The 'Freakonomics' of Behavior Change in Healthcare

So much of what I’ve learned through my years of interviewing CIOs, CMIOs, and other leaders is that culture change is usually at the heart of healthcare IT innovation. What I learned recently from Stephen J. Dubner, who was the keynote at the 2012 New York eHealth Collaborative Digital Health Conference, is that what incentivizes behavior change is often very hard to predict. Dubner, who is the co-author of the wildly successful Freakonomics and Superfreakonomics, presented an interesting example of the complexity involved with incentivizing better physician hand hygiene at Cedar-Sinai in Los Angeles. It just so happens that October 15 was Global Handwashing Day and this week is International Infection Prevention Week (founded by the Association for Professionals in Infection Control and Epidemiology Inc.).In the U.S., healthcare associated infections affect more than 2 million people every year resulting in approximately 100,000 deaths. Compliance by healthcare workers with optimal hand hygiene is considered to be less than 40percent. A 1996 medical study in Australia illustrated there was a perception gap of perceived and actual hand hygiene in pediatric physicians. When asked to report on their own hand washing practices, physicians self reported at a rate of 73 percent, but when that rate was validated by “nurse spies” in the hospital, the actual rate turned out to be an abysmal 9 percent. So the question is how do you solve a problem when the perception of the actual problem is so clouded? This Australian study, as well as the 1999 Institute of Medicine (IOM) report, which estimated there to be 44,000 to 98,000 deaths annually due to medical errors, triggered a lot of introspection and inspection by Cedar-Sinai around this issue. The hospital convened a committee with the chief of staff and other physicians try to achieve a 100-percent hand wash rate. The committee tossed around a lot of ideas, until settling on sending out a memo stating that Cedar-Sinai would reach this goal via fax and email. Nursing staff measured the physicians afterward and reported that the needle had not moved.

The Cedar-Sinai hand hygiene committee went back to the drawing board. Education is generally perceived to be the first solution to solving a problem like this, but the committee already knew that the doctors were the most educated group in hospital, leaving that point moot. Then next approach was to bring the message directly to the patient floors. The committee broke up into posses and wandered into patient rooms to see if physicians would indeed wash their hands. The posses designed an incentive program—more carrot than stick to prevent alienation—where the posse member would clap for the doctor upon successful hand washing and then award the doc with a $10 Starbucks card. It was a clever solution that solved the problem for the short-term. Hand washing rates soon plummeted. The committee was desperate at this point for ideas, and that’s when the staff epidemiologist proposed a different approach. Since the committee was telling other physicians how to behave, how clean were their own hands? She pulled 20 petri dishes and swabbed the palms of the committee members, and the results were astonishing; the majority came back carrying harmful bacteria.

“A lot of time incentives are about taking information and using it in a different way. The real hero of this story is the IT staff at the hospital. What they decided to do was make that photograph of the handprint [with the bacteria] the screensaver on every computer in the hospital,” said Dubner. “And they did it, and it worked for whatever reason. Incentives are very hard to predict, what will work and what won’t work. No doc could go on to any floor without seeing that image on multiple computers on the floor. For whatever reason that triggered a change a behavior.”

Hand hygiene soon ratcheted up to 100 percent. Other hospitals saw Cedar-Sinai’s success and even asked to borrow the photograph like it was some magic talisman for hand washing. What Cedars Sinai has subsequently found is that they have had to do a lot to maintain the high rate. The committee continued using negative feedback, in essence shaming physicians into compliance, by posting the name of doctors who had been observed in failing in hand hygiene at departmental meetings. Even if the physician wasn’t at the meeting, undoubtedly, they would get a text from a colleague saying they were on the “crap list.”

“So when you’re dealing with human behavior change, you have to see that even a simple behavior that we can all agree is fruitful, can be much harder to enact than we think,” said Dubner. “That’s why when you’re designing incentives , when you’re trying to change human behavior, often relying on humans to do the change can be fruitless.”

Dubner said that many organizations should focus instead of innovations through technology or design, like in the case of hygiene, investing in antimicrobial surfaces or disposable blood pressure cuffs to stop the spread of germs.

When Dubner was asked about the efficacy of an incentive program like meaningful use, he said that at the core human beings are motivated to benefit themselves and those they care about, rather than benefiting others.

“The problem with the U.S. government in recent history is that it doesn’t have a good track record in creating top-down incentive plans that benefit a lot of people in a system where there are many individual actors,” he said. “The better alternative is experimentation.”