Using Behavioral Psychology to Improve Quality Measure Compliance

Getting physicians and others to comply with your healthcare organization’s clinical quality measure reporting requirements can be tricky. However, experts say you can convert those negative habits into positive practices in your clinic or hospital by using proven behavioral psychology techniques.

Why don’t doctors always document properly if they know it betters patient care?

You know your doctors are smart, and you know that you’ve expended lots of energy explaining why it’s important to document things that will help measure and improve patient care. Doctors have signed a pledge to uphold value-based care, and they deeply care about the patients they see. 

And yet, physician compliance at your organization is still a struggle. You think of your doctors as rational beings who will respond appropriately when given the choice. Once you educate them, their behavior will change ... but that’s not always the case, is it?

Think of it this way: People know that smoking is bad for them and that seatbelts can save lives, but you still see patients at your organization with smoking-related diseases and avoidable injuries from car accidents.

As economist and health policy expert David Asch stated in his 2018 TEDMED talk, your doctors “don’t have a knowledge deficit. They have a behavior deficit.” Changing people’s behavior is much more difficult than changing their minds. Enter behavioral psychology.

We looked at a few knowledgeable sources for suggestions on how to use behavioral psychology as a tactic to potentially increase your physicians’ and other clinicians’ compliance. We came up with four applicable tenets of behavioral psychology.

1. The less friction, the better
2. Social influence works
3. Loss aversion is greater than financial reward
4. Inclusion creates investment

1. Identify and reduce sources of friction

Let’s start with friction.

In this TED Talks Daily podcast, Dan Ariely, the James B. Duke Professor of Psychology and Behavioral Economics at Duke University and co-founder of the Medical Professionalism Project, addressed how friction stops people from doing what they should be doing or what you want them to do. Friction makes it harder from a structural or process standpoint for people to complete a task, regardless of how beneficial or important the task is.

If physicians’ complaints about EHR systems are any indication, the most common deterrents of proper documentation are the frictions of technology and lack of time.

As a quality professional, your goal is to reduce friction as much as possible. When it comes to setting up your EHR to capture eCQMs, you could certainly include as many fields as you like to get the data you need. However, you may be creating unnecessary friction that could irritate your physicians and make collecting data harder.

Here are our best- to worst-case scenarios when mapping your eCQMs:

• Least friction: Don’t change any documentation requirements in your EHR. Use your current EHR system set-up to find the data elements you need to appropriately map your measure. No changes to physician documentation will add the least amount of friction to the process.
  
  
• Medium friction: Put rules in place in your EHR to prevent physicians from missing critical documentation requirements. For instance, if you have a field for “discharged with medication instructions” and a physician marks “no,” you could have a rule in place that does not let the physician move forward until they mark the reason the patient wasn’t given medication instructions.
  
  
• Most friction: Adding more fields to your EHR. If you must add more fields, there should be strict change control procedures in place. If someone in your IT department is adding a field to your EHR system, multiple people should already have vetted it to confirm that it’s necessary and there aren’t any alternative options.

2. Use social pressure to your advantage

I know we all want to believe that we don’t care what other people think of us, but the truth is that human beings are social animals who care deeply about our social connections. In David Asch’s speech, he references a study conducted in a Florida hospital’s intensive care unit. By simply pasting pictures of eyes over the sinks, visitors’ and health professionals’ hand-washing rates doubled. We care so much about what people think of us that even a fake set of eyes drives us to action.

So, you could use the data from your quality measures to highlight the providers who are doing the best job at collecting eCQMs. Perhaps list the top five and the bottom five performers. Stick that on the wall in the physician lounge or, even better, email the results on a monthly basis. Are you cringing inside? That’s behavioral psychology working! You don’t want to upset anyone or criticize or single out anyone. And yet, you are looking for a way to drive change. This may not work for your particular hospital, but it might be worth a shot.

3. People are more motivated by perceived loss than future gain

In his talk, Asch discusses a study his team conducted to get people to people walk more frequently. The first group, the control group, were simply told whether they’d achieved their goal of walking 7,000 steps a day. The second group received $1.40 every day that they walked 7,000 steps. The third group got $42 in a virtual account, and for every day they didn’t walk 7,000 steps, the researchers took away $1.40.

The researchers found that the second group was no more likely to meet their goal than the control group. However, the third group—the one with a “loss-framed” incentive—met their goal 50% more of the time. We are much more motivated by loss aversion than by future gains.

“Hard work pays off in the future, but laziness pays off right now.” – Steven Wright

Could you do something similar? Many organizations now have physician incentive plans. What if instead of incentivizing physicians after they meet their performance goals, you set up a virtual pot of money based on their past performance and take away money if they don’t meet their performance goals throughout the year?

4. When physicians are included in the process, they are invested in its success

A study by researchers from the Mayo Clinic identified another factor that can meet physicians’ behavioral psychological needs as you try to create effective quality improvement partnerships. To flourish in those partnerships, the researchers said physicians need some degree of choice and control over their lives. Prioritize choice as you customize your EHR to meet your eCQM needs.

Include your Physician Advisory Board in your decisions, especially as it relates to EHR changes. For example, your organization will soon be required to submit the new opioid measure to CMS. This is the year to get familiarized with this eCQM, which means you’ll need to make some decisions about how this measure is captured in your system. There are new data elements that must be mapped to appropriately capture this measure. Consult your physicians on the options and get their approval before rolling out any new procedures/requirements.

Successful physician compliance has to be about more than paperwork and requirements. It needs to be about patients and the integrity of the medical profession. Behavioral psychology techniques could be an effective way to make that transition.