Achieving Rapid Cost Reduction &
Revenue Improvement by
Engaging Clinicians &
Administrators
Kent Bottles, MD
Thomas Jeffe...
Old New
ickness System
ealth No Disease
cute Disease
ee for Service
ospital Beds Full
ospital Centric
• Wellness System
• ...
Old New
ost not considered
ndependent doctors
ndependent hospital
ed record secret
paque
rtificial harmony
• Decreased cos...
44
The Curve
Unhappy Doctors & Happy Doctors
Your doctor’s unhappiness is a catastrophic
problem that the new law didn’t anticipate and...
Dr. Daniel F. Craviotto, Jr.
ocs in the trenches do not have a voice
Damn the mandates…from bureaucrats who
are not in the...
Dr. Aaron Carroll
omplaining about not having a voice in WSJ
Most people have to choose between doing
God’s work and being...
Dan Munro
is criticisms are not patient-centered
rthopedics annual compensation of $413,000
4 million non-elderly were uni...
• My success depends on my individual
behavior
• Individual activities lead to personal financial
success
• Individual act...
• My success is enhanced by collaboration
• Individual activities lead to the financial success of parent
organization
• I...
• Represent local physician interests at
organization-wide venues
• Secure resources for local physicians
• Rally physicia...
• Holding physicians accountable for performance
• Working as part of a leadership team of the
organization
• Supporting d...
Administrators vs. Clinicians
roactive planners
ork well in groups
elayed gratification
d. with organization
stablish rule...
Administrators vs. Clinicians
ollective culture
ong time frame
nstitution centered
nfluence
ospital community
xpert cultur...
Administrators vs. Clinicians
urses, leaders
rocess oriented
hin skinned
ollaboration
Ds, Law, Engineers
utcome oriented
h...
Administrators vs. Clinicians
uccessful organization needs both
ayo Clinic dyad successful leadership
either group is more...
Expert Engineer Culture
Edgar H. Schein, DEC is Dead, Long Live DEC, 2003
ndividual commitment is not to employer
eople, o...
Partnership Requires Negotiation
ou can compete: win/lose
ou can accommodate: lose/win
ou can collaborate: win/win
ou can ...
Margaret Thatcher (b. 1925)
British Conservative politician, prime minister.
Quoted in: Denis Healey, The Time of My Life,...
Physicians Agree to
ractice evidence medicine
eet regulatory, quality, safety goals
eport quality data and outcomes
ome to...
Organization Agrees to
ave primary loyalty be to physicians
egotiate well to align incentives
nclude physicians in decisio...
Organization Agrees to
rovide services & education to ease burdens
ee feedback from physicians
aintain confidentiality
ake...
Engaging Doctors in the Health
Care Revolution TH Lee & T Cosgrove, HBR
oble shared purpose
elf interest
espect
radition
Engaging Doctors in the Health
Care Revolution TH Lee & T Cosgrove, HBR
oble shared purpose
– Shifts conversation from neg...
Engaging Doctors in the Health
Care Revolution TH Lee & T Cosgrove, HBR
elf-interest
– Compensation plans tied to citizens...
Engaging Doctors in the Health
Care Revolution TH Lee & T Cosgrove, HBR
espect
– Behavioral economics, peer pressure,
tran...
Engaging Doctors in the Health
Care Revolution TH Lee & T Cosgrove, HBR
radition
– Mayo Clinic dress code
– Physician comm...
Physician Benefits
CO participation (Medicare & Commercial)
uality rewards
FS quality contracts
arrow network participatio...
Multicare Health System Sepsis Program
http://www.healthcatalyst.com/success_stories/how-to-reduce-sepsis-
mortality-rates...
Multicare Health System Missed Charges
http://emrdailynews.com/2010/03/30/multicare-health-system-selects-apollo-data-tech...
emorial Hermann
– Second largest non-profit in Texas
– 6,000 practicing physicians
– 9 Acute Hospitals, 3 Heart & Vascular...
Memorial Hermann:
Clinical Integration Results
Memorial Hermann:
Clinical Integration Results
013 MSSP ACO Results
– Total savings = $33,190,528
 Actual beneficiary exp...
Case Study: Robert Wood
Johnson University Hospital
rganization: 600-bed Academic Medical Center in New Brunswick, NJ
hall...
Case Study: Griswold Hospital
(pseudonym)
rganization: 300-bed Hospital
hallenge: engage physicians to help
lower inpatien...
Case Study: Covenant Health
System
rganization: five-hospital integrated
delivery system in Lubbock, TX
(corporate parent ...
Case Study: Burley Medical
Physicians’ Group (pseudonym)
rganization: 70-physician group employed by a small health
system...
Tactic: Hardwire Future Options
• University of Tennessee Medical
Center (500-bed AMC)
• 16.9% savings on $4.7M CRM
supply...
3939
The Curve
APPENDIX
40
Formula for
Organizational Change
D + V x L > R
D = Dissatisfaction with how things are
V = Vision of what is possible
L =...
Symptoms of Resistance
uperficial agreement with change with no
commitment or follow-through
low progress
pathy
xcuses for...
Stages of Acceptance
enial
nger
argaining
epression
cceptance
Addressing Resistance
eaders cross bridge first by coming to terms
with own concerns
elp physicians let go of expectations...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
aster, flatter, more interconnected world
reater capacity for in...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
here is a mismatch between world’s
complexity and our own
educe ...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
ardiologists tell patients they will die unless
they change
nly ...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
olumn 1: Improvement goal
olumn 2: Doing/not doing that work aga...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
olumn 1 goal: Sources of input (yourself, your
colleagues, your ...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
EO/Father collective immunity
olumn 1 (Improvement goal)
– To be...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
EO/Father collective immunity
olumn 2 (Doing/not doing against g...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
EO/Father collective immunity
olumn 3 (Uncon. hidden commitment)...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
EO/Father collective immunity
olumn 4 (Big assumptions)
– I assu...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
rescribing narcotics: The doctors’ immunity
map
olumn 1 (Commitm...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
rescribing narcotics: The doctors’ immunity
map
olumn 2 (Doing/n...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
rescribing narcotics: The doctors’ immunity
map
olumn 3 (Hidden ...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
rescribing narcotics: The doctors’ immunity
map
olumn 4 (Big ass...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
eople that have succeeded
hange both mindset and behavior
ecome ...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
alendar exercise
urvey of colleagues, families, friends
iography...
Immunity to Change
Robert Kegan & Lisa Laskow Lahey, 2009
adder of inference: our tendency to adopt
inaccurate beliefs bas...
Gamification
he use of game thinking and game
mechanics to engage users in solving
problems
ompetition, achievement, statu...
What Makes Gamers Keep Gaming
John Tierney, NY Times, Dec 7, 2010
hy are virtual worlds more interesting than
school work?...
What Makes Gamers Keep Gaming
John Tierney, NY Times, Dec 7, 2010
hy do games create flow so easily?
ard fun: overcoming o...
What Makes Gamers Keep Gaming
John Tierney, NY Times, Dec 7, 2010
amers fail over and over again
hey remain motivated
eep ...
What Makes Gamers Keep Gaming
John Tierney, NY Times, Dec 7, 2010
One of the most profound transformations we
can learn fr...
What Makes Gamers Keep Gaming
John Tierney, NY Times, Dec 7, 2010
ikipedia took 8 years and 100 million hours of
work
eopl...
Gamification
e-Mission game from HopeLab treatment
adherence improvement in children with
cancer
CSF Benioff Children’s Ho...
Gamification
ane McGonigal. Reality Is Broken: Why
Games Make Us Better and How They Can
Change the World. NY: Penguin, 20...
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Presentation: Clinician, Administrator Engagement=Cost Reduction, Revenue Improvement

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At the 2014 HFMA National Institute, PYA Principal and Chief Medical Officer of PYA Analytics, Kent Bottles, MD, spoke about the strategies that hospitals and health systems are using to decrease per-capita cost, while increasing quality. In the session, “Achieving Rapid Cost Reduction and Revenue Improvement by Engaging Clinicians and Administrators,” Bottles offered tactics for engagement.

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  • Source: http://www.advisory.com/~/media/Advisory-com/Technology/Crimson-Continuum-of-Care/Case-Studies/CCC-Case-Study-RWJ-University-NJ-LOS.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Technology/Crimson-Continuum-of-Care/Case-Studies/CCC-Case-Study-RWJ-University-NJ-LOS.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Technology/Crimson-Continuum-of-Care/Case-Studies/CCC-Case-Study-RWJ-University-NJ-LOS.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Technology/Crimson-Continuum-of-Care/Case-Studies/CCC-Case-Study-RWJ-University-NJ-LOS.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Research/PEC/White-papers/27186-PEC-Partnering-with-Physicians-for-Supply-Chain-Reform.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Research/PEC/White-papers/27186-PEC-Partnering-with-Physicians-for-Supply-Chain-Reform.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Research/PEC/White-papers/27186-PEC-Partnering-with-Physicians-for-Supply-Chain-Reform.pdf
  • Source: http://www.advisory.com/~/media/Advisory-com/Research/HCAB/Research-Study/2013/Next-Gen-Supply-Cost-Savings/Next-Generation-Supply-Cost-Savings.pdf
  • Presentation: Clinician, Administrator Engagement=Cost Reduction, Revenue Improvement

    1. 1. Achieving Rapid Cost Reduction & Revenue Improvement by Engaging Clinicians & Administrators Kent Bottles, MD Thomas Jefferson University School of Population Health Chief Medical Officer, PYA Analytics HFMA National Institute June 24, 2014 Las Vegas, Nevada
    2. 2. Old New ickness System ealth No Disease cute Disease ee for Service ospital Beds Full ospital Centric • Wellness System • Health: Wellness • Chronic Disease • Value Based • Hospital Beds Empty • Community Centric • Patient Centric • Shared Dec Making • Measurable Metrics
    3. 3. Old New ost not considered ndependent doctors ndependent hospital ed record secret paque rtificial harmony • Decreased cost • Employed docs • Integrated delivery system • Open access record • Transparent • Cognitive conflict • Digital • Predictive analytics actionable correlations
    4. 4. 44 The Curve
    5. 5. Unhappy Doctors & Happy Doctors Your doctor’s unhappiness is a catastrophic problem that the new law didn’t anticipate and is not prepared to address.” Dr. Marc Siegel, Associate Professor of Medicine, NYU Langone Medical Center To us, supporting the ACA makes moral and medical sense.” Dr. Jeffrey Drazen, Editor-in- Chief, and Dr. Gregory Curfman, Executive Editor, New England Journal of Medicine
    6. 6. Dr. Daniel F. Craviotto, Jr. ocs in the trenches do not have a voice Damn the mandates…from bureaucrats who are not in the healing profession” HRs waste time oard recertification is time consuming hysicians as a group should not accept any health insurance
    7. 7. Dr. Aaron Carroll omplaining about not having a voice in WSJ Most people have to choose between doing God’s work and being in the 1%. Only doctors get to do both” oard recertification is mandated by doctors It’s tone deaf in today’s economy for people at the top end of the spectrum to complain so publicly about how little they are paid”
    8. 8. Dan Munro is criticisms are not patient-centered rthopedics annual compensation of $413,000 4 million non-elderly were uninsured or underinsured in 2012 00 million Americans in poverty or in the fretful zone just above it alf of all doctors believe they are fairly compensated
    9. 9. • My success depends on my individual behavior • Individual activities lead to personal financial success • Individual activities lead to successful clinical outcomes • Strong financial and clinical performance of my parent organization and physician colleagues have little impact on my personal success • “Cowboys” Mindset of the Traditional Physician
    10. 10. • My success is enhanced by collaboration • Individual activities lead to the financial success of parent organization • Individual activities lead to successful clinical outcomes because of collaboration • Strong financial and clinical performance of my parent organization • And physician colleagues have major impact on my personal success • “Pit Crews” Mindset of the Integrated Employed Physician
    11. 11. • Represent local physician interests at organization-wide venues • Secure resources for local physicians • Rally physicians against perceived enemy − Hospital administration − Insurance companies − Competing physicians Traditional Physician Leadership
    12. 12. • Holding physicians accountable for performance • Working as part of a leadership team of the organization • Supporting decisions they may not personally agree with • Modeling behavior that supports the overall organization goals • Leader’s job is not to protect, defend, and ensure local interests that may conflict with overall organization interests • Leading in an integrated aligned system is a real job Physician Leadership in Integrated Aligned System
    13. 13. Administrators vs. Clinicians roactive planners ork well in groups elayed gratification d. with organization stablish rules eactive agents ork well 1:1 nstant gratification d. with profession esent rules
    14. 14. Administrators vs. Clinicians ollective culture ong time frame nstitution centered nfluence ospital community xpert culture hort time frame ndividual centered ontrol ospital work shop
    15. 15. Administrators vs. Clinicians urses, leaders rocess oriented hin skinned ollaboration Ds, Law, Engineers utcome oriented hick skinned ollegiality
    16. 16. Administrators vs. Clinicians uccessful organization needs both ayo Clinic dyad successful leadership either group is more important than the other alignant administrators tend to become cynics and victims alignant clinicians tend to become narcissists
    17. 17. Expert Engineer Culture Edgar H. Schein, DEC is Dead, Long Live DEC, 2003 ndividual commitment is not to employer eople, organization, bureaucracy are constraints to be overcome ngineering culture disdains management and marketing o loyalty to customer: if trade-offs had to be made between building “fun,” “elegant” technologically challenging computers and the needs of “dumb” customers, guess who
    18. 18. Partnership Requires Negotiation ou can compete: win/lose ou can accommodate: lose/win ou can collaborate: win/win ou can compromise: lose/lose
    19. 19. Margaret Thatcher (b. 1925) British Conservative politician, prime minister. Quoted in: Denis Healey, The Time of My Life, pt. 4, ch. 23 (1989). Ah, Consensus… To me, consensus seems to be the process abandoning all beliefs, principles, values and policies. So it is something in which no one believes and to which no one objects.
    20. 20. Physicians Agree to ractice evidence medicine eet regulatory, quality, safety goals eport quality data and outcomes ome to meetings se the EMR ccept decisions made by leaders
    21. 21. Organization Agrees to ave primary loyalty be to physicians egotiate well to align incentives nclude physicians in decisions rovide clear and timely information (membership criteria, quality scores, improvement process, financial performance)
    22. 22. Organization Agrees to rovide services & education to ease burdens ee feedback from physicians aintain confidentiality ake meetings worthwhile & engaging reate physician leadership training academy
    23. 23. Engaging Doctors in the Health Care Revolution TH Lee & T Cosgrove, HBR oble shared purpose elf interest espect radition
    24. 24. Engaging Doctors in the Health Care Revolution TH Lee & T Cosgrove, HBR oble shared purpose – Shifts conversation from negative to positive – Acknowledge need for sacrifice – Duty to patients preempts other obligations  Urology patient story at Cleveland Clinic 2008  Advocate huddles lead to 40% increase in safety event reports – Mayo Clinic: “The needs of the patient come first”  Patients come first  Status quo is unsustainable
    25. 25. Engaging Doctors in the Health Care Revolution TH Lee & T Cosgrove, HBR elf-interest – Compensation plans tied to citizenship, quality – One year renewable contracts – Watch for conflicts of interest – Reward collaboration
    26. 26. Engaging Doctors in the Health Care Revolution TH Lee & T Cosgrove, HBR espect – Behavioral economics, peer pressure, transparent data – Partners unmasked data on MD use of imaging led to 15% drop in orders for high cost tests – University of Utah transparent patient experience ratings utilized gradual introduction
    27. 27. Engaging Doctors in the Health Care Revolution TH Lee & T Cosgrove, HBR radition – Mayo Clinic dress code – Physician communication standards – Organization must be willing to part ways with physicians who don’t support shared purpose
    28. 28. Physician Benefits CO participation (Medicare & Commercial) uality rewards FS quality contracts arrow network participation MR support are Management access
    29. 29. Multicare Health System Sepsis Program http://www.healthcatalyst.com/success_stories/how-to-reduce-sepsis- mortality-rates-by-22 2 month decrease in sepsis mortality by 22% .3 million dollars in validated cost savings ealth Catalyst data approach created algorithm to define a septic patient eams (clinicians, techs, analysts, quality) evere sepsis order set
    30. 30. Multicare Health System Missed Charges http://emrdailynews.com/2010/03/30/multicare-health-system-selects-apollo-data-technologies-to- automate-missing-charge-recovery/ redictive analytics captured $2 million in missed charges by using algorithms eyond rules-based charge capture software nalyze millions of records and provide simulations etermine individual physician billing patterns
    31. 31. emorial Hermann – Second largest non-profit in Texas – 6,000 practicing physicians – 9 Acute Hospitals, 3 Heart & Vascular Institutes – 98 Outpatient Sites emorial Hermann Physician Network (MHMD) – 3,500 practicing physicians with 2,000 clinically integrated Memorial Hermann Background
    32. 32. Memorial Hermann: Clinical Integration Results
    33. 33. Memorial Hermann: Clinical Integration Results 013 MSSP ACO Results – Total savings = $33,190,528  Actual beneficiary expenditures: $290,919,262  Benchmark expenditures: $324,109,790 – Total payment received = $16,263,359  50% quality performance share rate x total savings
    34. 34. Case Study: Robert Wood Johnson University Hospital rganization: 600-bed Academic Medical Center in New Brunswick, NJ hallenge: to reduce operating budget by $400,000 by targeting physicians to assist in building momentum for performance improvement olution: organization implemented Crimson to reduce LOS and cost – CMO reviews Crimson profiles with individual physicians and groups, uses timeline feature to review specific end-of-stay opportunities with LOS outliers – Physicians are given specific action steps (such as meeting with CDI staff and support from case managers to assist with discharge planning) – Decision support developed tools to track improvements and report results
    35. 35. Case Study: Griswold Hospital (pseudonym) rganization: 300-bed Hospital hallenge: engage physicians to help lower inpatient costs and meet quality goals olution: hospital entered into a co- management agreement with an independent cardiology and cardiovascular surgery group – 70% of physician pay distributed as hourly reimbursement for administrative tasks – 30% of physician pay based on their performance against selected clinical and operational metrics, including cost reduction on implant devices. Source: The Advisory Board Company
    36. 36. Case Study: Covenant Health System rganization: five-hospital integrated delivery system in Lubbock, TX (corporate parent of CHP, a 310- physician CI network) hallenge: design clinical integration program initiatives that will include inpatient quality and cost goals, including supply chain improvement olution: system created “hospital efficiency contract” with its 300- physician affiliated CI network that included several inpatient quality and cost measures chosen by hospital staff. – Efficiency contract strengthens alignment between the health system and physician network goals • Impact: decreased cardiovascular device costs by $400,000 and improved quality of services − After one year, hospital generated far more in cost savings than it had invested in the CI program Source: The Advisory Board Company
    37. 37. Case Study: Burley Medical Physicians’ Group (pseudonym) rganization: 70-physician group employed by a small health system in the South hallenge: engage physician in cost management olution: Burley’s leaders calculate the contribution margin ratio for both PCPs and specialists, using it as the basis for discussion improvement opportunities. mpact: increased the average contribution margin from 18.5% in 2010 to 22.7% in 2011 − By holding PCPs accountable for the costs of inpatient cases performed on
    38. 38. Tactic: Hardwire Future Options • University of Tennessee Medical Center (500-bed AMC) • 16.9% savings on $4.7M CRM supply basket • Hospital also unlocked additional 3% savings by meeting volume triggers • Total Savings: $793K Tactic: Improve Incumbent Pricing • Enloe Medical Center (391-bed medical center) • Incumbent bids creatively and unlocked 19% savings on $3M basket of orthopedic implants • Total Savings: $566K Tactic: Leverage Alignment • Munroe Regional Medical Center (400-bed community hospital) • Non-employed orthopedists in intensely competitive market agreed to demand-matching protocol after learning premium prices • Total Savings: $400K Tactic: Put a Price on Preferences • Beaumont Health System (1,750 bed, three-hospital system) • Physicians learned price difference for preferred items and agreed to shift to reach 14.4% savings on bone and tissue supplies • Total Savings: $618K Other Examples of Significant Cost Savings
    39. 39. 3939 The Curve
    40. 40. APPENDIX 40
    41. 41. Formula for Organizational Change D + V x L > R D = Dissatisfaction with how things are V = Vision of what is possible L = Leadership needed for success R = Resistance to change
    42. 42. Symptoms of Resistance uperficial agreement with change with no commitment or follow-through low progress pathy xcuses for lack of engagement or progress
    43. 43. Stages of Acceptance enial nger argaining epression cceptance
    44. 44. Addressing Resistance eaders cross bridge first by coming to terms with own concerns elp physicians let go of expectations that cannot be met et out the news isten to and honor resistance
    45. 45. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 aster, flatter, more interconnected world reater capacity for innovation, self- management, personal responsibility, and self-direction rganizations need employees who have higher level of independence, self-reliance, self-trust, capacity to exercise initiative
    46. 46. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 here is a mismatch between world’s complexity and our own educe the complexity of world ncrease our own complexity eaders need to run and reconstitute their organizations (norms, mission, culture) in an increasingly fast-changing environment
    47. 47. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 ardiologists tell patients they will die unless they change nly one in seven are able to change here is a gap between what we want and what we are able to do eople want to do more than one thing and they often conflict; we are a living contradiction
    48. 48. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 olumn 1: Improvement goal olumn 2: Doing/not doing that work against the goals in column 1 olumn 3: Hidden competing commitments olumn 4: Big assumptions
    49. 49. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 olumn 1 goal: Sources of input (yourself, your colleagues, your family) olumn 2: All the things you are doing or not doing to work against your goal olumn 3: If I imagine doing the opposite of the things in Column 2, what is the most scary feeling that I will have olumn 4: Some will be true, some will be false, some will be uncertain
    50. 50. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 EO/Father collective immunity olumn 1 (Improvement goal) – To be a better listener – To be able to stay in the present – To be more patient
    51. 51. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 EO/Father collective immunity olumn 2 (Doing/not doing against goal) – I allow my attention to wander – I start looking at BlackBerry – I think about best response to what is said – I think about what person should do rather than listen
    52. 52. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 EO/Father collective immunity olumn 3 (Uncon. hidden commitment) – To not look stupid – To not be humiliated – To not feel out of control – To not make a big mistake – To not allow someone else to make a mistake
    53. 53. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 EO/Father collective immunity olumn 4 (Big assumptions) – I assume limited number of chances with daughter and they will stop listening if I am stupid – I assume it is a disaster if kids ridicule what I say – I assume wife wants me to solve problems she shares with me – I assume helping is always a matter of telling other what to do
    54. 54. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 rescribing narcotics: The doctors’ immunity map olumn 1 (Commitment) – Prescribe narcotics appropriately – Treat pain appropriately – Not be seen as place to get narcotics easily
    55. 55. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 rescribing narcotics: The doctors’ immunity map olumn 2 (Doing/not doing instead) – Not taking time to do narcotic contracts – Writing prescription without taking full history – Not taking time to take complete pain history when request comes at end of visit – Not firing patients from the practice who violate contract
    56. 56. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 rescribing narcotics: The doctors’ immunity map olumn 3 (Hidden competing commitments) – Need to stay on time – Need to believe patients – Need to be liked by patients – Need to avoid stress of patient confrontation
    57. 57. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 rescribing narcotics: The doctors’ immunity map olumn 4 (Big assumptions) – If I’m late, I am an inefficient physician – If I don’t believe my patients, I am not their ally – If I respond thoroughly to every request, I will fail at my other important work – If I’m not liked by my patients, my reputation will suffer – If I don’t ensure all possible pain is treated, I may fail to reduce suffering
    58. 58. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 eople that have succeeded hange both mindset and behavior ecome focused observers of their own thoughts, emotions, behaviors indset changes are in direction of seeing more possibilities ake risks to challenge assumptions; use data around consequences of new action
    59. 59. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 alendar exercise urvey of colleagues, families, friends iography of big assumptions unning a test of one’s big assumption – SMART – Safe and modest – Actionable – Research test
    60. 60. Immunity to Change Robert Kegan & Lisa Laskow Lahey, 2009 adder of inference: our tendency to adopt inaccurate beliefs based on selective observations, false assumptions and misguided conclusions ata_Select data_Add meanings_Make assumptions_Draw conclusions_Adopt beliefs about the world_Take actions based on beliefs
    61. 61. Gamification he use of game thinking and game mechanics to engage users in solving problems ompetition, achievement, status, self expression, altruism, closure niversity of Washington FoldIt CSF Benioff Children’s Hospital yandus COPD simulation software
    62. 62. What Makes Gamers Keep Gaming John Tierney, NY Times, Dec 7, 2010 hy are virtual worlds more interesting than school work? an games be used to solve real world puzzles? hy can’t life be more like a video game?
    63. 63. What Makes Gamers Keep Gaming John Tierney, NY Times, Dec 7, 2010 hy do games create flow so easily? ard fun: overcoming obstacles in pursuit of a goal nstantaneous feedback ontinual encouragement from computer and friends layers get rewards for progressing to higher
    64. 64. What Makes Gamers Keep Gaming John Tierney, NY Times, Dec 7, 2010 amers fail over and over again hey remain motivated eep going until they succeed iero: proud
    65. 65. What Makes Gamers Keep Gaming John Tierney, NY Times, Dec 7, 2010 One of the most profound transformations we can learn from games is how to turn the sense that someone has ‘failed’ into the sense that they ‘haven’t succeeded yet’” Tom Chatfield
    66. 66. What Makes Gamers Keep Gaming John Tierney, NY Times, Dec 7, 2010 ikipedia took 8 years and 100 million hours of work eople play World of Warcraft in a single week 200 million hours
    67. 67. Gamification e-Mission game from HopeLab treatment adherence improvement in children with cancer CSF Benioff Children’s Hospital – CLABSI cost $16,500 per patient – LevelEleven Compete app encourages nurses to compete on mundane tasks associated with good outcomes
    68. 68. Gamification ane McGonigal. Reality Is Broken: Why Games Make Us Better and How They Can Change the World. NY: Penguin, 2011

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