Archive for the ‘Behavior change’ Category

Reduce obesity and improve Patient Safety?

In Behavior change, design, Force function, High Reliability Orgs, Human Factors on March 15, 2015 at 2:01 pm

I have read much material lately about addressing the obesity epidemic and there are many commonalities in the latest theories.
1. Motivation- focusing on motivation as a strategy is not the best approach. Willpower has been dismissed by many as a poor approach to weight management
2. Behavior change- changing behaviors is not easy. Much of a person’s day consists of habitual activities resulting from cues from tv, peers, childhood… example wanting to eat popcorn while watching a movie, reaching for the salt before tasting food…
3. Environment changes-For obesity this holds the most promise. Its seen in weight watchers programs and Wansink’s book Slimdown by design. Change architecture and nudging can help make behavior change easier and lasting. This includes things like using smaller colorfull plates, moving healthy foods to a prominent kitchen spot and unhealthy foods to hidden cabinets. In some estimates people who follow certain environmental patterns are 18% thinner than those who do not.

What’s the correlation with patient safety?
1. Motivation- focusing on motivation as a strategy is not the best approach. Motivating staff to be more vigilant? Teaching them? Telling them to Follow rules and policies? These have not been shown to increase safety measurably. In fact sometimes recognizing when to deviate from rules can add resilience
2. Behavior change- changing behaviors is not easy. Other articles on this cite describe many nursing behaviors as being based on tradition and automatic behavior. Often under stress people revert back to old knowledge. How many times has an initiative been rolled out only to see it vanished from practice within a year?
3. Environment changes- just as in obesity management here we might find the most bang for our buck so to speak. Make it easy for staff to do the right thing. Make it hard for staff to do the wrong thing. Create systems that nudge staff toward safe behaviors. Use change architecture to produce reliability

A healthier world depends on reducing obesity and unsafe patient care. Maybe the solutions to both are the same.

See Reference Page for some articles related to this page

Neuroscience Saturday: BJ Fogg and Starter Steps

In Behavior change, Patient Safety, Resiliency, Safety climate, usability, user experience on July 19, 2014 at 8:35 am

Anyone who knows me knows I love BJ Fogg’s behavior models. He is a design psychologist who runs a persuation lab out at Stanford. His latest behavior change model is based on his research about lasting change which basically falls down to: making things easy to do and changing the environment.
His latest little flip book sums up his findings to date.
Lots of lessons for us in healthcare and these are my take aways:
*we tend to love dramatic change initiatives: secret: they usually dont work
*Starter steps or baby steps arent glamorous and flashy but they work
*We clearly need to reward change and not the flashing marketing campaigns when it comes to safety (how many hours have you spent on catchy acronyms….did it make a difference??)
*BJ desribes certain things to look for that can warn you that you are designing for epiphany instead of change secret: hoping staff epiphanies will lead to behavior change doesnt usually work

If you care about patient safety AT ALL please read BJ’s latest little flipbook.. I have never read so much great info in one place

Story telling to change safety culture

In Behavior change, BEST.ARTICLE.EVER., Patient Safety, Safety climate on May 26, 2014 at 5:04 pm

While this study is about the workplace and not patient safety in particular, it shows the importance of story telling on culture.
Workplace culture influences patient safety.

The researchers identified several forms and functions of these stories:

To control behavior: These forms of stories serve as lessons, and indoctrination to the behaviors that are either encouraged or discouraged by the moral. Themes of punishment or reward are common.
Oppositional stories: These stories provide an outlet for expressing frustration with the company. Researchers suggested that even these types of stories can be used strategically, if key leaders in the organization are aware of them.
Differentiation/integration: This type of story serves to answer the question, “Who are we as a group?” These stories establish the unique identity of the company, and make a distinction between the organization and its competitors. These tales shape impressions of the organization, and the employees’ place within it.
Preparation for the future and change: These stories can be used to provide stability and a road map during times of difficulty or change by setting examples for solving problems.

Read more

Luck of the Irish or workflow?

In Behavior change, culture, user experience on March 17, 2013 at 9:27 am

According to the Office of the National Coordinator (ONC), 30% of all Health IT implementations fail. What causes failure? A workforce that doesnt want to change? Poor technology? Luck?
It’s unlikely to be any of these things. It is usually the inattention to workflow and culture that leads to failure of Health IT initiatives designed to improve patient safety.
What do hosptial IT execs know about the culture of their institutions? Probably not much. Aminstrators in general have different opinions of safety culture than front line staff (the latter see less safety). How often do we do post IT implementation and periodic surveys to see if workflow is indeed more “flowing” than bottlenecked? My guess is not very often or we would see these survey results at the top of every Health IT companies webpage. Most products now are only rated by IT execs through a propriatary report. We need a marketplace website for all thse like Amazon where end users can rate and evaluate the products!!

Read the chapter from Patient Safety and Quality for Nurses from the NIH
about workflow.
Cain C, Haque S. Organizational Workflow and Its Impact on Work Quality. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 31. Available from:

Do as I say not as I do

In Behavior change, Human Factors on February 3, 2013 at 12:01 pm

As healthcare workers, we are not always role-models for health. In a canadian survey 66% of healthcare workers were overweight and 18% smoked.

Do we eat breakfast?  Many healthcare workers who have children know that having  breakfast before school improves performance.

Boschloo, et al. (2012) studied kids age 11-18.  In their results, they found that habitual  breakfast skippers performed more poorly in school than habitual breakfast eaters.  Performance was measured by school grades and an attention scale. This effect was true for kids regardless of chronotype (day person or night owl).

Other studies have shown lack of breakfast can affect memory (particulary verbal in girls), mood and attention.

This research comes from the relatively new field of Mind Brain Health and Education which attempts to cohort the best research from psychology, neuroscience and education to facilitate the teaching and learning of our children, with the goal of every child reaching their full potential.  Perhaps patient safety might benefit if we use some of this research to help healthcare workers reach their full potentials?

Let’s start by making breakfast a habit for all healthcare workers!


(in a future post I will present some research on food types and Mind Brain Heath and Education)

Boshloo, A. et al., (2012). The relation between breakfast skipping and school performance in adolescence. Mind, Brain, and Education, 6(2), 81-88

Despite bacteria in labs, clean pharmacy report

In Behavior change, hospital, Patient Safety on October 31, 2012 at 9:15 am

Whenever a story comes out like this one regarding contaminated steriods causing meningitis and DEATHS, I cannot help but wonder whether our accreditation processes are majorly flawed. This is not intended to disprepect the amazing work of say the Joint Commission (their patient safety and quality journal is one of the best and their sentinel alerts have no doubt saved countless lives) however any kind of process such as theirs is going to encourage the hiding of deficits. Compare this with visits by a PSO such as ISMP and you get a totally different level of transparency.

I liken this to a court of law. On the witness stand the advice is to be evasive, answer only the question: don’t comment, add more info or compromise the case in any way.

This is sort of the same prep front line staff often get to be Joint commission ready. I am sure every institution has their own “survey tips” (example

Even the Joint comission tells you what to do

From an organizational psychology standpoint, it seems to me there is just no way that organizational problems will not be hidden in this type of survey. Staff will avoid surveyors, fearful that they will be “the one” who disgraces the organization. There is shame and blame inherent in this type of process. Staff do not usually speak with surveyors without a manager present.

Contrast this with a survey by a Patient Safety Organization where staff are encouraged to speak up and be truthful. They are allowed to speak to surveyors alone. Staff line up for opportunities like this: to share their concerns and frustrations. It seems PSOs are really the future of patient safety and not accreditation programs. Hospitals should be judged by their patient safety culture scores and their employee satisfaction scores. This would be much more enlightening as to whether or not an organization is safe for patients. Happy employees working in a safe culture are likely producing great outcomes.

Transparency and speaking up are two of the basic tennants of any safety program. I am sure many employees knew of the conditions in the compounding pharmacy. If only someone had asked them….in an open and non-threatening manner..

Behavior change and policy change: BJ Fogg for health!

In Behavior change on July 12, 2012 at 9:14 am

Great it on you tube. I think Bj’s model can apply to healthcare professionals who want to help their patients change to healthier behaviors as well as apply to helping staff change their workplace behaviors to add safety.

Change healthcare workers behaviors by Fogging them :)

In Behavior change on March 18, 2012 at 4:47 pm

Advice from BJ Fogg:

“1. Stop calling what you’re doing “education.” If what you really aim to do is change behavior, that’s how you should be talking about your activity. Just changing the term you use to talk about what you do can shift the mindset of everyone involved.

2. Be clear about what you want your HCPs to do. Do you want them to check  their diabetic patients’ feet as part of every appointment? Order a specific  test when presented with a certain set of symptoms? Follow up within a specific  time period after a procedure? Fogg says that those who plan the intervention  must be really precise about the desired behavior change.

3. Make the desired behavior easy to do. This, says Fogg, is likely going to  be the biggest challenge, but you have to make it simple for the docs to  do what you want them to do.”

Read more:

Cheese and safety; cookies and safety!

In Behavior change, culture, Force function on March 17, 2012 at 7:52 am

On this blog we have seen the analogy of swiss cheese to safety in the form of James Reason’s swiss cheese model of failure.  Now what could cookies, as yummy as they are, possibly have to do with safety?

Yesterday, I walked up to the city marketplace after work to get a snack:  Chipyard cookies were calling my name. As I approached the stand, I recalled a story from a colleague who was fired from this company in college. It seems after baking the cookies, the staff were required to take the hot trays from the oven and load them onto to a backing rack. The procedure would be to yell “hot tray” and then slide the tray onto the rack to cool. Several times, my colleague yelled “hot tray” and as she was placing the tray into the rack she would use a bit too much force and the tray would slide out the back of the rack through an open window panel! The “hot tray” of cookies would drop out onto the pavement behind the cookie stand rendering them unsellable.

She was shown the “safety” procedure several times yet somehow the cookies kept ending up on the pavement.  Thinking she hired a bad apple, the manager fired my colleague who is now an incredible nurse who saves kids’ lives…bad apple indeed.

When I walked up to the cookie stand last evening I noticed something amazing. They had built a small wall right behind the cooling rack!  I asked the girl at the counter “Hey does anyone ever ruin the hot tray of cookies by knocking them through the rack?” She looked at me increduously! This new generation of workers could not even conceive of making an error of this type.  This is forced function at its best and illustrates the effectiveness of this type of intervention over education and prompts to do better to eliminate safety hazards.

Do we have similar situations in healthcare? Are we telling staff over and over “Don’t make this mistake” “watch what you are doing!” “be more careful”  or are we building barriers to unsafe actions and behaviors that will create and sustain safety for our patients?

I can think of one success in particular.  Seasoned nurses will talk about the old days when they mixed chemotherapy in the kitchen on the inpatient units.  New nurses will listen with horror as they only know chemotherapy that comes in specially prepared and labelled containers from the pharmacy.

Real safety comes from designing safe systems and critiquing everyday provider choices and behaviors (Just Culture Community, 2008).  

Look around your environment. What safety hazards/behaviors could you render obsolete for the next generation?

Celebrate patient safety!

In Behavior change, culture, Patient Safety, Safety climate on March 4, 2012 at 4:57 am

Happy patient safety awareness week! it’s time to make one commitment to safety no matter how small. use bj fogg’s 3 tiny habits method to make it stick!

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