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What's Your Bucket? The Key to Long-Term System Change Is Larger Than Financial

What's Your Bucket? The Key to Long-Term System Change Is Larger Than Financial

In our first video blog, Dr. Jay Want, a health care consultant based in Colorado, talks with Barbara Leonard, MeHAF's Vice President for Programs, on what motivates health care professionals and their organizations to not only undertake, but persevere in long-term system change. Dr. Want was the featured speaker at the August 13th quarterly meeting of MeHAF Payment Reform grantees. A transcript of their 5-minute conversation follows. 

BL:  Jay, thanks for joining us to talk with our payment reform grantees today. I think it was really helpful for them to get your perspective on the work that they're doing. One of the things that you mentioned was that there are kind of three buckets of human motivation. I think you said [they were] financial, and social and ethical, and that seemed to resonate with a number of the grantees in the room. Can you talk about that a little bit?

JW:  OK, I'd be happy to. I was actually taught this by a physician that I worked with several years ago.  He said, you know, there really are only three big buckets of things that motivate people, and so if you're looking at the reward systems that you have for us as a practice group or whatever, you ought to think about these things. He said, they're financial, and social, and ethical. Financial is kind of self-explanatory, social is what others think of me, ethical is what I think of me. They're different, and the differences actually bear a lot on how you use them to motivate people.

Financial is a quick fix, and so while you can get people into change management efforts by offering financial rewards, the effect of financial incentives actually is relatively short term, so people become interested, they'll stay interested so long as the money is there, and as soon as the money is withdrawn, actually their motivation will go down.  There actually have been studies which show that when you do that with financial incentives, the withdrawal is perceived as punishment, and so sometimes their performance will actually drop below baseline because it's perceived as a kind of negative thing that you've done to them.

So clearly if you intend to keep people in some kind of change management effort on a long term basis, you have to appeal to more than financial.

So social is how do I compare with my peers, how do I feel within my community. So an example of that would be publishing rankings or basically saying... this is my dilated retinal exam rate versus your dilated retinal exam rate. The sharing of professional ethics, of [saying] this is something we want to do because it's a benefit for our patients.

And then finally, ethical. Ethical is the hardest to get to, and it is also the most long lasting because it doesn't depend on outside stimulus. It is basically who I see when I look in the mirror in the morning. And in Maslow's hierarchy of needs, most of us are very fortunate in terms of the incomes that we make. We're not really worried about the first couple of trapezoids- the security, the food, the clothing, shelter, not our biggest deal.  Our biggest deal [is] right at the top, it's self actualization, the person that we want to be, so if in fact, you're looking at motivations that will be sustained over long periods of time, you actually have to enter that top triangle, and you actually have to view interventions through how will this actually make me think of myself as somebody I will want to be.  How is this an expression of my best self, ultimately.

And so that's...you don't always get there, but those are the ones when you see true champions emerge within physician populations and other populations, are when they finally get it and say, I finally figured out why we're doing this.

I worked with an IT guy, a programmer, many years ago at my management company, and he said, you know, I came here because I was getting out of this GEO coding kind of thing for a utility, I just needed a change, I just needed a different thing, and then I got here. He said, it was about two months into it and I realized what we did, and that it mattered to people and so he said, it totally changed my understanding of the company and totally changed why I wanted to come to work in the morning.  And...he's a great guy, and he did wonderful work for us, but ultimately, it was satisfying to him to be the person that he could be within our company.

BL: You know, it's interesting, at the Maine Health Access Foundation, we talk a lot about patients, [and] patient perspective, and that's our motivation for what we do. We are trying to improve access to care, quality of care, and improve the health of Maine people, all Maine people, but especially people who are uninsured and underserved, and that is sort of an ethical mission.  And so, I think one of the things that we want to help the health system do is to remember that ethical purpose for itself-  it's  about helping patients, it's about providing the best care to patients.  Not the most care, but the best care, because sometimes the best care is less care, so you know, I think we are facing those challenges and figuring out how we can compensate and motivate and build a system that allows providers to be the best they can be and patients to be the best they can be as well. It's really important.

JW:  Absolutely. You have to be careful with those motivations. The use of them [has] to be absolutely genuine, and people have to absolutely understand that [they] come from the same deep place that you're trying to access in them.  If they gain that understanding, they will persevere longer [and] they will do things that are harder, because they understand that you're trying to achieve something larger than yourselves, together. 

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