Ted A James, MD, MHCM, FACS
February 22, 2018
Although it is important to ensure appropriate remuneration, financial incentives alone are a poor substitute for giving clinicians the tools, knowledge, and training needed to improve quality.
Transforming health care requires leaders to inspire collaboration in the process of care redesign and change long established norms. This is one of the greatest challenges for leaders. Unfortunately, health care continues to weigh heavily on the carrot-and-stick model to incentivize clinicians to engage with strategic priorities. Physician compensation models, pay-for-performance, and related financial incentives rely on extrinsic motivation to achieve change, and their impact to date has been limited.1
The science of behavior explains why this approach is ultimately unsuccessful. Extrinsic motivation will only result in improvements in simple, finite tasks. Focusing on extrinsic motivators also sends the wrong message about care priorities, and runs the risk of burnout. Although it is important to ensure appropriate remuneration, financial incentives alone are a poor substitute for giving clinicians the tools, knowledge, and training needed to improve quality. For example, if you want more patients seen or procedures performed, tie productivity to income; problem solved. However, if you want patient-centered, continuous quality improvement and team-based care, relying on financial rewards or penalties may actually lead to diminished results.
Studies show that monetary inducements can undermine motivation, decrease innovation, and worsen performance on cognitively complex and intrinsically rewarding work. Rather, the key to unlocking clinical engagement is to stimulate ‘intrinsic’ motivation. Echoing the work of Frederick Herzberg, Daniel Pink’s New York Times bestseller, Drive: The Surprising Truth about What Motivates Us, defines three principles of intrinsic motivation: autonomy, mastery, and purpose.2
In health care, autonomy consists of involving clinicians in the decisions and processes that affect them. The benefit is automatic buy-in and accountability. It also leverages the power of teams to solve problems. Autonomy is not a free-for-all, but rather promoting flexibility and self-direction wherever reasonable within the boundaries of best practices. When Atul Gwanade implemented the safe surgery checklist, a crucial strategy was allowing each site to decide how to incorporate the checklist into their workflow. This flexibility helped widespread adoption of this important quality improvement innovation.3
The concept of mastery recognizes that people thrive on improvement. In fact, research conducted by Harvard Business School Professor, Teresa Amabile, found that one of the greatest drivers of motivation is a sense of making progress.4 Leaders can promote mastery by giving constructive feedback, using meaningful performance metrics, providing necessary resources, and supporting opportunities for professional development. A recent case study by the Commonwealth Fund highlighted how Accountable Care Organizations used transparent performance data to allow physicians to obtain a greater awareness of how they were performing and whether they were improving, which helped to focus their quality improvement efforts. It also enabled recognition of top performers and fostered opportunities to learn from colleagues.5
People desire to derive meaning from their work and make meaningful contributions. When Cleveland Clinic embarked on a journey to improve patient experience in their system, they started by demonstrating the impact that a patient-focused approach would have, not only on patient experience, but also on safety and clinical outcomes. This proved to be a strong stimulus for changing their organizational culture and successfully implementing their “Patient First” program.
These principles have borne-out in my own experience. In a prior leadership role I was involved in a project expanding the number of disease-specific multidisciplinary care units in our cancer center. We used data to communicate why this approach was better for our patients, which led to a shared vision of how we would care for patients with cancer (purpose). The leaders of each disease site were given the flexibility to decide how to structure their multidisciplinary services to best meet the needs of their patients (autonomy). Finally, we employed scorecards to track progress and discussed the data openly (mastery). The cancer center transformation process was a successful and sustained endeavor. Leaders who use intrinsic motivation to engage clinical teams will obtain greater influence, better outcomes, and more creative output.
- Lee et al., Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 2012; 367:1428-1437. DOI: 10.1056/NEJMsa1202419
- Pink, D.H. (2009). Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhaed Books.
- Gawande, A. (2009). The Checklist Manifesto: How to Get Things Right. Gurgaon, India : Penguin Random House.
- Amabile, T., & Kramer, S. (2011). The Progress Principle: Using Small Wins to Ignite Joy, Engagement, and Creativity at Work. Boston, Mass. : Harvard Business Review Press.
- Phipps-Taylor, M., & Shortell, S. M. (2016, December). More Than Money: Motivating Physician Behavior Change in Accountable Care Organizations. The Milbank Quarterly, v94 n4: 832-861
Dr. Ted James is the Chief of Breast Surgical Oncology and Vice Chair of Academic Affairs at BIDMC/Harvard Medical School. Dr. James is an alumnus of the Harvard Master in Health Care Management program and is involved internationally in leadership development and health care transformation. Follow Dr. James: LinkedIn / Twitter
Dr. James blogs about health care transformation. To see more of his posts, click on his name in the tags below.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.