By Daniel Wolfson, MHSA and Anthony Suchman, MD
In the paper, Choosing Wisely®: A Case Study of Constructive Engagement in Health Policy, we describe how a constructive engagement approach to the Choosing Wisely campaign helped build strong partnerships with more than 70 specialty societies, Consumer Reports, and a bevy of consumer groups and other stakeholders with a shared goal of sparking conversations aimed at reducing waste and overuse in health care.
The framework of the Choosing Wisely campaign is based on two theories: Complexity Theory and Self-Determination Theory. Complexity Theory describes self-organizing, non-linear processes in natural and social systems that unpredictably and spontaneously create, sustain and disrupt patterns of behavior. Self-Determination theory describes factors associated with intrinsically-motivated behavior change, specifically autonomy support, competence and relatedness.
A complexity-based management approach used in Choosing Wisely is Minimum Specifications or “Simple Rules”. Specialty societies were free to develop whatever recommendations they felt most relevant to their members regarding overuse and in what whatever fashion so long as they honored simple rules: the recommendations should be evidence based; they should address frequently used tests or treatments whose use is within the control of the specialty; and the process for developing recommendations should be transparent. In keeping with Self-Determination Theory, this approach to the development of recommendations respected physicians’ sense of autonomy, mastery and purpose.
We believe that the successful demonstration of how principles from Complexity Theory and Self-Determination Theory can guide policy implementation and behavior change is one of the most important contributions of the Choosing Wisely campaign to health care. Oftentimes technical solutions, such as clinical guidelines or standard order sets, are imposed in a top-down fashion without meaningful engagement of the practitioner community, undermining their sense of professionalism and their commitment to making and maintaining the change.
Sustained commitment to change requires an appropriate social process – meaningful engagement and transparent decision-making—which gives legitimacy and commitment to the resulting technical solutions. When we fail to attend to this social dimension of change the result is poor acceptance of improvement strategies by frontline clinicians. They feel the implementation is being done to them rather than by or with them. Other examples of attending to the social dimension of change include framing the presentation of physician performance data as creating learning opportunities rather than pointing out failures, and offering computer decision support as a tool for enhancing clinician knowledge rather than remediating deficiencies.
There is reason to believe that the application of Complexity and Self-Determination Theories in Choosing Wisely is working, and we have begun to see how delivery systems can change if local microsystems are empowered to develop their own solutions to problems. For example, staff at the University of Vermont created a “bottoms up” approach by soliciting suggestions from faculty about what tests and treatments should be performed less frequently at their institution. More than 20 suggestions were submitted, resulting in creation of eight projects focused on areas such as reduction of unnecessary DEXA scans and chest x-rays. By working with frontline clinicians in identifying problems—as well as potential solutions—the University of Vermont has realized substantial reductions in both areas.
These lessons of Self-Determination Theory and Complexity Theory serve as the bedrock to over 70 specialty societies and 100 consumer and employer partnerships and are highly relevant to efforts to implement the recommendations. These important conversations between clinicians and patients tap into professional values of mutual respect, autonomy, purpose and mastery. By engaging the hearts and souls of the clinician, tapping into their calling to the profession and their desire to serve their patients as best they can we can mobilize a powerful force for transforming the health care system.
Daniel B.Wolfson is Executive Vice President and COO of the ABIM Foundation. Previously, Mr. Wolfson served for nearly two decades as the founding president and CEO of the Alliance of Community Health Plans (formerly The HMO Group).
Anthony L. Suchman, MD, MA, FACP is a practicing physician, organizational consultant and Clinical Professor of Medicine at the University of Rochester School of Medicine and Dentistry. Through his research and writing at the University of Rochester, he has become a leading proponent of Relationship-Centered Care, a partnership-based clinical approach.