaviorswill

makeyourgroup

succeed?

WhatBehaviorswill

makeyourgroupfail?

Canyoumeasureit?

Canyoureportit?

Moneyisnottheonly

positivereinforcer.

RememberHaifaDay

CareExperiment

Wearecompetitive.

PublishLists

“TakingWindoutofSail”

LastResort

MaintainTimelyFocus

(CarefulofOmission

Reinforcementby

accident)

Wasreinforcement

meaningfulto

others?

TheFollyof

RewardingA,

HopingforB

Questions?

SurgeonRidingaBike

Damn,

Anesthesia

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification

Reality

Healing is an Art

Medicine is a Science

Healthcare is a Business

Abouleish, Amr, MD, MBA

Incentives and Behavior Modification