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What Motivates Change?

Why It Matters

"Leaders of improvement cannot assume that the reasons they believe a change will be an improvement apply to other people and their perspectives."


Jamie Beach, Quality Data Manager at the University of Michigan Frankel Cardiovascular Center, had a problem. Staff engagement in the cardiovascular intensive care unit (CICU) scored in the bottom tier for two consecutive years, and most team members agreed that their multidisciplinary collaboration needed work. As part of a strategy to change this, Beach asked the team what mattered to them and why they chose health care as a profession.

Learning that they shared much in common (including their commitment to their patients) led to greater camaraderie. This opened the door to honest conversations about daily challenges and willingness to test systemic improvements. Tapping into their fundamental reasons — or intrinsic motivations — for wanting to continuously improve patient care helped them develop more effective collaboration and increased joy in work.

Tapping into intrinsic motivation is key to driving change, but how do you do it? The following excerpt from the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper explores the role of intrinsic motivation in improvement and how to release it.

Unleashing Intrinsic Motivation

What does it mean to unleash intrinsic motivation? Becky Margiotta and Joe McCannon, large-scale change leaders who co-founded the Billions Institute, define unleashing as “orchestrating the loss of control of people moving in the desired direction.” This involves an inherent tension of facilitating and guiding while losing control, as many people bring forward their energy and creativity to advance a shared cause.

Clinical and social psychologists Richard Ryan and Edward Deci define intrinsic motivation as “doing something for the inherent satisfaction that engaging in the activity provides.” (In contrast, extrinsic motivation means doing something because it leads to a separate outcome like reward, recognition, or avoidance of punishment.) Put together, unleashing intrinsic motivation means creating the conditions for many people to carry forward a shared cause on the basis of the inherent value that one experiences in the activity.

W. Edwards Deming likewise believed that improvers must move from systems driven by fear and extrinsic motivation to those driven by intrinsic motivation. Influenced by Alfie Kohn, author of Punished by Rewards, Deming rejected management by carrot-and-stick rewards, as well as other common practices such as quotas and merit ratings, which seek to affix blame and reward to individuals. In their place, Deming focused on motivations that arise from an environment of trust, relationships, interdependence, and pride in work.

Deming understood what psychologists Deci and Ryan and social scientists Richard Hackman and Greg Oldham show: intrinsic motivation generates creativity, engagement, adaptive learning, and achievement. Hackman and Oldham demonstrate that tasks designed to draw on intrinsic sources of motivation produce greater commitment than those associated with extrinsic rewards. The conditions for motivational task design include an experience of meaningfulness (the task is important to the overarching purpose), responsibility (how well the task gets done is up to me), and results (as I do the work, I can see whether or not I am doing it well). These intrinsic motivators are generative and sustainable sources of commitment for advancing and sustaining improvement.

To unleash intrinsic motivation, it is important for improvers to understand what matters to other people — individually, as related to the people they care about, and across society as a whole. When what matters to people is embraced and honored as part of the improvement work, it limits the fears associated with change because people are more likely to see and experience the fundamental value of change. In a 2012 article, Michael Barry and Susan Edgman-Levitan introduced the idea of asking patients, “What matters to you?” as well as, “What is the matter?” in the context of implementing shared decision making. Their ambition was to increase clinicians’ awareness of important issues in patients’ lives that could drive customized plans of care. Maureen Bisognano, IHI President Emerita and a champion of the “What matters to you?” concept in health care, argues that eliciting a patient’s goals, preferences, hopes, and dreams is essential to flip the focus from treating disease to co-producing health because it activates people’s intrinsic motivations for being healthy.

The same lesson applies in improvement work. Leaders of improvement cannot assume that the reasons they believe a change will be an improvement apply to other people and their perspectives. Instead, improvement leaders can ask each member of an improvement effort what matters to them so that those affected by the change can articulate why the change is, or is not, valuable from their perspective. The leader’s task is not to judge the source of the motivation, but rather to enable people to access this motivation, over and over, to advance and sustain improvement.

To learn more about the psychology of change methodology, read the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper.