behavioural insights in action forum

Behavioural Insights in Action ForumTuesday 13 August 2013

Presented by the Institute for Public Administration Australia (IPAA) and the NSW Department of Premier and Cabinet

Welcome

Peter AchterstraatPresident, IPAA NSWNSW Auditor General

Welcome

Professor Mary O’KaneNSW Chief Scientist and Engineer

FacilitatorStephen BradyDeputy Director GeneralStrategic Initiatives and PerformanceNSW Department of Premier and Cabinet

http://policytoolkit.nsw.gov.au/bi

Visit our Behavioural Insights Community of Practice website:

Keynote Speaker

Professor Peter JohnProfessor of Political Science and Public Policy at University College, London

Behavioural Insights: an International setting

Peter John

University College London

How interventions can find out how to get citizens to act pro-

socially

• Citizens are not passive - often interested in civic action and doing more for society

• But often they find it hard to translate interest and intentions into reality

• The behavioural economics take on this is that they tend to use short-cuts and go for easy options that can involve doing nothing -equivalent to leaving the letter on the mantelpiece

Influencing citizen behaviour

• A line of experimental work shows that light-touch contacts with citizens can stimulate them to carry out more civic acts

• Door knocks, requests (‘asks’), leaflets, telephone calls have effects on turnout (see Green and Gerber 2008), recycling (Cotterill et al 2009) – effect sizes of 4-7 per cent

• Content of the message does not matter • More controversially – the mode does not matter (see John

and Brannan 2008, Fieldhouse et al 2011)• Citizens respond to the cue - they want to do these things,

but they need reminding - cuts into a behavioural economics take on civic action - people need shortcuts to do good

Second generation experiments

• A new move to more targeted and manipulative experiments, using insights from social psychology

• Basic idea is that the citizen sees their actions in the light of what other citizens are doing

• Issue is that there are different ways of manipulating this information: a) social pressure b) recognition c) social information d) personalisation

Mechanism: recognition

• Cotterill et al. (2010) test the whether the numbers of books citizens donate to charity depend on the manner in which they were asked.

• The research team randomly allocated 11,812 households in two electoral wards:

– a control group that were just asked to donate books to Africa

– a pledge group which were asked to pledge

– a pledge-plus-publicity group, which got the pledge but who were told that if they donated their names would be put up in a public place.

Book Donations

Control Group Pledge Group Pledge & Publicity Group

Book donation 282 (7.2%) 320 (8.1%) 346 (8.8%)

No book donation 3665 (92.8%) 3617 (91.9%) 3592 (91.2%)

Total no. of households

3937 3937 3938

The wider context of citizen-responsive services

• Highly centralised traditions of public management, systems designed by experts, then path dependence

• Consumerist trends – especially changes in the private sector, with large companies collecting micro information about consumers cf. Google

• More vocal dissatisfaction with services > citizen action, complaints

• Move to bring the citizen back in put at the heart of services

The politics of nudge

• Not to do with fiscal austerity:– interest pre-dates current round, e.g. under New Labour– Obama employed Cass Sunstein, new White House Unit

• But more attractive in age of fiscal austerity -alternatives to money and laws (but note that laws and finance may be improved with behaviouraltechniques)

• Coalition government on its own with BehaviouralInsights team (set up for two years in July 2010, now extended)

How academics and policy-makers work together

• Successful element of BIT - academics willing to help, flexible input

• Need to find the right academics!

• Work to their incentives:– interest in study design

– interest in being close to policy

– not too costly in terms of time

– good to get a publication outcome

– money is less important (but we do need some reward!)

The limits to nudge

• How large are the effect sizes? How sustainable? (Depends on changing habits)

• How many defaults are there to change? • Diverts from traditional instruments: see

House of Lords Report, Behaviour Change• Natural life-cycle of new fads?• Depends on key people as supporters, e.g.

Head of Civil Service Gus O’Donnell (but successor just as enthusiastic)

Limits to nudge (continued)

• Does it really challenge the economic model?

• Paternalistic? – see work of Bob Sugden

• Top down: how to reconcile with

decentralisation:

see Nudging Citizens

Towards Localism

The ‘Think’ agenda

• Top down, manipulative

> needs a citizen directed

complement >

Think agenda

But think effects weak

Or long term?

The impact of discussion versus information on organ donation

• The project compared the impact of information alone versus information and discussion on organ donor registration levels.

• 180 students were randomly assigned to three groups to receive one of the following interventions: a four page information booklet encouraging registration, the booklet followed by a 15 minute deliberation, information booklet about swine flu (placebo control)

• After the intervention, students were invited to join the organ donor register.

• Registration increased across all 3 groups • The information booklet had the greatest effect, and raised the

number of students on the organ donor register from 23 to 57 per cent, an increase of 17 per cent whereas nudge+think increased from 26 to 41 per cent (control from 34 to 64!).

Conclusions

• Behavioural science offers a powerful set of insights for policy makers

• Part of citizen-orientated public management –making the citizen at the centre of decisions

• Does not get rid of incentives and the economic model: often behavioural insights and incentives work together

• How much evidence to change policies? Now moving beyond the quick wins. More RCTs

• Political support for nudge? Yes

From the Beach to the Bed:Lessons for the recognition and

management of the deteriorating patient

Professor Cliff Hughes AOClinical Excellence Commission

13th August 2013

Keynote Speaker

Professor Clifford HughesChief Executive of the Clinical Excellence Commission

From the Beach to the Bed:Lessons for the recognition and

management of the deteriorating patient

Professor Cliff Hughes AOClinical Excellence Commission

Safe Driving - NSW

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IIMS enthusiasm

CF Hughes AO1 August 2012 C F Hughes

The Problem• Unrecognised deterioration is a

significant problem for patients* in all health systems despite ‘hallmark’ clinical signs of deterioration.

•

• *Vanessa Anderson (aged 16)24th October 2012 C F Hughes

Aim: To improve early recognition and response to clinical deterioration and thereby reduce potentially preventable deaths and serious adverse events in patients who receive their care in NSW public hospitals.

Programme Aim

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Intervention on the Slippery Slope

PatientCondition

Time

ClinicalReview

ALS

Prevention

RapidResponse

The Solution

C F Hughes

The Solution

• Identify missed opportunities to: • prevent• recognise• escalate• respond

Standard Calling Criteria and Charts

• Simple to use- single trigger• Most sensitive indicator of deterioration first• Graphed vs. written observations• Clinical usefulness and relevance• Consolidation of observations for a ‘global’

view.• Ordered A-G to support patient assessment• National standards• ‘Photocopiable’ (including patient details)

Adult Chart

Human factors principles

• Reduce cognitive load and improve functionality– Top left hand corner is processed first– Font size and type– No overlap of parameters– Colour choice (emphasis)– Colour choice (colour blindness)– Consistency in formatting– Clear and descriptive labels– Low light legibility

Setting Vital Sign Thresholds:

Getting the Balance Right• Patient Risk• Sensitivity• Specificity• Resource availability

• Detecting Deterioration, Evaluation, Treatment, Escalation, and Communication in Teams

• Manual• E-learning modules• Clinical skills workshop

• Focus on improving the ability of clinicians to identify and respond to clinical deterioration at the ward level

• Launched by the Minister for Health at Liverpool Hospital on the 13th January 2010.

• Observation Charts in use in all NSW Health Facilities

• All AHS/facilities have developed CERS procedures

• Rural AHS’s have collaborated with the Ambulance Service to develop models for provision of assistance (“CERS Assist”)

• All AHS’s progressing with Awareness Training and DETECT e-learning modules

Implementation

• 4 KPI’s issued to LHD’s • 2 KPI’s have been included in

Performance Agreements (Rapid Response Call Rate and Cardio-respiratory Arrest Rate)

• Web-based system for collecting process data is being developed

Implementation (cont.)

Governance

Standard Calling Criteria

(CERS)Clinical Emergency Response Systems

Education Evaluation

The 5 elements

Frontline CliniciansClinical Leads

Frontline CliniciansRapid Response TeamCERS Committees

Workforce ManagersEducatorsClinical Leads

Clinical Governance UnitsBTF ManagersCERS Committees

Observation Charts

Clinical Review/Rapid Response

Awareness, DETECT, Rapid Responders

2 KPIs & Evaluation Collaborative

Stakeholder engagement and

consultation is vital

Clinicians• Coal face• Consult within

clinical context• Seek specialist

advice• Emergency• Maternity• Paediatrics

LHD• Executive

Sponsors• Programme

Managers• Equal

representation

DoH• Statewide

Services• CSQG• PSN• Family and

Community Partnerships

• NaMO

Child Health Networks NSW

Ambulance

Progress to date• State-wide implementation of observation

charts (Adult and Paediatrics)• All facilities have a CERS procedure• Mothers at Risk Chart implemented 2012• EMR chart introduced into Emergency

Departments• Hospitals reporting decreased numbers of

cardiac arrests and preventable deaths• Broad clinician engagement

24th October 2012 C F Hughes

State wide Results

Lessons Learned• Executive and Clinical Leadership• A good plan• Branding and marketing• Partnership with Department of Health

and Local Health Districts• Governance structures• Awareness and Education

Conclusions• Between the Flags has captured the

imagination of the staff of NSW• BTF is part of the language• Staff believe it is making a difference• Encouraging signs are there that it is

indeed reducing cardiac arrests• BTF must now become part of the

culture

Conclusions• We need:

– The vision to see what must be done and what is possible

– A plan to make it happen– A coalition of the willing– The power of stories– The courage of leaders

WE HAVE THESE

Small Group Discussion:NSW Case Studies

FacilitatorStephen BradyDeputy Director GeneralStrategic Initiatives and PerformanceNSW Department of Premier and Cabinet

http://policytoolkit.nsw.gov.au/topic/behavioural-insights-in-action

To continue the discussion, please visit our ‘Behavioural Insights in Action’ forum:

Close

Peter AchterstraatPresident, IPAA NSWNSW Auditor General

Behavioural Insights in Action Forum

Presented by the Institute for Public Administration Australia (IPAA) and the NSW Department of Premier and Cabinet