BJC HealthCare

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Beyond the Bundle The Art of Influence and
Science of Persuasion
Denise Murphy, RN, BSN, MPH, CIC Vice President,
Quality and Patient Safety Main Line Health
System Philadelphia, PA May 2009
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Session Objectives

• Describe three different soft sciences and how
  these can impact behavioral change
• Describe three principles of management that
  guide influence and persuasion
• Outline specific functions of a successful change
  agent in influencing positive outcomes
• Develop strategies for influencing administration
  related to needed resources such as support for
  an Infection Prevention program or Vascular
  Access Team

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Mans mind stretched to a new idea never goes
back to its original dimension.Oliver
Wendell Holmes
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Hard Science vs. Soft Science

• Hard science is used to describe certain fields
  of the natural sciences, usually physics,
  chemistry, and many fields of biology. The hard
  sciences are said to rely on experimental,
  quantifiable data or the scientific method and
  focus on accuracy and objectivity.
• The hard sciences are often contrasted with the
  'soft sciences' and social sciences, which are by
  contrast implied to have less rigor.
• Studies of Physics, computer science, chemistry,
  biology, and geology are sometimes called hard
  sciences.

From Wikipedia, the free on-line encyclopedia
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Hard vs. Soft Science

• Soft science is a colloquial term, often used
  pejoratively, for academic research or
  scholarship which is purportedly not based on
  reproducible experimental data and a mathematical
  explanation of that data.
• Examples of soft science include
• Social Science - the study of human society
  humans in their social relationships and includes
  the disciplines of sociology, psychology,
  anthropology, economics, political science, and
  history.
• Behavioral science - studies the actions and
  reactions of humans and animals through
  observational and experimental methods.

From Wikipedia, the free on-line encyclopedia
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The Sciences Influencing Infection
Prevention

• HARD SCIENCE
• Biology
• Chemistry
• Microbiology
• Virology
• Immunology

• SOFT SCIENCE
• Psychology
• Sociology
• Anthropology
• Computer science

So What About EPIDEMIOLOGY?
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So what about Epidemiology?

• Epidemiology is the study of the distribution and
  determinants of diseases and injuries in human
  populations.
• Relatively new science, emerged in 19th Century
  (Snow, 1854)
  essentially, the study of epidemics.
• Fundamental assumptions about epidemiology
• Disease doesnt occur randomly nor is it
  randomly distributed
  throughout population
• Disease has causal and preventative factors
• Uses a systematic approach to study differences
  in disease distribution and determinants in
  subgroups
• Quantifies existence or occurrence of disease
• Tests hypothesis about determinants using
  epidemiologic studies
• SOUNDS LIKE A HARD SCIENCE TO ME

The Broad Street Pump London, England
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The Epidemiologists Toolkit

• Surveillance tools and technology
• Data management, organization, analysis,
  reporting and presentation
• Epidemic investigation tools
• Education and tools for effective knowledge mgt.
• Evidence based interventions

John Snows Map of Cholera Epidemic
Geographical Location and Deaths
From The Visual Display of Quantitative Data,
Edward R. Tufte
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Is Epidemiology also an art?

• The application of the principles and tools of
  epidemiology to the reduction of risk and
  elimination of disease is the art!

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The Art of Infection Prevention what does our
palate look like?
S O F T S C I E N C E

• Leadership, management and communication
• Influence and Persuasion grounded in
  the behavioral sciences
• Change Management
• Performance/Process Improvement
• Human Factors Engineering
• Implementation Science or the
  Art of Execution

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Change Management

• Change management is the practice of
  administering changes with the help of tested
  methods and techniques in order to avoid new
  errors and minimize the impact of changes on an
  organization and individuals.
• Change management is a systematic approach to
  dealing with change, and has at least three
  distinct components
• adapting to change,
• controlling change, and
• effecting change.
• A proactive approach to dealing with change is at
  the core of all three aspects.

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Change Management

• Change Management is the process, tools
  techniques needed to
• manage the people side of change processes,
• to achieve expected outcomes
• and to realize the change effectively

Source The Change Management Toolbook
Introduction http//www.change-managementtoolbook
.com
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Performance Improvement

• Performance Improvement is the process of
  designing or selecting interventions which may
  include training directed toward a change in
  behavior, typically on the job.
• PI is a systematic process of discovering and
  analyzing human performance gaps, planning for
  future improvements in human performance,
  designing and developing cost-effective and
  ethically-justifiable interventions to close
  performance gaps, implementing the interventions,
  and evaluating the financial and non-financial
  results.

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Performance Improvement Art or Science?

• PDCA/PDSA
• Six Sigma DMAIC
• Toyota Production System (TPS) Lean
  Engineering Get the
  waste out!
• Lean Six Sigma the hybrid (Lean on the DMAIC
  framework)
• General Electrics Express Workout
• These approaches to PI are nothing without Change
  Mgt.!
• Bottom lineIts all getting much more
  analytical and based on
  scientific/mathematical principles!

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Human Factors Engineering

• Human Factors Engineering is based on sciences of
  physics and ergonomics and is essentially the
  study of man with his/her tools in the system
  (environment) in which they live or work.
• HFE is a multi-faceted discipline that generates
  information about human requirements and
  capabilities, and applies it to the design and
  acquisition of complex systems.
• Human factors engineering provides the
  opportunity to
• (1) develop or improve all human interfaces with
  the system
• (2) optimize human / product performance during
  system operation, maintenance, and support
• (3) make economical decisions on personnel
  resources, skills, training costs.

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Human Factors Engineering

• Embedding and integrating human engineering
  activities into the design of systems and use of
  equipment can
• lower lifecycle costs
• improve performance
• reduce technical risk
• eliminate rework
• improve patient safety
  and
  clinical outcomes

GOOD OR POOR ENGINEERING DESIGN?
Photo source Barnes-Jewish Hospital, Laurie
Wolf, Human Factors Engineer
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Implementation Science or the
Art of Execution

• 1- Maintain focus on the vital few goals
• Keep strategic plan simple, communicate goals
  often
• Employees must be clear about their roles in
  achieving the most critical 80 of the plan
• 2- Develop tracking systems that facilitate
  problem solving
• Set metrics use charts, graphics and other
  tracking tools for planning and execution
• The right measures make expectations clear
• Each key success factor must have only one owner
• Conduct RCA to drill down and uncover barriers
  to success
• 3- Set up formal reviews
• Conduct toll gate or milestone reviews
• Be specific about meeting structures, frequency,
  and agendas
• Personnel and resources needed should be at top
  of the agenda!

Root Cause Analysis
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Implementation Science or the Art of
Execution

• If youve got the right people in the right
  roles and
  are still not executing, then look at
  your resources.
• Tim Stratman, CEO RRD Direct
• The most creative, visionary strategic planning
  is useless if it isnt translated into action.
  Think simplicity, clarity, focus
• and review your progress relentlessly.
• Melissa Raffoni
• Source Three Keys to Effective Execution,
  Melissa Raffoni
• Harvard Business School Publishing
  Corporation, 2003

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Soft sciences hit hard on HAIs
Evidence

• Studies have demonstrated the impact of using
  principles of psychology, sociology, and
  behavioral science to understand drivers and
  barriers to infection prevention
• Larson and Kretzer looked at theoretical
  frameworks overlaid on individual and
  organizational factors suggests obstacles to be
  addressed and proposed how behavior change theory
  can be applied to improve success of hand hygiene
  interventions
• Health belief model (HMB)
• Theory of Reasoned Action (TRA)
• Theory of Planned Behavior (TPB)
• Self-efficacy (SE)
• Trans-theoretic Model

Source Am J Infect Control 199826245-253
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• Health Belief Model
• describes specific variables that influence an
  individuals self-protective health behaviors and
  is based on
• Perception of the risk or susceptibility to the
  illness
• Perception of the severity or degree of
  consequences of the illness
• Perception of barriers or cost of undertaking a
  particular health behavior (or not)
• Cues to action that trigger the health behavior
• Self efficacy

Source OBoyle et al (1994) Variables
influencing workers Compliance with universal
precautions in the ED. AJIC 22(3) 138-48
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Theories of Reasoned Action and Planned Behavior

• Best predictor of behavior is intention
• Intention is a persons readiness to perform a
  given behavior is considered to be the immediate
  antecedent to behavior
• Intention is determined by three things
• Their attitude toward a specific behavior
• Their subjective norms (beliefs about how people
  they care about perceive the behavior)
• Their perceived behavioral control or ability to
  perform the behavior
• These theories assume people behave rationally
  and consider implications of action or
  behavior before engaging in the behavior

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• Self Efficacy
• is a persons judgment about their ability to
  organize and execute an action to attain a
  performance. It is influenced by
• Enactive attainment success raises worth,
  failure lowers worth
• Vicarious experiences observing others
  performing process successfully raises worth
• Verbal persuasion being persuaded that one has
  the ability to change increases the effort
• Physiologic state physical response may be seen
  as vulnerability and decreases confidence

Source Kretzer et al (1998) Behavioral
intentions to improve infection
control practices. AJIC. 26 (3) 245-53
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• Trans-theoretical Model
• views health behavior changes as gradual
  continual stages
• Pre-contemplation no intention to change
• Contemplation considering change
• Preparation plans to change soon, may have taken
  small steps
• Action change is occurring
• Maintenance incorporated change into life 6 mos.
  beyond action
• Termination ultimate goal without relapse

Source Kretzer et al (1998) Behavioral
intentions to improve infection control
practices. AJIC. 26 (3) 245-53
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Theoretical Models of Behavior Change

• OBoyle described relationship between Health
  Belief Model and compliance with universal
  precautions in the ED and adherence to hand
  hygiene recommendations based on Theory of
  Planned Behavior (TPB)
• Source Am J Infect Control 199422138-148
• Source Am J Infect Control 200129352-360
• Seto studied the application of behavioral
  sciences related to staff compliance with IC
  practices
• Social power and theory of reasoned action
  (Social psychology)
• Participatory decision-making (Organizational
  behavior)
• Influence of opinion leaders (Consumer behavior)

Source J Hosp Infection 1995 30 (Supplement)
107-115
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We use theories from the behavioral
sciences everyday, usually unconsciously, to
practice any specialized form of patient care.
We are always appealing to what motivates people
to practice safely, to do the best things for
patients, asking patients to do the best things
for themselves.
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http//www.med.uni-marburg.de/bild/einrichtung/511
.jpg
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Consider Ecological Theory

• Pittet reviewed theoretical models but focused on
  Ecological Model of Behavioral Change and its
  application to hand hygiene behaviors
• Theory based on
• Behavior is affected by and affects multiple
  levels of influence
• Behavior both influences and is influenced by
  the social environment
• People learn from own and others experiences
  and learn best from role modeling

Source The Lowbury Lecture in Journ of Hosp
Infect (2004) 58, 1-13
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Ecological Factors

• influencing health-related behaviors
• Intra-personal knowledge, attitudes, beliefs,
  personality traits
• Inter-personal factors support of family,
  friends, peers that provide role definition
• Institutional factors availability and access to
  rules, systems and infrastructure that promote
  or discourage behavior change
• Community factors support of social networks,
  participation in identifying and solving health
  problems, public policies
• Administrative support mandate teams, develops
  strategy, and allocates resources!

Source The Lowbury Lecture in Journ of Hosp
Infect (2004) 58, 1-13
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Missing Link in Infection Prevention

• Dixons challenge in 1981 to IC community was to
  recognize the missing link in infection
  PREVENTION
• First link in preventive medicine chain is to
  identify characteristics of a disease in order to
  understand its attributes, causes and effects.
• Second link comprises prevention and control
  techniques to mitigate effects of disease.
• Third link Implementing prevention and control
  measures to reduce morbidity and mortality in
  populations at risk.
• Most research done on first two links
  understanding HAIs and what reduces them, yet
  studies show we have had little success

Source Richard Dixon in Am J Med 1981 70976-78
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Missing Link in Infection Prevention

• Dixon defines the missing link in infection
  prevention as our being less comfortable with
  techniques used to influence human behavior,
  manage programs or evaluate program
  effectiveness. The research techniques for
  addressing this final link in IC have
  traditionally been in the province of social
  psychologists, psychologists and management
  consultants, biomedical investigators have felt
  uncomfortable with, or skeptical of, such
  techniques.
• ICmust become involved in the management of
  programs and people, seeking to learn why control
  programs succeed or fail. In doing so, they must
  begin to consider the most complex of biologic
  phenomenahuman behavior.

Source Richard Dixon in Am J Med 1981 70976-78
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Evidence-based medicine and infection prevention
measures can go no where without effective
programs and knowledgeable professionals that
have the ability to influence healthcare workers
to change. We must also be able to influence
decision-makers to provide the resources that it
takes to build and maintain effective infection
prevention programs, part of which is holding
healthcare teams accountable for safe behaviors.
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The Chief Executives View of the Worldand the
factors that shape it
Influencing the C suite
Source Steve Miller, MD
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Clearly Articulate Organizational VALUE
Start with being able to
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The Art of Persuasion

• After youve established your value, use your
  influence to persuade executive and physician
  leadership to commit resources needed to do what
  it takes to build an effective infection
  prevention program. Resources you need are not
  always people.
• The language of influence is persuasion.
• Leaders use language to motivate employees,
  articulate vision and strategy, and mobilize
  their organizations to adapt to challenging
  business environments.
• Jay Conger

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The Process of Persuasion 4 Steps

• Establish credibility through expertise and
  relationships
• Frame goals on common ground describe benefits
  of your position if you cant find shared
  advantages, adjust your position compromise
• Vividly reinforce your position dont use
  ordinary evidence make numerical evidence more
  compelling with stories, examples and
  metaphors that have emotional impact.
• Connect emotionally adjust your emotional tone
  to match the audiences ability to receive your
  message. Learn how people have interpreted past
  events in the organization and predict how they
  will probably interpret/react to your proposal.

Source Jay A. Conger. The Necessary Art of
Persuasion. Harvard Business Review May-Jun 1998
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Framing the Message
Much of persuasion is about how we deliver the
message
Persuasive content needs a focused context.
Framing gives perspective, rationale, and
structure to what you want to say.
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To frame a message effectively

• Clearly express your objective
• Conduct a focused SWOT analysis
• of the other partys current status
• 3. Determine the other partys core values
• Write a simple, vivid, evaluative
• statement that links 1-3.

Strengths, Weaknesses, Opportunities, Threats
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If the organizations priority is patient safety
Be careful not to frame your objective as simply
needing more resources. Focus on needing to be
more effective in meeting the organizations goal.
An effective Infection Prevention program may
save money, but most importantly, it will save
lives. We cant afford to do a poor job.
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If the organizations priority is financial
health
An effective Infection Prevention program will
save lives and equally as important, it will
save dollars and decrease LOS. We cant afford
not to do this.
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Fundamental Principles of Persuasion

• 1) People like those who like them Uncover real
  similarities and offer genuine praise.
• 2) Reciprocity Give what you want to receive
  and compromise!
• 3) Social proof People follow the lead of
  similar others use peer power
  when available.
• 4) Consistency People will align with their
  clear commitments make their commitment active,
  voluntary and public.
• 5) Authority People defer to experts expose
  your expertise, dont assume it is
  self-evident. Use expert partners.
• 6) Scarcity People want more of what they can
  have less of highlight unique benefits and
  exclusive information.
• Use 6 principles together for best effect be
  genuine and honest!

Source Robert B. Cailidini (2001) Harnessing the
Science of Persuasion. Harvard Business Review
Oct 2001
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Hand Hygiene Intervention -Which principle is
being used here?
Got foam?
Social proof?
Consistency?
Authority?
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Principles I Use Most to Influence C Suite

• Establish Credibility and Authority of team
• Vividly Reinforce My Position
• Share evidence with data and graphics first
• Attach stories with data about REAL PEOPLE with
  HAIs
• Social Proof use power of expert partners

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Surgical Care Improvement Project
Example of what we did wellESTABLISH CREDIBILITY!

• Authority -
• People defer to experts establish your own OR
  YOUR TEAMs expertise find things you/they do
  that no one else can
• Six Sigma approach used
• Data collection, observations, analysis, focus
  groups, interventions, reporting, process
  redesign, further analysis, program maintenance
• Social Proof - Every service had surgical
  champion involved
• Chief of Service sanctioned this work
  Consistency make commitments verbal and public

MO grant to increase PI capacity in industry
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SCIP Pre-intervention state for
colorectal service
Source Pat Matt, BJH 2006
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Interventions to improve pre-op antibiotic timing

• Colorectal pre-op and post-op standing orders
  were revised to reflect SCIP guidelines
• Roles were clarified
• Surgeons are responsible for writing pre-op
  antibiotic orders
• Anesthesia staff are responsible for
  administration of pre-op antibiotics
• An antibiotic question was added to the surgical
  time out
• Education on SCIP guidelines
• Surgeons
• Anesthesia
• OR Nursing Staff
• Rapid electronic feedback of individual service
  compliance rates

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SCIP Post-intervention state
Next steps - Roll out to all surgical
services - Develop control plans to sustain gain
for colorectal services - Electronic method to
monitor post-op glucose in cardiac pts. -
Electronic method to monitor core temp in
colorectal surg. pts.
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SCIP Cost Estimates
Principle of Scarcitypeople want exclusive
information

• Organization and facilitation of an active
  multidisciplinary team by ICP - 3360
• Organization and facilitation of focus teams and
  sub-groups by ICP - 3360
• Focus group meetings with all services - 3940
• Pre/post-op order set revisions - 9888
• Data collection and feedback - 120,960
• Clerical support - 1080
• PI Oversight Committee and PI Facilitator
  Meetings - 2352
• Education and Staff/Dept. Mtg. Presentations -
  35,939
• Minitab software and license - 1,000
• Total cost estimate SCIP project over 14 mos.
  181,879

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Intervention to Reduce BSI
Consistency People align with clear commitments

• Reporting rates routinely
• Self-study modules
• Fact Sheets, Poster
• Pre and Post Test
• Incentives for completion
• Strict application of best practices for
  insertion and site care

Source Amy Hueffmeier, BJH, 2006
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C L A B S I

• Pictures of each step of catheter care
  insertion
• Reviewed with nursing staff as a refresher to BSI
  module
• Provided to incoming residents during sharps
  safety training each year
• Copies attached to procedure carts
• Maximum sterile barriers
• Full drapes are included in central line
  insertion kits
• Implementation of 2 CHG
• 2 CHG and 70 isopropyl alcohol implemented for
  central line insertion and site care
• 2 CHG and 70 isopropyl alcohol added to
  insertion and dressing change kits
• Individual CHG applicators also available
• Femoral Line Tracking
• Total of femoral lines inserted
• Total of central lines inserted
  femoral lines
• Patient may have multiple lines inserted each
  is counted
• Femoral lines are also counted in the denominator
  

Source Amy Hueffmeier, BJH, 2006
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ICU A
Femoral Line Utilization and
Primary Bloodstream Infection Rates
Once problem identified, act on itdemonstrate
expert authority
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20
18
35
16
30
14
25
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Femoral Line Tracking
Femoral Line Utilization Percent
BSI Rate (per 1000 line days)
20
10
8
15
6
10
4
5
2
0
0
Jul
Jul
Oct
Apr
Jan
Mar
Apr
Jun
Jan
Feb
Mar
Jun
Oct
Feb
May
Aug
Sep
Dec
May
Aug
Sep
Dec
Nov
Nov
2004
2005
Source Barnes Jewish Hospital Epidemiology
BSI Mean
Fem Line Mean
and Infection Control Department
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Making the Business Case forInfection Prevention

• Ultimately a question of the balance between...

Benefits of IP
Costs of IP
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We use strategies and tactics from leadership and
business science everyday, usually
unconsciously
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Examples of fundamentals of persuasion and
process steps
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Enhancing Resources Option 1

• Add 1 FTE experienced
• 75K salary/benefits, computer, equipment,
  training
• Dedicated medical director (0.5 FTE)
• 75K purchased services plus 2,500 training
• Secretarial support (1.0 FTE)
• 20K
• Negotiate with PI to support 2 IC-related
  improvement projects/yr. to reduce HAI or OE
• Support intern from School of Public Health
• Financial Impact 172,500

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Enhancing Resources Option 2

• Add 1 FTE experienced
• 75K salary/benefits, computer, equipment,
  training
• Contract for physician leadership for committee,
  review data, recommendations for interventions,
  meet with med staff leadership prn (8-10 hrs./
  month)
• 10-12K contract services plus 2,500 training
• Secretarial support - share OHs secretary
• Barter we will assist with their data
  mgt./reporting functions
• Share IC liaisons to assist with flu vaccine
  campaign
• Negotiate with PI to support 1 IC-related
  improvement project /yr. to reduce HAI or OE
• Support intern from School of Public Health
• Financial Impact 89,500

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Enhancing Resources Option 3

• Add 1 FTE for IC and OH to share experienced
• 75K salary/benefits, computer, equipment,
  training
• Contract for physician leadership for 1x/month
  meeting to prepare for IC committee, review data,
  make recommendations for interventions. (4 hrs./
  month)
• 5K
• Negotiate with laboratories to pick up
  communicable disease reporting functions to free
  up time for clerical work.
• Negotiate with PI to support 1 IC-related
  improvement project /yr. to reduce HAI or OE
• Support intern from School of Public Health
• Financial Impact 80,000

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PI Project (Eliminating CLABSI)

• Problem Varying staff skill levels placing
  peripheral IVs
• Initial State
• Multiple attempts patient discomfort/dissatisfac
  tion
• Excessive utilization of central lines
• Medication delays
• Future State Increased staff skill levels in
  placing peripheral IVs Develop and implement
  plan for multidisciplinary training to include
  simulation training
• Metric Decreased CVC utilization rates

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TOP TEN ideas for Influencing Your CEO

• 1. Stay grounded in science.
• 2. Know the hard soft sciences that support
  your work.
• 3. Know leadership competencies business skills
  that
• promote effective infection preventiondeploy
  them consciously.
• 4. Leverage theoretical models of behavior
  change deploy them consciously.

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5. Partner with well-liked, influential
experts to help you get what you need.
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TOP TEN ideas for influencing your CEO

• 6. PLAN your program goals and strategies for
  success.
• 7. Evaluate program effectiveness often and
  honestly!
• 8. Meet with senior leaders, be persuasive, offer
  options.
• 9. Frame your message for success
• - be clear about your objective (and concise!)
• - conduct SWOT analysis of organizations status
• - determine the organizations core values
• - write simple statement that is vivid and
  evaluative linking your objective with what
  they need and value most.
• 10. Never negotiate for resources during the
  budget cycle.

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As healthcare professionals, we are both
scientist and artist. Lets use all of our
tools, a wide brush and colorful palette to paint
a better healthcare experience for our
patients!
Thanks for listening.