changing practitioner behavior gail d’onofrio md, ms professor and chief section of emergency...
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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