Scaling up quality improvement: How do we motivate providers?

Engaging clinicians in change will require a cultural shift. (David Oliva/Wikimedia Commons)
Engaging clinicians in change will require a cultural shift. (David Oliva/Wikimedia Commons)
Alyssa Bianca Velasco, ScB, is a clinical data specialist for the Standardized Clinical Assessment and Management Plans (SCAMPs) program at Boston Children’s Hospital.

Reducing health care costs doesn’t have to involve making sacrifices in patient safety or quality of care or holding clinicians to rigid guidelines. Over the past several years, Boston Children’s Hospital has rolled out a methodology known as Standardized Clinical Assessment and Management Plans (SCAMPs). Described in the May issue of Health Affairs, SCAMPs are based on the idea that clinicians should be able to diverge from established medical best practices, provided they document the reasons and track the results—in essence making continual data-driven modifications to practice.

The success of SCAMPs in reducing practice variability and costs and improving outcomes at Boston Children’s has led other institutions, one by one, to adopt them. In the next phase, we plan to expand SCAMPs much more broadly, creating a network of hospitals that will pool pertinent clinical data into a centralized non-profit institution, the Institute for Relevant Clinical Data Analytics (IRCDA).

I am part of a team that is providing training, analytics and IT support to help make that large-scale implementation happen. But while we can supply hospitals with the tools, engaging them will require a real cultural shift—a fundamental change in how physicians make clinical decisions and how they think about best practice. Motivation is integral to success, and sustainability will ultimately depend on users’ commitment and enthusiasm.

SCAMPs have intrinsically appealing features. Unlike other evidence-based guidelines, they preserve clinicians’ autonomy by encouraging them to exercise their own judgment and make real improvements to patient care. But doctors are extremely busy people, and documenting why they’re diverging from a SCAMP can be a tedious task, no matter how user-friendly we make it. Unless providers see its value and make it a priority, the work involved with adhering to SCAMPs can take a back seat to other responsibilities.

Deci and Ryan proposed (PDF) that human motivation requires three things: autonomy, competence and relatedness. SCAMPs are designed to promote autonomy and competence, but we need to focus on relatedness—the most difficult factor to control.

“Relatedness” has been defined as the universal desire to interact, be connected to and experience caring for others. Providers are more likely to invest their valuable time and effort if they see that their individual contributions, however small, connect to a larger network that’s working toward better and more cost-efficient care.

Most providers have never heard of a SCAMP. Awareness of SCAMPs and their positive outcomes will, we hope, give providers perspective on why they are being asked to do extra paperwork. Fostering their feeling of connection to the SCAMPs mission and method is vital to the program’s long-term viability, and should be a priority for IRCDA.

For most people, seeing is believing. Proof of the program’s benefits in their own clinical communities may help win over skeptical users and motivate them to accept a change in prevailing medical culture. Skeptics, with time and evidence, often become a program’s strongest advocates.