Changing Practitioner Behavior
Gail D’Onofrio MD, MS
Professor and Chief
Section of Emergency Medicine
Yale University School of
Medicine
Principles of Motivational Interventions
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Create cognitive dissonance
Lessen ambivalence by reflection on
conflicting motivations
Negotiate strategies for change
Steps: Brief Intervention
Raise the subject
 Provide Feedback
 Enhance Motivation
 Negotiate & Advise
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NIDA: Principles of Drug Addiction
Treatment
#10
Treatment does not need to be voluntary
to be effective
Strong motivation can facilitate the treatment
process. Sanctions or enticements in the family,
employment setting, or criminal justice system can
increase treatment entry, retention rates and
success of interventions
Approaches to Quality Improvement and
Their Assumptions on Improving Medical
Care
Grol, R. Improving the quality of medical care:
Building bridges among professional pride, payer
profit and patient satisfaction JAMA. 2001:28:2578-86
Approach
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Evidence-based
Medicine
Clinical guidelines
Decision Aids
Assumption
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Provision of best
evidence and
convincing information
leads to optimal
decision making and
optimal care
Approach
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Professional education
and development
Self-regulation
Recertification
Assumption
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Bottom up learning
based on experiences
in practice and
individual learning
needs leads to
performance change
Approach
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Assessment and
accountability
Feedback
Accreditation
Public reporting
Assumption

Providing feedback on
performance relative to
peers, and public
reporting of
performance data,
motivate change in
practice routines
Approach

Patient-centered care
Patient involvement
Shared decision making
Assumption

Patient autonomy and
control over disease
and care processes
lead to better care and
outcomes
Approach

Total quality improvement
Restructuring processes
Quality systems
Assumption

Improving care
comes from changing
the system, not from
changes in
individuals
Effects of Different Strategies to
Improve Patient Care
Strategy
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Educational Materials
Continuing education
Interactive education
meetings
Educational outreach
visits
Use of opinion leaders
Feedback on
performance
Conclusions
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Limited
Limited
Few studies, mostly
effective
Affects prescribing and
prevention
Mixed effects
Mixed effects, effect on
test ordering
Strategy
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Reminders
Substitution or delegation
of tasks
Use of computer
Total quality management
and CQI
Patient-oriented
interventions
Combined and
multifaceted interventions
Conclusions
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Mostly effective
Pharmacist: effect on
prescribing; Nurse: No
Mostly effective
Limited effects, weak
study design
Mixed effects, reminding
pts good for prevention
Very effective
Clinical Inertia
“Recognition of the problem, but
failure to act.”
Phillips LS, et al. Clinical inertia. Ann Intern Med.
2001;135:825-834
Clinical Inertia
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Problem of the provider and system
It is not related to patient adherence to
treatment regimens
Result of:
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Overestimation of care
Use of “soft” reasons to avoid changes
Lack of training and practice structure needed to
attain goals
Strategies to approach practitioner
behavioral change
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Provide skills-based educational sessions
Elicit opinion leaders
Institute systems changes (forced computer
entry, reminders, multiple screeners etc.)
Provide ongoing feedback to practitioners
Provide incentives (positive or negative)
Be creative