- Issue: A deep understanding of human behavior is critical to designing effective health care delivery models, tools, and processes. Currently, however, few mechanisms exist to systematically apply insights about human behavior to improve health outcomes. Behavioral design teams (BDTs) are a successful model for applying behavioral insights within an organization. Already operational within government, this model can be adapted to function in a health care setting.
- Goal: To explore how BDTs could be applied to clinical care delivery and review models for integrating these teams within health care organizations.
- Methods: Interviews with experts in clinical delivery innovation and applied behavioral science, as well as leaders of existing government BDTs.
- Findings and Conclusions: BDTs are most effective when they enjoy top-level executive support, are co-led by a domain expert and behavioral scientist, collaborate closely with key staff and departments, have access to data and IT support, and operate a portfolio of projects. BDTs could be embedded in health care organizations in multiple ways, including in or just below the CEO’s office, within a quality improvement unit, or within an internal innovation center. When running a portfolio, BDTs achieve a greater number and diversity of insights at lower costs. They also become a platform for strategic learning and scaling.
Introduction: The Power of Applying Behavioral Science
All too often policies, programs, and services are designed in a vacuum, apart from human behavior. Most design — even thoughtful, human-centered design — is guided by our intuitions about what might work and influenced by our assumptions about how humans will decide and act. The practice of behavioral design is instead steeped in a rigorous approach to building products, processes, and systems based on the science of how humans actually behave. It has been applied extensively and successfully to improve outcomes in many areas, including personal savings,1 financial aid for postsecondary education,2 and energy conservation.3
Behavioral scientists have discovered that many behaviors result from systematic tendencies in our thinking that are predictably activated by specific features of different contexts. For example, people’s sense of risk is heavily influenced by their memory of recent experiences, which helps explain why a plane crash in the news leads to more people driving instead of flying (even though driving is more dangerous) or why seeing an accident on the highway causes people to drive more slowly. Discoveries about systematic tendencies allow behavioral designers to unpack the black box of human behavior — to isolate specific cues or contexts that lead to success or failure.
These insights can be applied to core problems in health because many of the levers used to improve patient health and health care delivery ultimately concern behavior. Behavioral design has been used already to reduce physician medical errors,4 improve medication adherence,5 and promote smoking cessation,6 but could be applied to many more areas. Insights could be targeted at provider behaviors, patient behaviors, or both. Below are some ways behavioral design has started to generate new solutions for challenges in health care where standard approaches have fallen short. There are a variety of issues behavioral science could and has started to tackle (Exhibit 1).
One pathway to widely implementing behavioral sciences in an organization is embedding behavioral design teams (BDTs) within an organization’s operations. This brief explores how BDTs could be applied to clinical care delivery, and discusses several models for integrating these teams within health care organizations. BDTs previously launched within both federal and city governments may offer lessons for executives and innovators looking to tackle health care challenges. Future publications will further explore problems that BDTs could address and potential behavioral design approaches to resolving them. (See Appendix for examples of how behavioral design can change the way health care is delivered.)
Achieving the Promise: Integrating Behavioral Design Teams in Health Care
BDTs are cross-functional, multidisciplinary teams led by behavioral scientists — individuals experienced in the application and operationalization of behavioral science principles — and experts with deep experience in the specific domain, like physicians and care coordinators. BDTs have had success working within government, which share many similarities with health care providers: large bureaucracies that are struggling to innovate quickly, privacy and security issues, and the delivery of core human services. Consequently, BDTs may hold promise for health care organizations.
Behavioral Design Teams in Government
Since the launch of the original BDT in the federal government in 2014, BDTs have successfully improved the quality and effectiveness of local and federal programs with low-cost solutions that target behavior.23 For example, a BDT within the federal government increased enrollment in college by 9 percent and nearly doubled the enrollment rate of service members in a savings plan, among many other results.24 A New York City BDT increased flu vaccinations among city employees by 5 percent with a behaviorally informed email, and a Chicago BDT increased total revenue payments, the speed of city fee payments, and the digital payment frequency.
BDTs apply a rigorous, evidence-based process for creating behaviorally informed approaches, implementing and testing the impact, and scaling successful and cost-effective solutions. BDTs often begin with incremental change and, through their investigative and diagnostic data-gathering processes and pilots, generate ideas for larger, transformative designs. For instance, the New York City BDT started with a simple intervention to increase flu vaccinations among 400,000 city employees. In the process of investigating the flu vaccination, the BDT and city realized there were opportunities to increase a range services, such as the use of one-minute clinics and telemedicine. The city’s BDT is now starting to design a larger package of health interventions, including for example, access to health insurance by those eligible for Medicaid as well as reduction in unnecessary emergency department use.
The processes a BDT uses vary to fit the needs of the partner, but typically work starts with identifying multiple leads and prospective projects in line with the organization’s goals. The most promising opportunities have three main features: a well-defined goal or outcome of interest, a link between that outcome and individuals’ decisions or actions, and touchpoints of direct interaction between the organization and individuals. BDTs often operate as part of a larger project or an interdisciplinary team that wants to add behavioral science to its efforts.
The behavioral design process
Once a project is selected, the team works using a multiphase process (Exhibit 2):
Define. Accurately define the problem, focusing on a specific behavior, and eliminate assumptions about what
may be contributing to the problem and possible solutions.
Diagnose. Generate insights about the psychological processes contributing to the problem, and the specific contextual features activating or influencing those processes. An initial behavioral map is created and continually refined to hone hypotheses as additional data are collected and analyzed. Data come from site visits, interviews, literature reviews, and the analysis of existing qualitative and quantitative information.
Design. Scalable interventions that address the key bottlenecks are designed and operationalized.
Test. Rigorously test interventions to determine efficacy of design, ideally through a randomized controlled trial.
Scale. Solutions are refined and scaled using a variety of channels, including policy changes, dissemination and replication, or creation of separate organizations or services.
BDTs also chip away at one of the biggest challenges in innovation: keeping up with, and effectively learning from, what does and does not work, both inside an organization and in the broader field. By drawing on learnings across a portfolio, BDTs can optimize designs based on prior successes and failures. By tackling multiple issues simultaneously, they can uncover opportunities to bundle interventions to achieve greater impact. When connected to behavioral scientists in other domains, BDTs can assess the effectiveness of behavioral interventions being tried elsewhere in the world, further speeding the exchange of ideas.
This platform of shared learning and dissemination can occur as a regular interaction between two or three teams at different organizations or at a larger convening. For example, the White House Summit for State and Local Governments, which took place in December 2016, gathered government officials from across the U.S. to learn about projects completed and under way within the federal and city BDTs, as well as other independent behavioral science work in the public sector. One example was school districts sending letters home to parents that compared their child’s attendance rate with other students in the school and district; this strategy reduced student absenteeism by 15 percent.
Attendees learned from projects and approaches across a range of government settings, and from the insights on what works and what doesn’t. Many cities and states are now exploring launching BDTs.
Components of Effective Behavioral Design Teams
A BDT can adapt to the context and culture of various departments and units within providers, but there are certain critical success factors.
- BDTs operate best when top-level executives have bought in and facilitate the integration and operations of the team. This support is critical for opening channels to projects across departments and assembling the diverse skill sets needed to build new designs and implement them. Top-level support also creates space for risk-taking and experimentation, which will vary according to the institution’s risk preferences.
- BDTs are most effective when led by a combination of a domain expert (like a physician) and a behavioral scientist with experience managing applied research and design projects. Effective design will rely on the behavioral science expertise to identify, diagnose, and design for behavioral challenges.
- BDTs rely on active collaboration with key staff and departments, including department managers and front-line staff (i.e., clinical providers in the health setting). Partnership with project stakeholders and domain experts is critical to successful problem identification, analysis, and innovative behavioral design.
- BDTs need data support. BDTs use data to assess new leads and quantify the size and scope of challenges. Data are also valuable because providers will want to see evidence of meaningful, cost-effective results from rigorous evaluations before moving to scale.
- IT support is required to both pilot and implement redesigns. Many behavioral designs are delivered through technology systems; this support will become increasingly valuable as the number of behaviors and choices executed in digital environments grow.
- BDTs offer more value when operating a portfolio of projects across a variety of issue areas. When running multiple projects, BDTs increase capacity for department leads and front-line staff by using centralized team resources to augment existing staff resources, increase value by executing additional projects at significantly improving marginal costs, can share and replicate learnings rapidly, and can start to shift culture.
Opportunities for Integrating BDTs Within Health Care Provider Organizations
Cities interact with people all day long, but they’re not built around people. The NYC BDT is helping change the way our agencies think about their constituencies. It’s using evidence-based insights into people and iterative, rigorous design to create cost-effective solutions. We’re starting to see specific improvements in outcomes for residents and city employees.Matt KleinSenior Advisor
New York City Mayor’s Office of Operations
A health care organization could integrate a BDT in multiple ways, depending on its priorities, culture, and organizational structure.
Integrated within or just under the CEO’s office
Positioning a BDT with close ties to the CEO’s office would ensure it receives the requisite executive support, is directly linked to top priorities of the organization, and has access to key staff and resources that are crucial for success. This positioning also may foster greater buy-in from other staff and departments, which could catalyze faster and more thorough cultural changes within the organization.
Integrated within quality improvement units
Integrating a BDT within an existing quality improvement (QI) unit would enable close collaboration with department leads, front-line staff, and the data and IT teams that frequently staff them. These members are all critical to effective diagnosis and solution development. It would facilitate creation and production in collaboration with stakeholders who will ultimately be adopting and implementing the solutions. It also could be a useful location for a BDT because of its shared mission with QI units of improving outcomes and experiences while reducing costs through system delivery redesign. The arrangement would be mutually beneficial: the behavioral design lens would complement the QI teams’ skills in improving processes; at the same time, the BDT would enjoy built-in executive support.
One consideration that should be made before placing a BDT in a QI unit is ensuring the BDT can effectively build a diverse portfolio of behavioral issues, including transformative, breakthrough project opportunities. QI teams may be more inclined to focus on optimization and incremental change.
Integrated within an internal innovation unit
Alternatively, providers could embed a BDT within an existing or as a new innovation unit. The BDT would independently develop new solutions outside the clinical workstream but pilot them in partnership with department leaders and front-line staff. In this model, BDTs would rely on strategic partnerships with leaders across the provider system to source leads, diagnose challenges, and pilot solutions, but would operate with relative autonomy to design and develop new processes or products. One example is the Center for Innovation at the Mayo Clinic.
The independence conferred by this model may offer the autonomy to pursue behavioral issues that fall outside the scope of other units’ priorities and the space needed to develop transformative innovations. Yet independent BDTs may struggle to gain consistent access to front-line staff, department leaders, and data and IT support teams and to secure the buy-in from key stakeholders.
A systematic and rigorous approach to the application of insights about human behavior could be a key tool for building better health care delivery. BDTs, armed with potent insights about behavior and a rigorous evidence-based methodology and modeled on a successful approach in both federal and city governments, may enable effective changes in the delivery of health care. BDTs are composed of trained experts in behavioral science experienced in designing, implementing, and testing interventions inspired by the behavioral sciences. The team structure is adaptable. BDTs can integrate to suit the provider’s organizational structure, either adjacent to the CEO’s office or within existing quality improvement or internal innovation units.