ORIGINAL ARTICLE
Gamification as a strategy to engage and motivate clinicians to improve care Shari McKeown, RRT, MA1,2; Christina Krause, MSc1,3; Meher Shergill, RD, MHA1; Andrew Siu, BMgmt, BDes1; and David Sweet, MD FRCP(C)1,3,4
Healthcare Management Forum 1-7 ª 2016 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415626528 hmf.sagepub.com
Abstract Approaching change through seeking commitment rather than requiring compliance is an effective way to promote desired behaviours in healthcare. Gamification was explored as a technique to engage clinicians in the adoption of sepsis identification and management tools. Positive extrinsic (eg, feedback and rewards) and intrinsic (eg, mastery, autonomy, relatedness, and purpose) motivators were integrated into a campaign to save lives, leading to a significant reduction in severe sepsis mortality and improvement in processes of care.
Introduction Motivating and engaging clinicians to adopt new evidenceinformed guidelines is an ongoing challenge in healthcare.1 Evidence has shown that a commitment-based, intrinsically motivated approach to change is more successful and sustained over time than a compliance-based (eg, mandated) approach.2,3 Self-determination theory outlines key design elements that lead to intrinsically motivated (eg, values based) behaviour. When our actions are fully connected to our core values and occur of our own volition, they are more likely to continue when extrinsic motivators (eg, accountability targets) are removed. These design strategies include building competence, providing for autonomy, and encouraging a sense of relatedness.4 A sense of purpose or meaning has also been described as a factor leading to lasting commitment when adopting new behaviours.5 Figure 1 depicts a conceptual model of extrinsic and intrinsic motivators and provides examples for each. Amotivation: Unwillingness to engage in the desired behaviour, for example, ‘‘I will not exercise.’’ External regulation: Engaging in the behaviour to satisfy external pressures, avoid negative consequences, or receive praise/rewards, for example, ‘‘I will exercise if you pay me.’’ Introjection: Engaging in the behaviour to avoid guilt, gain status, or build self-esteem, for example, ‘‘I’ll exercise because my friends do it.’’ Identification: Engaging in the behaviour to achieve personally valued outcomes, for example, ‘‘I’ll exercise to stay healthy.’’ Integration: Engaging in the behaviour because it is congruent with your sense of self, for example, ‘‘I’ll exercise because I’m an athlete, it’s who I am.’’ Intrinsic motivation: Engaging in the behaviour because it is inherently pleasurable to do so, for example, ‘‘I’ll exercise because . . . I enjoy spending time with friends/I can choose my own activity/I enjoy improving my performance/It gives me meaning and purpose in my life.’’
Gamification (the use of game elements and design in nongaming contexts)6 is receiving worldwide attention across many sectors as a powerful technique to promote engagement and motivation. Its use in private industries and academic contexts is well described,7-12 and it has shown to be effective in motivating adults or children towards personal health and wellness.13,14 While ‘‘serious games’’ (full-fledged games used for a non-entertainment purpose)6 have been used to enhance learning in medical contexts,15,16 use of gamification (application of game design and elements) as a clinical engagement strategy in health quality improvement initiatives is less explored. Game elements that can be applied include overall game dynamics (big-picture aspects of the design), game mechanics (the processes by which the action is driven forward), specific components (tangible manifestations of the dynamics and mechanics), and aesthetics (design that evokes desirable emotional responses in a player).17 We believe that the application of game design to an improvement initiative provides a unique opportunity to build in aspects of extrinsic motivators (feedback, rewards) and intrinsic motivators (competence, autonomy, relatedness, and purpose) to promote positive changes in behaviour leading to improvement in quality of care. In February 2009, the British Columbia Ministry of Health mandated Clinical Care Management—the implementation and standardization of evidence-based guidelines in nine highpriority clinical areas, including sepsis, as part of the province’s Innovation and Change Agenda to improve health 1 2 3 4
BC Patient Safety & Quality Council, Vancouver, British Columbia, Canada. Thompson Rivers University, Kamloops, British Columbia, Canada. University of British Columbia, Vancouver, British Columbia, Canada. Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.
Corresponding author: Christina Krause, Vancouver, British Columbia, Canada. E-mail: [email protected]
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Figure 1. Self-determination theory and motivators for change (adapted from Ryan & Deci,4 with the addition of purpose5 as an intrinsic motivator)
outcomes.18 All acute care hospitals with Emergency Departments (EDs) receiving over 10,000 visits per year (57 in total) were required to submit sepsis process and outcome data for accountability. The British Columbia Patient Safety & Quality Council (BCPSQC) was tasked with supporting province-wide change management and implementation. Sepsis identification and management tools have been shown to be an effective way to reduce mortality and morbidity from sepsis19—a disorder that has one of the highest in-hospital mortality rates in Canada.20 Despite widespread distribution of protocols across British Columbia, provincial mortality rates for severe sepsis averaged 20%, and patients were receiving appropriate therapy less than 30% of the time (British Columbia Ministry of Health, unpublished data). In 2012, the BCPSQC brought over 50 frontline ED physicians and nurses together to form the British Columbia Sepsis Network. Together, the network members co-created a vision to reduce mortality and morbidity for patients with sepsis and adopted the British Columbia Sepsis Guidelines as the evidenceinformed standard of care in the province. In 2013, the BCPSQC created a provincial sepsis campaign incorporating gamification, with a belief that it could be an effective way to increase uptake of sepsis protocols in EDs.
Methods The number of affected patients presenting to the province’s EDs within a 5-month period was estimated and used to set a
provincial goal of achieving protocolized care for 750 patients. Working from the ‘‘number needed to treat’’ (an epidemiological measure used to assess effectiveness of health interventions) ratio of 1 life saved for every 5 protocols used for severe sepsis and septic shock,21 this translated to saving 150 ‘‘lives.’’ The 150 Lives in 150 Days campaign was announced on World Sepsis Day (September 13, 2013). The campaign was promoted through the British Columbia Sepsis Network, the BCPSQC newsletter and web site, and through communications leaders within the six regional health authorities of British Columbia. Interest was predicted from approximately 10 of the local EDs, but the actual response was surprising; 32 multidisciplinary teams (31 EDs and 1 team from an intensive care unit) voluntarily joined the campaign, representing more than half of the 57 EDs (with >10,000 visits per year) in the province. Any clinician working in an ED could sign up a team and identify a team leader through a web-based form. The prerequisite to participate involved setting up a local sepsis protocol based on the British Columbia Sepsis Guidelines algorithm. Once teams had joined the campaign, they were ready to ‘‘play.’’ A measurement system was devised to provide three options for data collection. Data could be entered directly on the BCPSQC web site, through an ‘‘app’’ (a mobile-friendly web page that functioned as an app when saved on the desktop of a smartphone), or on paper forms posted in the ED by the team leader. Clinicians were asked to enter minimal data for each patient with sepsis (date, lactate 4 mmol/L, systolic blood
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McKeown, Krause, Shergill, Siu and Sweet
Figure 2. Sample of customized infographic provided to sites
pressure < 90 mm Hg, whether or not a sepsis protocol had been used, and their name). At the same time, they were asked to drop a copy of the patient’s label into a box (called a ‘‘Box Full of Lives’’) set up by their team leader in their ED. Each week, the team leader was asked to review their team’s cases and compare entries against the patient labels to ensure no duplicates, thereby maintaining a sense of fairness in the ‘‘game’’. Between the campaign announcement and the start date, there was approximately 30 days for teams to sign up and prepare to take part. During this time, resources were provided including sepsis awareness posters, a guide to prepare team leaders for their role, a label to use on their Box Full of Lives, instructions to install the data collection app on various mobile device models, a common hashtag for tweeting about the campaign (#150 Lives), e-mail drafts to invite their colleagues to join, paper entry forms, a guide to improving sepsis care, access to key sepsis literature promoted through a knowledge translation app, and a laminated copy of the British Columbia Sepsis Guidelines Algorithm.
3 Elements of game design were incorporated throughout the campaign. Dynamics included the narrative or story, the design for progression through the game, and the constraints around the gameplay. Mechanics included challenges, competition, feedback loops, transactions, and time pressure. Components included points, badges, leaderboards, quests, and social networking. Aesthetics were designed to evoke feelings of triumph, mastery, camaraderie, and compassion. Communication styles and graphics used in the campaign were designed to be simple, playful, cheeky, and fun, adding to the game-like ambience. The web site (www.150Lives.ca) was designed to include a prominently featured countdown clock, which was changed daily to count up the lives saved and count down the days left in the campaign. This added to the sense of urgency within the game and provided a visual cue for provincial progress. Feedback in the form of tweets, e-mails, newsletters, and phone calls was provided weekly and monthly to individuals and teams to enhance engagement and provide encouragement. Virtual learning opportunities were hosted several times during the campaign to educate and promote best practices. Virtual badges were provided to all participants who entered sepsis cases. A provincial on-line learning module was created to support nurse education during and after the campaign. At the conclusion of the campaign, prizes were announced and awarded. The individual champions and winning teams from each region who entered the most cases (averaged against the number of ED admissions) were awarded with a pizza party and a plaque to display in their EDs. Prizes were also given for teams with the most creativity and engagement evidenced through photos, tweets, quotes, or stories during the campaign. Recognition for each team was displayed on the BCPSQC web site, and each team received a customized infographic of the results to display at their site (Figure 2).
Results Within 150 days between October 2013 and March 2014, 997 patients were screened for sepsis as part of the campaign. Seven hundred and fifty-six evidence-informed protocols were used for severe sepsis or septic shock, translating to 151 lives ‘‘saved.’’ Eight hundred and seven clinicians registered for the sepsis e-learning module and 495 completed it. Two thousand six hundred and fifty-nine clinicians (primarily ED physicians, residents, and medical students) viewed the key sepsis literature promoted through the knowledge translation app. The British Columbia Sepsis Network grew by 52% to 204 participants by the end of the 150 days. Although common provincial metrics for accountability had been mandated by the Ministry prior to the campaign, retrospective sepsis data were routinely collected only within one health authority where data were available electronically. This region experienced a significant reduction in mortality (Figure 3) corresponding with the dates of the campaign and sustained for several periods afterwards. The average mortality
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Figure 3. In-hospital mortality rate of patients investigated for severe sepsis in Fraser Health Authority’s emergency departments
Figure 4. Percentage of patients with severe sepsis in Fraser Health Authority’s emergency departments with appropriate lactate measurement by time goal specified in the British Columbia Sepsis Guidelines
for severe sepsis during this period was 6.4% (n ¼ 436) when compared to 21.1% (n ¼ 627) in prior periods. The same region showed a significant improvement in lactate measurement by time goal (Figure 4) during the period of the campaign (an average of 16.0% [n ¼ 326], when compared
to the average in prior periods of 5.5% [n ¼ 818]). These results appear to have been sustained for over a year beyond the end of the campaign. This region had no significant changes in their other sepsis process metrics (percentage of ED patients with sepsis having antibiotics received by time goal; percentage of
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McKeown, Krause, Shergill, Siu and Sweet ED patients with sepsis having blood cultures taken before antibiotics are started; and percentage of ED patients with sepsis having second liter of fluid received by time goal).
Discussion Although collection of provincial sepsis outcome and process metrics had been identified prior to the campaign launch, retrospective data collection required significant resources, and most health authorities were unable to comply with the British Columbia Ministry of Health’s request for data collection. Fraser Health Authority was an exception, as their clinical information systems provided an ability to screen for sepsis indicators electronically. Their participation in the campaign proved effective in improving patient outcomes and processes for sepsis, where a mandated approach had failed; in the 17 months prior to the launch of the campaign, there had been no significant improvement seen in their data. Process metrics for time to lactate measurement were sustained for over a year following the campaign, although the other timed process metrics included in sepsis treatment patterns did not show similar improvement. There may have been a greater focus by improvement teams on increasing the speed of lactate testing than on other sepsis therapies. Although the reduction in severe sepsis mortality did not show significantly sustained improvement after the campaign, the average mortality remained lower than it was before the campaign was announced. In contrast with the provincially mandated, retrospective data collected for accountability in the Clinical Care Management initiative, the 150 Lives campaign allowed for realtime, point-of-care data collected by clinicians for local quality improvement. We used a voluntary, grassroots, values-based approach to build commitment and motivation for improving care rather than a top-down, performance-monitoring approach requiring compliance to a process. The use of gamification provided an effective way to foster strong engagement and incorporate positive extrinsic and intrinsic motivators. Use of extrinsic motivators has been described as operant conditioning, where positive or negative reinforcement is used to promote desired behaviour.22 Negative feedback (sometimes called ‘‘shamefication’’)23 is a technique used in some gamified processes to prompt the user to make certain choices based on unfavourable consequences. We chose to use only positive reinforcement, as we felt clinicians would be more likely to stay engaged if we added to their feelings of self-worth. Although positive feedback and rewards were an important part of this campaign, we were conscious of a consideration in the use of incentives. The ‘‘over-justification effect’’ has been well-described in literature and occurs when external motivators are offered for performing a task.24 Over time, these extrinsic rewards can replace intrinsic motivation, and when the external stimulus is removed, the task is no longer performed by the individual as their primary motivation to continue has ceased. With that consideration, we worked to incorporate intrinsic motivators (mastery, autonomy,
5 relatedness, and purpose) so that the desired behaviour might continue once the campaign ended. Competence or mastery was built into the campaign through the provision of education around sepsis protocols. An interactive provincial e-learning module was made available for all participants at the start of the campaign. This free module focused on early recognition and treatment of sepsis. It included an invitation to join the British Columbia Sepsis Network and promoted the use of the British Columbia Sepsis Guidelines. Additional education was provided in the form of a British Columbia Sepsis Guide, which contained a driver diagram with change ideas for aiding implementation of a sepsis protocol. In addition, virtual learning sessions with key sepsis experts were hosted monthly through the campaign and recorded for later viewing. Competence was also gained through the repeated use of sepsis screening and protocols throughout the campaign, and the rewards given were contingent on this performance. Participants were offered choice and autonomy throughout the voluntary campaign. For example, they could choose to either enter protocols on-line directly through our web site (an option some preferred to do at the end of their shift), through a mobile app (useful for those who wanted to use digital entries at the point of care), or by writing on a paper entry form posted in their ED. Choices were also offered in how the campaign was promoted internally by the team leads; we provided them with a template e-mail and letter as well as posters to spread the word to their colleagues in a way that fit with their internal communication styles. Most importantly, we provided the British Columbia Sepsis Guidelines as an algorithm with key, evidence-informed steps but left the development and implementation of the sepsis protocols up to the sites, so they could create something that fit within their local context and culture. Relatedness was incorporated by promoting the growth of the British Columbia Sepsis Network through the campaign. Although most of the team leaders who signed up for the campaign were already members of the network, many clinicians who joined the 150 Lives teams were not. Joining the network connected them to other peers who were interested in improving sepsis care, and there were opportunities to share protocols and innovative strategies to further their local improvement efforts. Announcing the campaign on World Sepsis Day linked the British Columbia Sepsis Network with global citizens working to decrease sepsis mortality. Providing a compelling social norm promoted solidarity over isolation and may have influenced individuals to conform to group expectations.25 Providing participants with a sense of purpose was accomplished through the narrative of saving 150 lives. By aligning this narrative with the vision co-created by British Columbia Sepsis Network, we were able to connect our activities to something that we knew was meaningful to the clinicians and connected to their internal values. Setting a provincial goal to which all teams contributed created a shared purpose, and the alignment with World Sepsis Day connected our provincial efforts to a greater need.
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Given the pathophysiology of sepsis and the potential for its devastating consequences in the lives of patients and their families, we were cautious about being perceived by health professionals as making light of the serious subject matter. For this reason, we kept the focus of our communication firmly on the purpose of the campaign: to save lives. Although we used elements of games in the campaign, we did not use the terminology of ‘‘games,’’ ‘‘play,’’ or ‘‘gamification’’ in our communication with clinicians. In retrospect, it would have been advantageous to have included patient representatives in the planning of this campaign. We would recommend those planning to use gamification in a health improvement context include patient representatives from the outset to provide their perspective on acceptability. Due to significant variation in case mix, population, and hospital acuity between the province’s health regions, it would be difficult to ascribe similar success in outcomes and processes outside Fraser Health Authority. Determining whether the incorporation of intrinsic motivators through this gamified health improvement initiative will result in permanent and sustained behaviour change would make for interesting further study.
Conclusion As organizations continue to strive to achieve rapid improvements in healthcare, those responsible for leading change will need to consider both intrinsic and extrinsic motivators for engagement. Gamification is a tool that provides an opportunity to incorporate both types of motivators in a health improvement context. Healthcare has been long dominated by an extrinsic motivator approach with mixed results. True engagement of all of those involved in health system improvement—patients, providers, and administrators—is required for sustained change. The use of gamification is a new opportunity for engagement and motivation that holds promise. Acknowledgments The British Columbia Patient Safety & Quality Council would like to acknowledge the British Columbia Sepsis Network and members of the 150 Lives teams for their participation in the campaign and the Fraser Health Authority for sharing their results with us for this manuscript.
References 1. Pronovost PJ. Enhancing physician’s use of clinical guidelines. JAMA. 2013;310(23):2501-2502. 2. Bevan H, Fairman S. The new era of thinking and practice in change and transformation: A call to action for leaders of health and care. National Health Service Improving Quality website; 2014. Available at: http://www.nhsiq.nhs.uk/resource-search/ publications/white-paper.aspx. Accessed September 19, 2015. 3. Dickinson H, Ham C. Engaging doctors in leadership: Review of the literature. University of Birmingham website; 2008. Available at: http://www.birmingham.ac.uk/Documents/college-socialsciences/social-policy/HSMC/research/leadership-literaturereview.pdf. Accessed September 19, 2015.
4. Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic definitions and new directions. Contemp Educ Psychol. 2000; 25(1):54-67. 5. Pink DH. Drive: The Surprising Truth about What Motivates Us. New York, NY: Riverhead Books; 2009. 6. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: Defining ‘‘gamification’’. MindTrek’11 Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments, Tampere, Finland, 2011. 7. Blohm I, Leimeister JM. Design of IT-based enhancing services for motivational support and behavioral change. Bus Inf Syst Eng. 2013;55(4):275-278. 8. Burke B. Gamify: How Gamification Motivates People to Do Extraordinary Things. Brookline, MA: Bibliometion, Inc.; 2014. 9. Dominguez A, Saenz-de-Navarrete J, de-Marcos L, FernandezSanz L, Pages C. Gamifying learning experiences: practical implications and outcomes. Comput Educ. 2013;63:380-392. 10. Sheth S, Bell J, Kaiser G. Increasing Student Engagement in Software Engineering with Gamification. New York, NY: Department of Computer Science, Columbia University; 2012. 11. Insley V, Nunan D. Gamification and the online retail experience. Int J Retail Distrib Manag. 2014;42(5):340-351. 12. Zichermann G, Linder J. The Gamification Revolution: How Leaders Leverage Game Mechanics to Crush the Competition. East Windsor, NJ: McGraw Hill Education; 2013. 13. King D, Greaves F, Exeter C, Darzi A. ‘Gamification’: Influencing health behaviours with games. J Roy Soc Med. 2013;106(3): 76-78. 14. Lin RJ, Ramakrishnan S, Chang H, Spraragen S, Zhu X. Designing a web-based behavior motivation tool for healthcare compliance. Hum Factor Ergon Man. 2013;23(1):58-67. 15. Evans KH, Daines W, Tsui J, Strehlow M, Maggio P, Shieh L. Septris: A novel, mobile, online simulation game that improves sepsis recognition and management. Acad Med. 2015;90(2): 180-184. 16. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99(10):1322-1330. 17. Werbach K. Gamification. [Recorded lecture]. Coursera: University of Pennsylvannia; 2015. 18. Innovation and change agenda: Detailed 2010-2013 health system strategy map. British Columbia, Canada: Ministry of Health. Available at: http://www.llbc.leg.bc.ca/public/pubdocs/ bcdocs2012_2/520128/the_plan_en.pdf. Accessed September 19, 2015. 19. Rivers EP. Point: Adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest. 2010;138(3):476-480. 20. Canadian Institute for Health Information. In focus: A national look at sepsis. Available at: https://secure.cihi.ca/free_products/ HSMR_Sepsis2009_e.pdf. 2009. Accessed September 19, 2015. 21. Daniels R, Nutbeam I, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: A prospective observational cohort study. Emerg Med J. 2011;28(6):507-512.
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McKeown, Krause, Shergill, Siu and Sweet 22. Skinner BF. The Behaviour of Organisms: An Experimental Analysis. New York, NY: Appleton-Century-Crofts; 1938. 23. Das R. Gamification applied to employee engagement: Is it shamefication at work? 2014. Available at: http://www.pakragames. com/plugged-in/entry/gamification-applied-to-employee-engagement-is-it-shamefication-at-work.html. Accessed September 19, 2015.
7 24. Deci EL, Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999;125(6):627-668. 25. Cialdini RB, Trost MR. Social influence: Social norms, conformity, and compliance. In: Gilbert DT, Fiske ST, Lindzey G, eds. The Handbook of Social Psychology. 4th Ed. New York, NY: Oxford University Press; 1998:151-192.
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Gamification as a strategy to engage and motivate clinicians to improve care Shari McKeown, RRT, MA1,2; Christina Krause, MSc1,3; Meher Shergill, RD, MHA1; Andrew Siu, BMgmt, BDes1; and David Sweet, MD FRCP(C)1,3,4
Healthcare Management Forum 1-7 ª 2016 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415626528 hmf.sagepub.com
Abstract Approaching change through seeking commitment rather than requiring compliance is an effective way to promote desired behaviours in healthcare. Gamification was explored as a technique to engage clinicians in the adoption of sepsis identification and management tools. Positive extrinsic (eg, feedback and rewards) and intrinsic (eg, mastery, autonomy, relatedness, and purpose) motivators were integrated into a campaign to save lives, leading to a significant reduction in severe sepsis mortality and improvement in processes of care.
Introduction Motivating and engaging clinicians to adopt new evidenceinformed guidelines is an ongoing challenge in healthcare.1 Evidence has shown that a commitment-based, intrinsically motivated approach to change is more successful and sustained over time than a compliance-based (eg, mandated) approach.2,3 Self-determination theory outlines key design elements that lead to intrinsically motivated (eg, values based) behaviour. When our actions are fully connected to our core values and occur of our own volition, they are more likely to continue when extrinsic motivators (eg, accountability targets) are removed. These design strategies include building competence, providing for autonomy, and encouraging a sense of relatedness.4 A sense of purpose or meaning has also been described as a factor leading to lasting commitment when adopting new behaviours.5 Figure 1 depicts a conceptual model of extrinsic and intrinsic motivators and provides examples for each. Amotivation: Unwillingness to engage in the desired behaviour, for example, ‘‘I will not exercise.’’ External regulation: Engaging in the behaviour to satisfy external pressures, avoid negative consequences, or receive praise/rewards, for example, ‘‘I will exercise if you pay me.’’ Introjection: Engaging in the behaviour to avoid guilt, gain status, or build self-esteem, for example, ‘‘I’ll exercise because my friends do it.’’ Identification: Engaging in the behaviour to achieve personally valued outcomes, for example, ‘‘I’ll exercise to stay healthy.’’ Integration: Engaging in the behaviour because it is congruent with your sense of self, for example, ‘‘I’ll exercise because I’m an athlete, it’s who I am.’’ Intrinsic motivation: Engaging in the behaviour because it is inherently pleasurable to do so, for example, ‘‘I’ll exercise because . . . I enjoy spending time with friends/I can choose my own activity/I enjoy improving my performance/It gives me meaning and purpose in my life.’’
Gamification (the use of game elements and design in nongaming contexts)6 is receiving worldwide attention across many sectors as a powerful technique to promote engagement and motivation. Its use in private industries and academic contexts is well described,7-12 and it has shown to be effective in motivating adults or children towards personal health and wellness.13,14 While ‘‘serious games’’ (full-fledged games used for a non-entertainment purpose)6 have been used to enhance learning in medical contexts,15,16 use of gamification (application of game design and elements) as a clinical engagement strategy in health quality improvement initiatives is less explored. Game elements that can be applied include overall game dynamics (big-picture aspects of the design), game mechanics (the processes by which the action is driven forward), specific components (tangible manifestations of the dynamics and mechanics), and aesthetics (design that evokes desirable emotional responses in a player).17 We believe that the application of game design to an improvement initiative provides a unique opportunity to build in aspects of extrinsic motivators (feedback, rewards) and intrinsic motivators (competence, autonomy, relatedness, and purpose) to promote positive changes in behaviour leading to improvement in quality of care. In February 2009, the British Columbia Ministry of Health mandated Clinical Care Management—the implementation and standardization of evidence-based guidelines in nine highpriority clinical areas, including sepsis, as part of the province’s Innovation and Change Agenda to improve health 1 2 3 4
BC Patient Safety & Quality Council, Vancouver, British Columbia, Canada. Thompson Rivers University, Kamloops, British Columbia, Canada. University of British Columbia, Vancouver, British Columbia, Canada. Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada.
Corresponding author: Christina Krause, Vancouver, British Columbia, Canada. E-mail: [email protected]
Downloaded from hmf.sagepub.com at Bobst Library, New York University on February 16, 2016
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Figure 1. Self-determination theory and motivators for change (adapted from Ryan & Deci,4 with the addition of purpose5 as an intrinsic motivator)
outcomes.18 All acute care hospitals with Emergency Departments (EDs) receiving over 10,000 visits per year (57 in total) were required to submit sepsis process and outcome data for accountability. The British Columbia Patient Safety & Quality Council (BCPSQC) was tasked with supporting province-wide change management and implementation. Sepsis identification and management tools have been shown to be an effective way to reduce mortality and morbidity from sepsis19—a disorder that has one of the highest in-hospital mortality rates in Canada.20 Despite widespread distribution of protocols across British Columbia, provincial mortality rates for severe sepsis averaged 20%, and patients were receiving appropriate therapy less than 30% of the time (British Columbia Ministry of Health, unpublished data). In 2012, the BCPSQC brought over 50 frontline ED physicians and nurses together to form the British Columbia Sepsis Network. Together, the network members co-created a vision to reduce mortality and morbidity for patients with sepsis and adopted the British Columbia Sepsis Guidelines as the evidenceinformed standard of care in the province. In 2013, the BCPSQC created a provincial sepsis campaign incorporating gamification, with a belief that it could be an effective way to increase uptake of sepsis protocols in EDs.
Methods The number of affected patients presenting to the province’s EDs within a 5-month period was estimated and used to set a
provincial goal of achieving protocolized care for 750 patients. Working from the ‘‘number needed to treat’’ (an epidemiological measure used to assess effectiveness of health interventions) ratio of 1 life saved for every 5 protocols used for severe sepsis and septic shock,21 this translated to saving 150 ‘‘lives.’’ The 150 Lives in 150 Days campaign was announced on World Sepsis Day (September 13, 2013). The campaign was promoted through the British Columbia Sepsis Network, the BCPSQC newsletter and web site, and through communications leaders within the six regional health authorities of British Columbia. Interest was predicted from approximately 10 of the local EDs, but the actual response was surprising; 32 multidisciplinary teams (31 EDs and 1 team from an intensive care unit) voluntarily joined the campaign, representing more than half of the 57 EDs (with >10,000 visits per year) in the province. Any clinician working in an ED could sign up a team and identify a team leader through a web-based form. The prerequisite to participate involved setting up a local sepsis protocol based on the British Columbia Sepsis Guidelines algorithm. Once teams had joined the campaign, they were ready to ‘‘play.’’ A measurement system was devised to provide three options for data collection. Data could be entered directly on the BCPSQC web site, through an ‘‘app’’ (a mobile-friendly web page that functioned as an app when saved on the desktop of a smartphone), or on paper forms posted in the ED by the team leader. Clinicians were asked to enter minimal data for each patient with sepsis (date, lactate 4 mmol/L, systolic blood
Downloaded from hmf.sagepub.com at Bobst Library, New York University on February 16, 2016
McKeown, Krause, Shergill, Siu and Sweet
Figure 2. Sample of customized infographic provided to sites
pressure < 90 mm Hg, whether or not a sepsis protocol had been used, and their name). At the same time, they were asked to drop a copy of the patient’s label into a box (called a ‘‘Box Full of Lives’’) set up by their team leader in their ED. Each week, the team leader was asked to review their team’s cases and compare entries against the patient labels to ensure no duplicates, thereby maintaining a sense of fairness in the ‘‘game’’. Between the campaign announcement and the start date, there was approximately 30 days for teams to sign up and prepare to take part. During this time, resources were provided including sepsis awareness posters, a guide to prepare team leaders for their role, a label to use on their Box Full of Lives, instructions to install the data collection app on various mobile device models, a common hashtag for tweeting about the campaign (#150 Lives), e-mail drafts to invite their colleagues to join, paper entry forms, a guide to improving sepsis care, access to key sepsis literature promoted through a knowledge translation app, and a laminated copy of the British Columbia Sepsis Guidelines Algorithm.
3 Elements of game design were incorporated throughout the campaign. Dynamics included the narrative or story, the design for progression through the game, and the constraints around the gameplay. Mechanics included challenges, competition, feedback loops, transactions, and time pressure. Components included points, badges, leaderboards, quests, and social networking. Aesthetics were designed to evoke feelings of triumph, mastery, camaraderie, and compassion. Communication styles and graphics used in the campaign were designed to be simple, playful, cheeky, and fun, adding to the game-like ambience. The web site (www.150Lives.ca) was designed to include a prominently featured countdown clock, which was changed daily to count up the lives saved and count down the days left in the campaign. This added to the sense of urgency within the game and provided a visual cue for provincial progress. Feedback in the form of tweets, e-mails, newsletters, and phone calls was provided weekly and monthly to individuals and teams to enhance engagement and provide encouragement. Virtual learning opportunities were hosted several times during the campaign to educate and promote best practices. Virtual badges were provided to all participants who entered sepsis cases. A provincial on-line learning module was created to support nurse education during and after the campaign. At the conclusion of the campaign, prizes were announced and awarded. The individual champions and winning teams from each region who entered the most cases (averaged against the number of ED admissions) were awarded with a pizza party and a plaque to display in their EDs. Prizes were also given for teams with the most creativity and engagement evidenced through photos, tweets, quotes, or stories during the campaign. Recognition for each team was displayed on the BCPSQC web site, and each team received a customized infographic of the results to display at their site (Figure 2).
Results Within 150 days between October 2013 and March 2014, 997 patients were screened for sepsis as part of the campaign. Seven hundred and fifty-six evidence-informed protocols were used for severe sepsis or septic shock, translating to 151 lives ‘‘saved.’’ Eight hundred and seven clinicians registered for the sepsis e-learning module and 495 completed it. Two thousand six hundred and fifty-nine clinicians (primarily ED physicians, residents, and medical students) viewed the key sepsis literature promoted through the knowledge translation app. The British Columbia Sepsis Network grew by 52% to 204 participants by the end of the 150 days. Although common provincial metrics for accountability had been mandated by the Ministry prior to the campaign, retrospective sepsis data were routinely collected only within one health authority where data were available electronically. This region experienced a significant reduction in mortality (Figure 3) corresponding with the dates of the campaign and sustained for several periods afterwards. The average mortality
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Figure 3. In-hospital mortality rate of patients investigated for severe sepsis in Fraser Health Authority’s emergency departments
Figure 4. Percentage of patients with severe sepsis in Fraser Health Authority’s emergency departments with appropriate lactate measurement by time goal specified in the British Columbia Sepsis Guidelines
for severe sepsis during this period was 6.4% (n ¼ 436) when compared to 21.1% (n ¼ 627) in prior periods. The same region showed a significant improvement in lactate measurement by time goal (Figure 4) during the period of the campaign (an average of 16.0% [n ¼ 326], when compared
to the average in prior periods of 5.5% [n ¼ 818]). These results appear to have been sustained for over a year beyond the end of the campaign. This region had no significant changes in their other sepsis process metrics (percentage of ED patients with sepsis having antibiotics received by time goal; percentage of
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McKeown, Krause, Shergill, Siu and Sweet ED patients with sepsis having blood cultures taken before antibiotics are started; and percentage of ED patients with sepsis having second liter of fluid received by time goal).
Discussion Although collection of provincial sepsis outcome and process metrics had been identified prior to the campaign launch, retrospective data collection required significant resources, and most health authorities were unable to comply with the British Columbia Ministry of Health’s request for data collection. Fraser Health Authority was an exception, as their clinical information systems provided an ability to screen for sepsis indicators electronically. Their participation in the campaign proved effective in improving patient outcomes and processes for sepsis, where a mandated approach had failed; in the 17 months prior to the launch of the campaign, there had been no significant improvement seen in their data. Process metrics for time to lactate measurement were sustained for over a year following the campaign, although the other timed process metrics included in sepsis treatment patterns did not show similar improvement. There may have been a greater focus by improvement teams on increasing the speed of lactate testing than on other sepsis therapies. Although the reduction in severe sepsis mortality did not show significantly sustained improvement after the campaign, the average mortality remained lower than it was before the campaign was announced. In contrast with the provincially mandated, retrospective data collected for accountability in the Clinical Care Management initiative, the 150 Lives campaign allowed for realtime, point-of-care data collected by clinicians for local quality improvement. We used a voluntary, grassroots, values-based approach to build commitment and motivation for improving care rather than a top-down, performance-monitoring approach requiring compliance to a process. The use of gamification provided an effective way to foster strong engagement and incorporate positive extrinsic and intrinsic motivators. Use of extrinsic motivators has been described as operant conditioning, where positive or negative reinforcement is used to promote desired behaviour.22 Negative feedback (sometimes called ‘‘shamefication’’)23 is a technique used in some gamified processes to prompt the user to make certain choices based on unfavourable consequences. We chose to use only positive reinforcement, as we felt clinicians would be more likely to stay engaged if we added to their feelings of self-worth. Although positive feedback and rewards were an important part of this campaign, we were conscious of a consideration in the use of incentives. The ‘‘over-justification effect’’ has been well-described in literature and occurs when external motivators are offered for performing a task.24 Over time, these extrinsic rewards can replace intrinsic motivation, and when the external stimulus is removed, the task is no longer performed by the individual as their primary motivation to continue has ceased. With that consideration, we worked to incorporate intrinsic motivators (mastery, autonomy,
5 relatedness, and purpose) so that the desired behaviour might continue once the campaign ended. Competence or mastery was built into the campaign through the provision of education around sepsis protocols. An interactive provincial e-learning module was made available for all participants at the start of the campaign. This free module focused on early recognition and treatment of sepsis. It included an invitation to join the British Columbia Sepsis Network and promoted the use of the British Columbia Sepsis Guidelines. Additional education was provided in the form of a British Columbia Sepsis Guide, which contained a driver diagram with change ideas for aiding implementation of a sepsis protocol. In addition, virtual learning sessions with key sepsis experts were hosted monthly through the campaign and recorded for later viewing. Competence was also gained through the repeated use of sepsis screening and protocols throughout the campaign, and the rewards given were contingent on this performance. Participants were offered choice and autonomy throughout the voluntary campaign. For example, they could choose to either enter protocols on-line directly through our web site (an option some preferred to do at the end of their shift), through a mobile app (useful for those who wanted to use digital entries at the point of care), or by writing on a paper entry form posted in their ED. Choices were also offered in how the campaign was promoted internally by the team leads; we provided them with a template e-mail and letter as well as posters to spread the word to their colleagues in a way that fit with their internal communication styles. Most importantly, we provided the British Columbia Sepsis Guidelines as an algorithm with key, evidence-informed steps but left the development and implementation of the sepsis protocols up to the sites, so they could create something that fit within their local context and culture. Relatedness was incorporated by promoting the growth of the British Columbia Sepsis Network through the campaign. Although most of the team leaders who signed up for the campaign were already members of the network, many clinicians who joined the 150 Lives teams were not. Joining the network connected them to other peers who were interested in improving sepsis care, and there were opportunities to share protocols and innovative strategies to further their local improvement efforts. Announcing the campaign on World Sepsis Day linked the British Columbia Sepsis Network with global citizens working to decrease sepsis mortality. Providing a compelling social norm promoted solidarity over isolation and may have influenced individuals to conform to group expectations.25 Providing participants with a sense of purpose was accomplished through the narrative of saving 150 lives. By aligning this narrative with the vision co-created by British Columbia Sepsis Network, we were able to connect our activities to something that we knew was meaningful to the clinicians and connected to their internal values. Setting a provincial goal to which all teams contributed created a shared purpose, and the alignment with World Sepsis Day connected our provincial efforts to a greater need.
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Given the pathophysiology of sepsis and the potential for its devastating consequences in the lives of patients and their families, we were cautious about being perceived by health professionals as making light of the serious subject matter. For this reason, we kept the focus of our communication firmly on the purpose of the campaign: to save lives. Although we used elements of games in the campaign, we did not use the terminology of ‘‘games,’’ ‘‘play,’’ or ‘‘gamification’’ in our communication with clinicians. In retrospect, it would have been advantageous to have included patient representatives in the planning of this campaign. We would recommend those planning to use gamification in a health improvement context include patient representatives from the outset to provide their perspective on acceptability. Due to significant variation in case mix, population, and hospital acuity between the province’s health regions, it would be difficult to ascribe similar success in outcomes and processes outside Fraser Health Authority. Determining whether the incorporation of intrinsic motivators through this gamified health improvement initiative will result in permanent and sustained behaviour change would make for interesting further study.
Conclusion As organizations continue to strive to achieve rapid improvements in healthcare, those responsible for leading change will need to consider both intrinsic and extrinsic motivators for engagement. Gamification is a tool that provides an opportunity to incorporate both types of motivators in a health improvement context. Healthcare has been long dominated by an extrinsic motivator approach with mixed results. True engagement of all of those involved in health system improvement—patients, providers, and administrators—is required for sustained change. The use of gamification is a new opportunity for engagement and motivation that holds promise. Acknowledgments The British Columbia Patient Safety & Quality Council would like to acknowledge the British Columbia Sepsis Network and members of the 150 Lives teams for their participation in the campaign and the Fraser Health Authority for sharing their results with us for this manuscript.
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