Academic Pediatric Association
QUALITY
IMPROVEMENT
TRAINING:
Module #2
This work is supported by a grant from
The Centers for Disease Control & Prevention.
Improvement Cycles &
the Psychology Of Change
National Partnership for
Adolescent Immunization
PI: Peter Szilagyi
Coordinators: Christina Albertin, Nui Dhepyasuwan
FACULTY & CONSULTANTS
 Donna D'Alessandro
 Ed Marcus
 William Atkinson
 Cindy Rand
 Paul Darden
 Jan Schriefer (QI expert)
 Sharon Humiston
 Stanley Schaffer
(moderator)
 Keith Mann (QI expert)
 Janet Serwint
 William Stratbucker
This is part of the APA series on Quality
Improvement. The examples focus on
adolescent immunization, but the principles
are widely applicable. The series includes:
1. Overview: The Model for Improvement and
2.
3.
4.
5.
6.
Deming’s System of Profound Knowledge
Improvement cycles and the psychology of change
Initiating a QI project
More tools to better understand the system
How will we know that a change is an
improvement? An introduction to QI measurement
Changes we can make that will result in
improvement
Module 2 Objectives
After viewing this segment, you will be
able to:
1. Describe 5 key ideas for integrating
change
2. Contrast incentive types (intrinsic,
extrinsic, and dis-incentives)
3. Explain Everett Rogers’ 5 attributes to
facilitate change
5 key ideas for
integrating
change
Based on The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance. Langley GJ, et al.
2nd Edition
www.josseybass.com
5 Key Ideas for Integrating Change
1.
2.
3.
4.
5.
The differences in people
Behavior is driven by motivation
Fundamental attribution error
Attracting people to the change
Intrinsic, extrinsic, and dis-incentives
The Differences in People
 Individual preferences, aspirations,
motivations, learning styles, levels of need,
beliefs, values
 What appeals to one individual does not
appeal to another
 No appeal  people unwilling to make the
change
Behavior Is Driven by Motivation
 Observed behavior does not give us a clear
window into motivation
 We see through our own “lens” (created by
our assumptions)
 Example
 What I saw
 The story I made up about what I saw
 The truth
 Seek to understand the motivation
underlying the behavior
“Understanding what is motivating someone
rather than relying on the interpretation of the
behavior can help us take appropriate actions
to build commitment to change.”
The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. Langley GJ, et al.
2nd Edition
www.josseybass.com
Fundamental Attribution Error
 Tendency to place an undue emphasis on internal
characteristics to explain someone else's behavior
in a given situation, rather than thinking about
external situational.
 Does not explain interpretations of one's own
behavior—where situational factors are more
easily recognized and can thus be taken into
consideration.
 If the problem is the system, a pep talk is not the
solution.
Attracting People to the Change
 There is more to change than the tangible
and technical aspects.
 Workers may resist change if
 They do not feel included or
 They have not truly understood the
change’s expected benefits to the
organization or themselves
 Communication throughout the process
“Make people part of the solution.”
The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. Langley GJ, et al.
2nd Edition
www.josseybass.com
123 - Easy
ABC - Easy
QI
- Not easy
Question #1: The fundamental attribution
error is best described by which of the
following?
A. Tendency to attribute fundamental errors
to laziness and stupidity
B. Tendency to place an undue emphasis on
internal characteristics to explain someone
else's behavior
C. Tendency to to place an undue emphasis
on system problems to explain observed
phenomenon
D. Tendency to attribute QI quotes to Dr.
Deming
Question #1: The fundamental attribution
error is best described by which of the
following? B is correct
A. Tendency to attribute fundamental errors
to laziness and stupidity
B. Tendency to place an undue emphasis on
internal characteristics to explain someone
else's behavior
C. Tendency to to place an undue emphasis
on system problems to explain observed
phenomenon
D. Tendency to attribute QI quotes to Dr.
Deming
Intrinsic incentives,
extrinsic incentives,
and disincentives
Disincentive
A person can expect that the failure to act
in a particular way will result in some form
of punishment
Extrinsic Motivation
Agent can expect some form of
material reward – especially money –
in exchange for acting in a particular way
Often very
effective at first
Difficult to sustain
Intrinsic Motivation
 Moral incentives – “ the right thing to do” or
a particularly admirable thing to do
 Natural incentives – E.g., curiosity, mental
or physical exercise, admiration, joy, the
pursuit of truth, or control (over oneself,
others, things in the world)
3 Key Intrinsic Motivators
Autonomy
Mastery
Purpose
Too often, planned QI approaches diminish
at least one of these.
Drive, Daniel Pink
Usually intrinsic incentives
are more sustainable than
extrinsic incentives.
QUESTION #2
Ron despises anything associated with
“quality improvement” so, when faced
with his team’s low adolescent
immunization rates he announces:
“We are not doing any of that QI
balderdash. I’ll fix this problem myself
in one minute flat. Here is a $100 bill
and it goes to the nurse who gives the
most vaccines to patients 11-18 years
of age this month.”
Which of the following is FALSE about
Ron’s approach to the problem?
A. It’s unlikely to be sustainable
B. It ignores some important potential “side
effects” (e.g., adolescent patients being
brought in from the waiting room
preferentially, decrease in nursing staff
morale, sabotaging other people’s efforts
to vaccinate teens)
C. It creates constancy of purpose for
continual improvement at the clinic
D. It relies primarily on extrinsic motivation
Which of the following is FALSE about
Ron’s approach to the problem?
A. It’s unlikely to be sustainable
B. It ignores some important potential “side
effects” (e.g., adolescent patients being
brought in from the waiting room
preferentially, decrease in nursing staff
morale, sabotaging other people’s efforts
to vaccinate teens)
C. It creates constancy of purpose for
continual improvement at the clinic FALSE
D. It relies primarily on extrinsic motivation
5 attributes to
facilitate change
Everett Rogers, The Diffusion of Innovations, 5th Edition
5 attributes facilitate change:
1.
2.
3.
4.
5.
Relative advantage
Compatibility
Simplicity
“Trial – ability”
Observability
Relative Advantage
 The extent to which the innovation is better
than existing practices
 A key indicator of adoption
 But not the only indicator…good ideas do
not sell themselves because "good" can be




A matter of debate
Not immediately evident
Complex to understand
Circumvented by economic/business/political
circumstances
 Considered as morally abhorrent
 Difficult to implement
Compatibility
Innovations are easier to adopt if they are
perceived as being consistent with:
Existing values
Past experiences
Needs of potential adopters
Simplicity
Innovations are easier to adopt if the end
user perceives the innovation as easy to
understand and use
Trial-ability
Innovations are easier to adopt if they can
be tried out in part, on a temporary basis,
or easily dispensed with after trial.
Observability
Innovations are easier to adopt if we can
easily observe relative advantages of the
change.
Summary
 Key ideas for integrating change include: recognizing and
responding to people’s different motivations (which are not
always apparent); discerning when something is a system
problem & when it is personnel problem; communicating with
everyone involved in the change to make sure they feel
included & understand the change’s expected benefits.
 Intrinsic incentives tend to be more long lasting than extrinsic
incentives or disincentives.
 Innovations are easier to adopt if they are perceived as
improvements; compatible with the existing values, past
experiences, and needs of potential adopters; simple to
understand and implement; easy to test; and have results
that are easy to observe.
Your vision is at the heart of QI.
Quality improvement is not for the faint of heart.
The End
of Module #2