We could use more nudges in health care. Can you think of any?

A nudge is a form of social engineering to make better choices. In the world of patient safety and medical decisions, it shares some of the concepts of  human factors engineering.

Richard Thaler and Cass Sustein may be the world’s authority on the nudge concept, and have a great book by the same name.

Nudges help people to choose their own best decisions by making the easiest, laziest choices — the defaults — also the best for the person or for society. Free will is completely preserved, but it is easiest to make the right choices.

An example of success stories includes helping people to save for retirement, increasing organ donation status for people who want to be organ donors, and healthier food choices by school kids in their cafeterias — even when the unhealthy choices were still readily available.

When I was in Stockholm earlier this year, I noticed some very effective nudges to conserve energy in my hotel. As an example, check out the hotel card key holder.


Conveniently mounted on the wall, just inside the door to the room, it serves a second purpose. The key must be inserted in order for the lights to turn on. While I’m in my room, I can have all of the lights on, or some, or none — just like an ordinary hotel room. But when I leave, and grab my keycard (no more searching!) on the way out, any lights I happen to leave on simply turn off.

Seems simple, but image the cumulative impact.  Most of a traveler’s day is likely spent outside of the hotel room, with no need to leave the lights on.  Most of the evening, lights will be off for sleeping.  The electricity wasted on a just a few lights —  all day every day in thousands of hotel rooms — really adds up.

Importantly, note that this setup gives me, the customer, a series of conveniences and benefits rather than burden and extra steps. I don’t have to manually turn off the lights when I leave, if I wish to be conscientious of energy conservation. I can have my desired lights turn on all at once immediately upon my return, instead of doing it myself one by one. I never have to spend any time searching for the key. I don’t have to check my bag, wallet, or travel partner on the way out. (“Do you have the key?”)

Also, there’s a big button just below the keycard holder (not shown in this photo).  With a simple press, I can override the function of the holder.  So if I really want to leave the lights on while I’m gone, I can.  Freedom of choice!

This is in contrast, of course, to the typical “help us conserve water by declining housekeeping” approach, which is essentially asking the customer to give up a level of service and comfort in order to be environmentally helpful.

Another contrast is the nudge #fail.  Here’s something you’ve likely seen in a public restroom.  The idea is to conserve water.  First, note that so much explanation is needed for this: the bright green handle, the arrows next to it, and the dissertation on proper use that I inset for ease of viewing but that normally is on the inside stall wall, so you are facing it while you are seated.  It seems like a lot of thought went into this.


But the #fail is clear when you consider the amount of explanation necessary, and also in context of the change itself.  People have been flushing “down” forever.  But now, (based on the biological frequency of events), the desired default is “up.”  Changing a universal habit is very hard.  I’m no plumber, but I’m guessing it could have been engineered in reverse, so that flushing “down” remained the default and used less water than flushing “up.”

In health care safety, we talk about systems fixes, acknowledging that the vast majority of health care professionals are competent and careful, and intend to do their best. Yet, mistakes still slip through.

Therefore, it is logical to target the engineering of the environment and workflow, identifying safety vulnerabilities, and building in systems that make the desired safe practices also very easy to do, or impossible to avoid. This approach supports clinicians, and is not offset by red tape, production pressures, or the need for clinicians to improvise their own safety nets.

Regardless of your specialty or role, if you are a health care professional, you can probably identify some nudges that would enhance your clinical environment. Look around today and imagine the possibilities for safer, higher quality health care by implementing some nudges — simple, easy defaults that attractive to the user, and beneficial to the world at large.   I’d love to hear your ideas.

Marjorie Stiegler is an anesthesiologist who blogs at her self-titled site, Marjorie Podraza Stiegler.  She can be reached on Twitter @DrMStiegler.

Image credit: Shutterstock.com

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