Designing for Health: Interview with Billy Nicolich [Podcast]

In 2008, authors Richard Thaler and Cass Sunstein published their book Nudge, popularizing nudge theory and bringing a new focus on behavioral economics into the worlds of business and government. In their book, they demonstrate how small but intentional adjustments to a given environment, or “nudges,” can gently push users toward a desired outcome. In the world of healthcare, this theory has been used to show how something as simple as changing the order of a dropdown menu in an electronic health record can have an outsized impact and nudge clinicians to choose the best prescription option more frequently. While it’s not without its critics, understanding nudge theory and employing it in simple ways can result in breakthrough insights, helping clinicians and patients “do the right thing” more easily and more often.

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, chats with Billy Nicolich, healthcare product manager at Press Ganey. They discuss Billy’s background in healthcare and experience design, the legacy and impact of nudge units, and why he sees history as being divided into “pre-manifesto” and “post-manifesto.” They also discuss the scientific study of “stupidity,” how bad decisions create real pain points for users, and in what ways human-centered design can remediate some of that pain and stupidity.

Listen here:




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Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.


Resources Discussed:

Delgado, M. K., & Mahoney, K. (2023). Opening remarks [Video]. Penn Medicine, Center for Health Care Transformation and Innovation.

Hallsworth, M. (2023). A manifesto for applying behavioural science. Nature Human Behavior, 7, 310–322.

Harris, S. (Host). (2016, July 11). Complexity & stupidity: A conversation with David Krakauer (No. 40) [Audio podcast episode]. In Making Sense. Sam Harris.

Linos, E., & Driscoll, D. A. (2023). Elizabeth Linos keynote: Burnout on the frontline: Using behavioral science to support employee well-being [Video]. Penn Medicine, Center for Health Care Transformation and Innovation.

Meeker, D., McCoy, A. B., Mehta, S., McGreevey, J., & Johnson, K. (2023). Stories from the field: Balancing nudge design with clinician well-being [Video]. Penn Medicine, Center for Health Care Transformation and Innovation.

Senderey, A. B., Lauffenberger, J., Courtright, K., Oermann, E., & Sridhara, S. (2023). Stories from the field: Applications of machine learning and AI [Video]. Penn Medicine, Center for Health Care Transformation and Innovation.

Taleb, N. N. (2020). Skin in the game: Hidden asymmetries in daily life (Reprint). Random House. (Original work published 2018)

Volpp, K., & Asch, D. (2023). Kevin Volpp keynote: Behavioral science at a crossroads: Nudges past, present, and future. [Video]. Penn Medicine, Center for Health Care Transformation and Innovation.


Show Notes:

[00:00] Intros

[01:02] Billy Nicolich’s background

[06:45] The history and impact of nudge units

[15:22] A manifesto for applying behavioral science

[22:02] Studying “stupidity”

[28:11] Dealing with pain points



Dr. Craig Joseph: Welcome to the pod, Billy Nicolich. How are you, sir?

Billy Nicolich: Doing great. Happy to be here, Craig.

Dr. Craig Joseph: It's an honor and a privilege. You and I met at a conference and we're going to get into that a little bit more. But as I recall, you saw that I had a book that I had written, and you pulled it out of my hand and you ran away. And then I saw you the next day at the same conference. And I told the police I did not want to press charges. And so are you going to deny that or are you going to go with that?

Billy Nicolich: No, I love it. I still have it. I was honored to get a copy of this. Extremely honored. And then I found out that you were leaving it on the airplane and truck stop bathroom stalls just everywhere. Then it started feeling a little less that way. But I still loved it. By the way, I love designing for health. The human centered approach. That's what immediately gripped me was the title. And I just thought to myself, absolutely, before I ever read it, we need a book like this. And I know we're not here to promote the book, but I'm just saying it immediately gripped me. And in fact, it's a true story. When I went back to the hotel, it wasn't actually a hotel. I was on the cheap. It was an Airbnb place. But I read it like not word for word, but I read through it and immediately enjoyed some of the content. Maybe we could talk about some of that.

Dr. Craig Joseph: Yeah, that's great. I have yet to read it, but I am told it is good and I'm not going to argue with you about the airplane seats and the truck stop bathrooms. Those are good places to find free copies of books about design and healthcare. I think we all agree on that. So let's start talking about your background. You have an odd sort of a background. You went to college and you said, I love technology. I want to major in computer science. Is that is that what happened? I'm pretty sure I got that wrong.

Billy Nicolich: Yeah, that's totally not it. And you know what? My background makes no sense. Unless you treat it like an onion and start out with the outer layers. And honestly, we could just start with. Okay, I showed up at this highly specialized conference. You were there. I, you know, I was there. And in fact, the two of us showed up to a pre-conference session. Now you have to have some dedication to even go to that. Right? So this was before it even started. We go to this session, it was on clinical decision support. It was very interesting. And how did I end up there? Now, I do have to admit that there was a lot of people, because this is Penn medicine, and there was Penn's, you know, nudge unit people. There is there is researchers. I do have a Penn affiliation. And the reason is because I am an alumni of a master's degree program from Penn called the master of healthcare innovation. So it wasn't like I had zero, you know, exposure to Penn and what the nudge unit there has to do. I actually did, because I am an alumni of Penn. And the reason I'm an alumni of Penn is because right before the pandemic started, I found that they had a program for people similar to me, which is you're in the healthcare industry, now you don't necessarily have to be a clinician, in my case, healthcare IT. In fact, I had spent several years at Athena Health. That's one of the, you know, well-known health companies. So I'm in healthcare IT and this program was meant not for coming into right out of a four-year degree, but mid-career professionals in healthcare. So you have a sense for, wow, the US healthcare system has a lot of problems. Right? It's kind of twice as expensive as our peer countries, and yet our outcomes sometimes are even worse. Right? So it was designed for mid-career professionals and you could do it online. And in fact, it was University of Pennsylvania's first fully online program. And I thought that I had a magic wand and I had designed the program of my dream. And one of the things that really gripped me about the program is actually Kevin Volpp, who is one of the luminaries that spoke at the conference and as maybe we can discuss, is one of the most prolific researchers in this area of applying behavioral science in the healthcare domain. And I signed up to be in the program partially and largely in part because I could be a student of Kevin Volpp. And I went to his lectures, and so I was familiar with some of that work. So it's it's best to understand my trajectory starting there. And then you, you find that, yeah, undergraduate I did economics and behavioral, you know, behavioral science type stuff. And so I, I had known about, you know, some of the work earlier works of Daniel Kahneman and, you know, some of these researchers in the past. So I wasn't a completely random person off the street shows up at this conference. I had a little bit of, you know, some reasons to be there. But, you know, I wasn't one of the people who got to go there for free because I was, you know, working for Penn. It's not like that. I had skin in the game. Craig. I had to.

Dr. Craig Joseph: Fair enough. Fair enough. So let's rush right into this. There’s a nudge. It's called the nudge unit at the University of Pennsylvania. And as far as I'm aware, a nudge is like a push, but not an aggressive push, a slight push. And this was the first university that I'm aware of that had such a unit and they put on this conference. Now, this was the first time I ever attended the conference. I know that you've been there before. How did this conference differ from previous nudge conferences?

Billy Nicolich: Yeah, and in fact I was at the very first one, this is 2018, and at the time, I was again a student at Penn Medicine. I was in this master's degree program. And this is the first time in 2018 they have the conference. And at that conference you could say kind of version one of this symposium was that first conference. And I would say the one of the main messages is and you are right, at least partially right about how Penn medicine was, had the first, you know, nudge unit embedded within a health system that was that was the thing that they had done the first and they said, hey, we've we've done this and now we want to share what we've learned so that other health systems can have nudge units and do this, too. And so they, you know, very interesting. If you saw a map dotted all over the country, health systems, you went to this conference to figure out, hey, how can we have a nudge unit in our health system, which would be a group of people who have these behavioral science backgrounds who can then go find those nudges that you were mentioning. And the hope is that you could find a way to have a small tweak is something that had could have a really massive positive impact. One of the big examples, Penn Medicine changed a drop down in their EMR for what drugs to prescribe, and they just changed the order. They just changed the order so that at the top, rather than spread around or at the bottom would be the generic, less expensive drugs. And they found that as they tracked, you know, the usage or the, you know, which which ones the doctors were selecting that overnight they started selecting less expensive drugs. And it happened over the course of a year, you know, a couple million dollars of savings. And they found that that it was persistent. And also they also found that doctors, when the drug that they were prescribing was, let's say, not bios exact with the generic, that they were in fact going in and, you know, adjusting for that. So they were doing all the right things, but there was all this money being saved. So it was it was just an amazing example of one of these nudges you're talking about and how you can go into a health system and just start finding these opportunities.

Dr. Craig Joseph: I love two things about what you said. The first is that I was partially right about the origin of the of the nudge conference, which is and I think our listeners will know unusual because usually I'm completely wrong. And so to be partially right, it's like it's a big win for me. The second thing that I liked was that how successful they were with these tiny little changes. And I think that's really what the nudge is supposed to be, right? Like, hey, we're not taking away your opportunity to choose these three medications A, B, and C, but we think B is really the the best one, according to our experts. And so we're going to put B at the top and we know that a lot of times you're just going to choose whatever you see first. And but if you really wanted A or C, they're still right there, you know, not too far away from you. And especially when you have an expensive electronic medical record, you're able to make these little tweaks. And when we do them all the time, but we don't normally, I shouldn’t say we, many of us don't normally study when we make those little changes, we we make one either accidentally or purposefully. And, you know, and we and we hope for the best. So that was, as you called it or as you like to say version one.

Billy Nicolich: That was version one, that was the year one. And now we were in our fifth year and what you and I saw, Craig, was version three. So what was version two? I’ll just cover that real quick. So version two was, Hey, we have this, we have a good thing going here, and it's gaining a lot of traction. We have nudge units, this is an amazing idea. People are finding that this is doing great things in their health systems. But what we're going to do is evolve that a little bit and we're going to marry it up to the researchers who try to get all the good ideas that that researchers distill when it comes to finding new treatments. You know, sometimes it takes ten years or even longer for that to become the common practice. Let's let's get those researchers in on this. And maybe they can use nudge principles to cut that time in half or even more. And so phase two is getting those people in the room and evolving in a little bit, which I think is really cool. Now, there was no in-person there because that's when the pandemic hit. So that was version two and version three, I guess one of the exciting things why, you know, it's worth having this conversation, is that it's what I would call post-manifesto. We're going to have to talk about that manifesto. But it was the post manifesto conference that applied really all of the manifesto insights. And really there's a line in the sand of history. You know, there's there's pre manifesto and now there's post manifesto. And really, I would say if I were, if you were to ask me, Bill just what's the punch line? Look, let's give our listeners the punch line of what is, what is the manifesto? We'll get into the details. But here's what comes to mind. Okay. First of all, this stuff is not just hype. I know behavior science has really rocketed. And you could say it started gaining a lot of attention when Richard Thaler, Cass Sunstein had their nudge book back in 2008. Then they had strong friends, one of them being Barack Obama. Barack Obama. He issued an executive order to have his own nudge unit in his executive order to work in government, the UK did something very similar, and Richard Thaler, Cass Sunstein were integral to, you know, influencing the right people to have that happen. But is there this sort of hype bubble going on? People are so, so excited. Right? But I think what we've found in this manifesto is that it's not just hype, that the behavior science is now listening to the skeptics and the critics. It has learned from them so that it's not just people in a vacuum who got excited about an idea. It's learning and listening to the skeptics and critics and making sure it's not just hype, but it's something that can go from the lab to the field, and we could take advantage of it. In fact, I'll tell you, Craig, the minute I got home, I was able to apply some of the stuff that we talked about in our pre conference directly to the work that I do and implemented it immediately. And it led to good things. We could talk about that also in a minute. So the other thing is there's a clearer direction. We talk about how whether it be a health system, a hospital, any kind of organization in healthcare. What you want is a learning organization that is an organization that knows how to have feedback loops to do continuous improvement, to continue to do better so that it's serving the people they're meant to serve even better, whether that be the people who are trying to serve our patients or, you know, you're trying to serve a health plan member or whatever it may be. Right? So there's a clear direction. What you want to do is, is be a learning organization that has behavioral science, the behavioral science lens applied to everything you're trying to do as you continually improve. So there's a clear direction about what orgs should do. And the idea is to think about these behavioral science things as not just a tool or a set of tools, but a lens by which to see what it is that you're doing. So you have design thinkers and behavioral insight thinkers, and they end up being more diffused across your organization and not just a group of nudge unit experts. So now our listeners have really hopefully heard an amazing summary of that, the third version, but don't tune out because we have some things to discuss. Right?

Dr. Craig Joseph: Well excellent. So let's talk about the manifesto. When you had first brought this up to me, I was like, wait a second. You know, I'm familiar with a few manifestos in my life, and most of them involve danger and people that get arrested. But this was not your, this was not you labeling this idea or article as a manifesto. In fact, I'm looking at this manifesto right now, and it's really just an article in Nature Human Behavior, and it's entitled A Manifesto for Applying Behavioral Science and so the author, Michael Hallsworth, also thinks of it as a manifesto. And basically it's it seems to be kind of a criticism of, as you mentioned, hey, looking at behavioral science in a superficial way and kind of getting quick wins and getting a sugar high, that boy, I can get any problem that I want to solve. I just need to make it just push people in the right direction or acknowledge and understand how they how they think about things. And every human will do everything that someone wants them to do. Maybe it's what they want to do. Maybe it's what the government wants to do. Maybe it's what their physician wants them to do. And that seems to be overblown. Right? Do I have that right?

Billy Nicolich: Yeah, there's so many, there's some amazing things about this manifesto for those who have been watching behavior science. And for a while, I think, you know, it's been met with a lot of a lot of positive feedback. One of the things I love about it is that it does take into account what the critics have said. You know, not that that I've listened to all the critics, but I one, I was going to mention one critic that I that I thought was worth talking about, and that is Nassim Nicholas Taleb. I've got one of his books here that a lot of people have read, Skin in the Game. And in this book, he, if you look in the back, you'll find that there's actually several places where he mentions the nudge authors, Thaler and Sunstein and he has some criticisms there. But Mr. Taleb, obviously, he's not on our podcast and he can speak for himself. But if I were to venture to guess what, what his main beef was, and by the way, kind of famously on Twitter, he called the Nobel Prize winner Richard Thaler nudge boy. And in this book, he even calls him a creepy interventionalist. And so, first of all, you're going to get Mr. Taleb ire if you talk anything about risk-taking because he's an options trader, he knows all about the science and the mathematics of risk. And in the world of behavioral science, people, including Thaler, had talked about a set of biases that kind of people tend to have one of them being loss aversion, and that has to do with risk. So if you if you mentioned loss aversion and you label it as a bias and then you start prescribing that maybe people should not be following that bias, then you're going to catch the ire of Mr. Taleb. Absolutely. One hundred percent. So he was one of the critics. Now, one of the things that the manifesto suggests beautifully is that we actually kind of stop talking so much about these human biases and just focus in on just the fact that people do respond differently to some of these interventions and nudges in different ways. So talk more about what is versus what ought when it comes to these biases, because it honestly is it's interesting, but it's not necessary in order to start applying what we're finding in the lab to the workplace. So I hope that makes sense. So in other words, if you have a book, you know, you shouldn't spend too much time talking about the human biases. Now, I'll give you credit because you have only one page devoted to listing out all these biases. So I have it here. You have a list of biases. You only you only devoted one page.

Dr. Craig Joseph: Billy, that's my favorite page. That's my favorite page of the whole book. And you're not happy.

Billy Nicolich: You'll want to take that one out immediately. No, but I loved how you only, you know, only devoted one page. And I think that's fine. One page is good. Now, had you done an entire chapter on it, I would say, look, Craig, we need to do a total rewrite of this thing because it's pre-manifesto, but it's one page and that's fine. And it was really just sort of a side note. And we're still good.

Dr. Craig Joseph: All right. Awesome. So, you know, distilling that message down to, hey, it's actually not that simple and that's the first thing I've heard. And the second thing is the idea of a of a nudge unit again, great idea when it started. But what it would be better yet is no nudge unit just everyone understands the concepts and the goals of the nudge unit and instill that in everything that they do from designing a new building to, you know, figuring out how patients can schedule to ensuring that workflows that nurses have to follow in the hospital, make sense and make it easy to do what they want to do to help both themselves and the patients.

Billy Nicolich: Yeah. Yep. And in fact, that article and the manifesto has a map in it, and in it, what it does, it describes a journey of an organization. An organization may start out having no emphasis on applying the nudge lens to the various challenges. And then it may start on a journey where maybe there are some entrepreneurs that pop up within the organization that do know about some of these things. They start doing it entrepreneurially and then the organization might start looking for outside help consultants who may do it, but maybe there is no expertise in the organization. And then maybe from there are some now there's some expertise in the organization, but they're sort of like they're a nudge unit. So they’re a group and then everybody comes to them and but it's really the group's job to understand this stuff. And then finally you arrive at what we hope is more infused within the organization. So if your organization is a tea, and behavioral insights is say, camomile, then then the tea is now infused with the camomile and now it's a better tea.

Dr. Craig Joseph: Wow. I wasn't going to go there but that now I'm thirsty and I'm not sure if that was your intent. But let's talk about something else that you found that resonated from, I think, the conference and from the book, which is stupidity. Now, this is I have a particular, as I referenced earlier, I have a particular expertise in this area. But, you know, you had mentioned to me that you're aware of people with strong English accents who study stupidity. And I was fascinated by the strong English accents because as an American, I assume if someone says something with a strong US accent, they're generally smarter than me, which I, I think maybe you were implying so. So what is it about stupidity? And how does one how does one study that?

Billy Nicolich: Yeah. So first of all, I mean, who knew that stupidity is, is a proper, you know, topic of scientific inquiry. Right? And I didn't know that, but I was listening to Sam Harris podcast and he had David Krakauer, who, you know, has a British accent, and he said, you know, I study stupidity and it made me laugh. I don't know why, but here he's a scientist and he studies to stupidity because it really begs the question, how could there be stupidity when typically, you know, when we have evolutionary forces on us, we thrive or not, you know, based on how well we're doing. How could there be all this stupidity all over the place? Now, the thing I would say, first of all, that we should say at the outset is, is that we're not really talking about stupidity on a personal level. We're not talking about stupid people. We're talking about stupidity in the systems and processes where these processes start off with the best of intentions, right? It hopes to guide people. And let's say, you know, you build an EMR and with the best of intentions, you hope it's going to help clinicians do the right things and stay out of the way. But you find that instead, you know, creating burnout because it's such a burden to use and they're all the wrong things are in the wrong places and it's causing, you know, too much overhead and stuff like this. So how could that possibly happen? So one I think it's kind of fascinating that stupidity is a subject of science. You mentioned stupidity in the book and I thought that was brilliant because there is a lot of stupidity in the systems and processes that are that are in healthcare. And what would be even more stupid is to not do something about it. Right? And I think you had keyed in on some great research that had been done by a group of people who found and discovered that you could even on a yearly basis just decide that you're going to find some of the stupidity and cut down on it. Right? And you have great examples from the book.

Dr. Craig Joseph: You know, we say research. It was an article in the New England Journal of Medicine, which apparently is a journal that is well-respected, I guess, where it was, the title was Getting Rid of Stupid Stuff, and it was basically the chief medical information officer at Hawaii Pacific Health who said, hey, we did this crazy, innovative thing. We asked people for specific examples of stupid stuff, and I think that's their term, not that I agree with it, in our electronic health record. Right? And people were a little hesitant to kind of come up with some of those examples, even though they had them. One, they thought they might get in trouble for speaking out and maybe that wasn't cool with the culture, and two, though, more specifically, yeah, I've told people before and nothing happens and why would I go to the trouble of identifying this for you if you're not actually going to do something? And so, you know, that was the key was one. It was kind of a almost like a patient safety culture. Like, No, it's your job to tell us when you find stupid stuff, and even if it's minor, it's still kind of destroying your psyche that every day you have to do that. You have to answer these questions that are relevant for a newborn, but not so much for a six-month-old who's now coming in for a different kind of a problem. And it just kind of potentially lowers your IQ just a little bit every time you have to do it. And so, yeah, I think getting rid of stupid stuff is underrated and it's an easy win. But I've never I've never really considered kind of studying stupidity. But it makes sense as, you know, something to try to understand. Well oftentimes as I think you referenced it, maybe it wasn't stupid when we did it right when we were implementing this technology or creating this workflow or building this building, like everyone knew it had to be this way. And looking back on it now, we're like, well, maybe that wasn't a great decision, but it actually might have been at the time based on what they knew and what they were doing and the regulations that they had to deal with and the level of, you know, where science was.

Billy Nicolich: Absolutely. So, you know, let's not point fingers, but let's go, now that we have, you know, the benefit of hindsight for the things that have been built, let's go back and then, by the way, as we think about building new things, you know, there's ways we can approach that. And I think that's where, again, we can kind of tie back to this concept of designing for health, that the concept of designing is taking a humble, thoughtful, deliberate approach to understanding the problems we're trying to solve and to make sure we're matching those up with solutions that are on target for solving those problems. Right? And that's where this design thinking really marries up quite nicely with the concept right. Of well, well, let's not perpetuate stupidity in our systems. Let's use design principles to lead to better solutions. Right?

Dr. Craig Joseph: Yeah. Agreed. And oftentimes, you know, bad decisions are made because we actually don't at the very beginning figure out what are we trying to do, right? We think we know what we're trying to do. We're recreating that paper form in the computer. But if we were actually thinking about, wait, why do we have that paper form? What information is it collecting? Is it already available? You know, kind of going back to the very beginning, it will decrease the stupidity and then the pain that's associated with the stupidity.

Billy Nicolich: Yeah, absolutely. Now, okay, so, so the system has stupidity in it and we can go back and thoughtfully figure out how to address that. However, maybe that's a good segue to a similar point in your book that you mentioned. And that is pain, right? There's stupidity and there's also pain. There's pain points, right? And the pain points are you know, some of the indicators, if you find a pain point and then there's a little arrow to it, maybe this is an area that we need to think about in our continuous improvement. Maybe we ought to look here. Where does it hurt, where are the pain points? But, you know, it isn't a free for all. And in fact, a lot of organization will struggle to eradicate stupidity and do something about those pain points because making a change is also a little bit of a painful process. And so one of the comments I made that in our earlier discussion is that if you looked at a let's say a little graph that said, you know, over, you know, you have over time and then, you know, you have the kind of impact that would be made and, you know, the pain that that you're going through, you would find that there's what some might call a J curve. In other words, as you start a path of improvement, sometimes the pain actually increases and you have a J curve where you're going to go through a period of pain before you get out of that and then start a trajectory upward with less pain and more effectiveness. Because change itself is difficult and a little bit painful as well. And in in that trough of the j curve is where a lot of organizations struggle, and that's where the design thinkers and the behavior science lens and consultancies and other people can help an organization get past that J curve that can cause so many organizations to either go back to the way things were or to stagnate from there. I've seen that in the work that I do. There was this big continuous improvement initiative that led to a process workflow to change, halfway through, you could say, that transformation, the group of people who are impacted by a set of additional milestones, you could say, came back and said, you know, this is causing extra work for us and we'd like to go back to the way things were. And what we said, though, is, you know, the reason why we got on this journey in the first place is because there was a lack of transparency. And our chief operating officer, you know, had a lack of confidence that we were steering things in the right direction. So sometimes you have to remind the people who have to undergo the change, the pain that that caused us to do this transformation in the first place. Right? And once they were reminded of the stupidity and the pain that we were leaving behind, they realized that, yeah, you know what? We should continue this journey. So we did continue the journey. And it turns out that adding additional milestones and visibility did increase the confidence and the effectiveness with the chief operating officer and we ended up in a much better place. So I've seen that that play out. So in other words, I guess the point is that it's not easy. So it might be easy to find the organizational system stupidity and maybe find the pain points, but doing something about it is a little bit more challenging. And I think that J curve, at least for me, is a nice illustration of that.

Dr. Craig Joseph: Yeah. I think one group because of that the trough of disillusionment and you know I don't know anything about that because I often work with physicians, they love change, they love it and they can't get enough of it. And I'm being a little bit sarcastic. And so, yeah, you know, I think one way that organizations can help with that is to identify it ahead of time. Right? And tell your chief clinical officer or your executives, hey, in the long run, which is maybe three months from now, this is going to be great. But for the next two or three months, this is going to be horrible and people are going to come to you and they're going to corner you in the elevator and in the parking structure and tell you about how painful it is to change like this. And can’t we just go back? And that's a short-term gain for sure. If you go back and it'll be easier, but you're not going to get that long-term fix. And another effective way I've seen of dealing with that is talking about the cell phone. Right? Like I have an app. It's great. I love this app and I wake up one morning and the app looks different and it's not completely different, but I don't know how to do what I normally do. And I have to like, where's my button? The buttons gone and I hate it and it's horrible. And I'm contemplating getting rid of the app. But that takes some more effort because I have to find another app to replace it and do the same thing. And two weeks later, if someone comes to me and says, Hey, heard you didn't like the changes we made for the app, do you want to go back? Almost always, my answer is, I don't even know what you're talking about. It's been two or three weeks. I figured it out. My wiring, my muscle memory is, you know, been redeveloped, and I just needed a little bit of time to kind of get over my hatred. And then it's much better now. So that's one thing I think that people can kind of they're like, Yeah, I guess you're right. This is one of the few instances where I've been I've been right before, so I'm excited about that. But yeah, it's the changes is, change management is really essential and continuous improvement can't happen unless you're managing that change and making sure that people are understanding it, explaining that that j curve and that trough of disillusionment so that people are not shocked when they're like, Wait, I hate this thing. Like, wait, we told you were gonna. But we all agree that the outcome is going to be great at the end. So remembering yeah, remembering that the end result helps get you there.

Billy Nicolich: So if you recall kind of going back to you and I for whatever reason, felt compelled to go not only to this specialized symposium but the pre-symposium session on clinical decisions support. You were just talking about cell phones and you think about an electronic medical record where physicians are spending so much of their time, right? So this pre-conference session was dedicated to thinking about and actually practicing having like, having some practice sessions on, hey, there's some challenges faced by this healthcare organization. And this organization is contemplating some changes to the electronic medical record in response to some pressures from coming from regulatory pressures, a physician should be doing some new things. And so you might want to enshrine that in some of your workflows that are in the EMR, for instance. So you and I were in this room where a bunch of people were going to try this out. So what we were given, these really cool handouts. One of them was, if you recall, the five rights of clinical decision support, and then there was this other one, the ten commandments for effective clinical decision support, right? Ten commandments, the five rights. And we quickly looked over that and then we picked a challenge or a problem and then we were given just a very short period of time to get with some people in the room who happened to join our different tables. And then we did that. And if you recall, at the very end of that whole session, Kit Delgado who heads up Penn's nudge unit today. Right? He did mention that in addition to the ten commandments and the five rights we do need to also consider the change management principles. And that was something that I highlighted in my notes, is you're absolutely right. Like no matter what you're going to do, if you're going to implement changes, you're going to have to think about change management as well. But I mentioned the clinical decision support example, the ten commandments and the five rights, because those were adapted from research that had been done previously and I thought they were brilliant and I was able to take them back to my work and what I do and actually apply those directly to a project that I was working on. I was working on ways to simplify and improve all of the workflow processes that go into managing projects for very complex projects in the area of market research studies that have that usually have a component of a survey that would go out to people over mail, internet, phone, etc. These are very complex projects and we were improving the project workflows. So I, I came, I adapted to these and came up with said guidelines of the ten commandments or guidelines of operational workflow design and the five rights of operational workflow design. And I found that I was able to make that adaptation and come up with really great principles that I could apply these types of efforts of improving workflows and doing design work where the design work is impacting internally within the organization in addition to thinking about how things are designed for end users and customers. So I loved it. I don't know if you took your sheet away, but if you recall, there was the five rights, right? And those were the right information given to the right person at the right time through the right channels and in the right format. Right? So, brilliant.

Dr. Craig Joseph: Yeah, it's simple and brilliant. And I'm glad that you were able to kind of take those and co-opt them and modify them, you know, similar to the five rights for drug delivery, just to make sure that you give the right medication to the right patient via the right route at the right time in the right format. So we are running short on time. Any concluding thoughts or concepts that you wanted to address?

Billy Nicolich: Buy the book. I know we're not here to explicitly promote the book, but I loved it. I thought the universe needs this book. I think we need to apply design principles. One of the big takeaways of that great conference that happened only a month and a half ago, we’re still, you know, in the afterglow of that amazing conference. One of the big takeaways for me is, is this very, very enthusiastic suggestion to apply design thinking to the behavior science lens and marry those principles together and diffuse that into more people. And if you can just diffuse some of that into me, I'm pretty simple person then that I think that's a great indication that more organizations can infuse it throughout their organizations.

Dr. Craig Joseph: Awesome. Well, that is a great way to end. I thank you. It's been a pleasure and I look forward to continuing the conversation at the next nudge conference.


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