Gamification: A New Tool for Improving the Performance of Healthcare Organizations

Healthcare organizations should be prepared to engage a new generation of workers who are accustomed to tackling challenges with a gamer’s mentality, and who may be best motivated by nonmonetary rewards of accomplishing goals within a game-like context.

Healthcare organizations’ efforts to improve processes and manage change can all too often be thwarted by legacy structures and cultures that impede the flow of information, knowledge, and expertise. Change management presents a difficult challenge where resistance is pervasive throughout the organization and business processes are intractable to change efforts.

Nonetheless, it is a generally accepted principle that employees will change their behaviors so long as they have been provided with the right incentives to do so. Identifying the most effective incentives requires creativity, and although it may seem counterintuitive, studies have shown that the best incentives are not necessarily monetary. ^a

The effectiveness of nonmonetary incentives has been demonstrated through gamification, a new management tool that has been gaining momentum across various industries in recent years. Gamification is a means of engaging employees in the organization’s performance improvement and cost reduction efforts by appealing to their inner motivations to accomplish goals and objectives that do not involve monetary rewards.

The term gamification can be defined as the use of game elements in any context that is not game-related, where users are encouraged to interact with learning material and usually are provided with rewards for accomplishments. Although the term is relatively new—with widespread use emerging only as recently as 2010—the underlying concept has existed for some time, and it has become increasingly touted as a potent means for shaping employees’ behaviors to boost employee morale and productivity.

Gamification accomplishes behavioral changes by tapping into the elements of human behavior in three fundamental ways—through a person’s motivations, abilities, and behavioral triggers.

All three of these elements must be addressed to change behavior, although there are trade-offs between motivations and ability levels that need to be considered. For example, an individual who has strong ability tends to require less motivation to accomplish a task, because the individual will find the task relatively easy to perform. Meanwhile, an employee who has less ability will likely require increased motivation to undertake the task because of the difficulties it presents.

Both of these, however, are not enough to entice the individual to perform an action; there must be a trigger. Simply stated, a trigger is a stimulus or prompt that gets the individual’s attention. For instance, a trigger in healthcare finance can be as simple as placing a sign with key performance indicators (KPIs) in the office that reminds individuals of the key metrics to focus on.

If gamification is applied properly, it promotes an experience that engages the user and enhances learning and creativity—two properties that are critical to improving operations.

Rationale for Using Gamification

A widely cited statistic, based on findings of a leading research scientist at Carnegie Melon University in Pittsburgh, is that many young adults in the United States will have spent more than 10,000 hours playing video games by the age of 21. ^b A whole generation of Americans has spent as much time mastering games as they have on their general education. And these younger individuals are now entering the American workforce, including the staffs of healthcare organizations. They understand games and are motivated by gaming mechanics.

Given this reality, healthcare leaders have a strong rationale for using gamification as a means to garner staff support and engagement in efforts to reduce waste and improve processes. Nonetheless, the broad adoption of gamification in health care faces a significant obstacle in the skepticism of many healthcare leaders about whether such techniques really work and their common tendency to dismiss the tool as a fad.

There is extensive literature published that counters these perceptions. For example, a recent literature review that looked at 24 empirical studies to analyze whether gamification works based on user motivation and behavioral-related outcomes found that gamification is capable of producing positive effects and benefits. ^c Another recent report points to the recent massive growth in the gamification industry, which is predicted to be worth $11.1 billion by 2020. ^d In fact, by some reports, 70 percent of Forbes Global 2000 companies have either implemented or intend to implement gamification in some form to manage performance. ^e Such reports suggest that, far from being a passing fad, gamification is well on its way to becoming standard business practice.

Components of Effective Games

To create a game that employees will find engaging and motivating, it is necessary first to understand what constitutes an effective game. The requisite elements typically begin with a story, which provides context to the game and a challenge for the user. A healthcare leader can use past patient experiences to find a compelling story that will give staff a sense of direction and enable them to know what success should look like. For instance, the storyline could be walking through the patient billing experience using real patient experiences to determine what key components should be improved.

Games also should include immediate feedback to the user, providing instant gratification for success and knowledge of failure, which in turn increases the user’s motivation to continue. An effective game instills in users senses of curiosity or problem-solving, autonomy, accomplishment, and—ultimately—mastery.

All four of these qualities were reflected in a gamification initiative undertaken at Baltimore-Washington International Airport in mid-2016. A device was introduced in the terminal that would teach hands-only CPR to people waiting for flights or simply passing through the terminal. According to the American Heart Association, more than 350,000 heart attacks occur outside of hospitals, and more than 20 percent occur in places like airports. So what better place than an airport terminal to train people in CPR? The CPR kiosk offered a five-minute lesson, followed by a practice session and a 30-second CPR test using a rubber mannequin. It also provided real-time feedback on hand placement, pressure, and rate of compressions during the lesson. What was most striking about this initiative was its popularity among travelers, who often could be seen using the teaching device.

Healthcare leaders seeking creative ways to apply gamification principles to improve employee productivity and reduce waste can take a lesson from this CPR initiative: Game mechanics motivate employees best when the focus is on a single behavior for a relatively short period of time, such as 60 to 90 days. This time frame is ideal because it allows users to focus on the issue at hand while retaining the ability to respond to other pressing needs. An example is the 90-day action plan implemented by UNC Health Care in Chapel Hill, N.C., to improve quality and measuring for excellence. ^f UNC was able to set specific goals that the team could concentrate on for 90 days to reduce average ICU length of stay by 10 percent, decrease the central line-associated bloodstream infection (CLABSI) rate per 1,000 central line-days by an additional 25 percent, and other important goals. This same approach can be used to improve net cash collection rates or lower total denial rates.

Types of Motivators

Clearly, consideration must be given to the various motivations people might have to “play the game,” because what motivates one person may not motivate another. An important preliminary step, therefore, is to identify the personality types in the department or area targeted for gamification and understand their different motivational triggers.

Amy Jo Kim, PhD, a behavioral neuroscientist, has identified four types of gaming personalities, each associated with a different motivational tendency:
^g

• Creators—individuals who are motivated by a desire to demonstrate their creativity and express who they are
• Competitors—individuals who are motivated by competition and a belief that everyone likes competition, including the idea of self-
development, where the focus is on competing with oneself and improving one’s own metrics
• Explorers—individuals who simply enjoy exploring the context of the game and discovering new worlds and areas within it, and who have a primary interest in information, access, and knowledge and, accordingly, less interest in points and leaderboards
• Collaborators—individuals who enjoy using games to socialize and win with others and being a part of something larger than themselves

Rewards and Recognitions

Again, providing a reward or recognition for successfully completing, or mastering, a game is important. Recognitions generally take the form of points, levels, achievements, missions, and leaderboards. Although most of these elements promote competition in the workforce, the initiative could instead promote collaboration by furnishing rewards to teams or units rather than to individuals. One of the inherit challenges in choosing which game components to include is the urge to design around available features instead of considering the needs of the user and the behavior that is to be encouraged or discouraged. Gamification should, first and foremost, be an engaging experience that promotes learning. Therefore, if the tools for recognition are used without considering the needs of the end-users and how they will react to each component, then the project will fail. For instance, if the goal is to work in teams, but there are competitive individuals on the team, then a leaderboard style might be the best choice.

When defining rewards, it also is important to acknowledge the distinction between intrinsic and extrinsic rewards. Intrinsic rewards appeal to the individual’s inherent desire for personal growth through the achievement of some personal goal or competence. By contrast, extrinsic rewards—such as grades, salaries, badges, and leaderboards—are externalities designed to entice individuals into a certain behavior. This distinction is important because, although gamification typically offers extrinsic rewards to encourage behavior change, engagement in the activity always must be intrinsic to avoid the risk that the employees will have no personal stake in the improvement or change activity and might actually come to object to or regret the changes made.

To ensure the gamification strategy achieves the right balance between intrinsic and extrinsic rewards, it is essential to involve the users in the design of the strategy. This involvement can be elicited through surveys, focus groups, or strategy design meetings with select individuals.

Ultimately, healthcare improvements can be achieved through a gamification initiative only if the employee users have the latitude to play, fail, and try again, which is the essence of what makes the activity of learning and improving captivating. As previously suggested, the reward shouldn’t be financial; in fact, a great reward could be to have lunch with the CFO or some other leader in the organization. Such a reward can communicate leadership’s involvement in the strategy and promote the “fun” aspect of gamification. These and other nonmonetary rewards are all too rarely used, yet they are among the most effective ways to encourage staff to try new ideas and to aspire to make effective improvements.

Implementation Recommendations

To ensure success with gamification, while avoiding its most common pitfalls, healthcare leaders should adopt the following recommendations.

Plan well before launching. As all good leaders know, planning always must precede action. Before a gamification initiative is launched, it should be well planned, with a clear understanding of the organization’s goals and objectives for pursuing the initiative. Leaders should think carefully about the company’s culture and determine whether gamification is appropriate and the organization’s staff is ready for such an innovative approach. Careful planning is required to maximize the full effects of gamification and ensure that the motivating concepts enhance work and do not simply force employees to do something they despise.

Identify specific behaviors targeted for improvement. Another area of focus should be the behaviors the organization is trying to change or encourage. Leaders should identify the triggers and activities that gamification could potentially promote. For example, a hospital’s wellness program could encourage employees to take more steps throughout the day by using pedometers to track steps, thereby utilizing gamification to promote wellness.

Allow the initiative to evolve, and ensure its fairness. To promote continuous employee engagement, and prevent employees from becoming bored with the game, rewards should be changed occasionally. The initiative also should be fair and should not “game” the workers. For example, an initiative should not manipulate employees’ liberty to choose to participate by docking workers’ pay if they do not perform a task. Remember, gamification should never be punitive in nature. Gamification works because it encourages employees to change behaviors, so organizations should be careful not to exploit workers when designing games.

Keep the game’s level of sophistication high. Even though the underlying gamification concepts may be simple—e.g., measure behavior, set milestone goals, visualize accomplishments—the actual initiative should not look like a child’s game. It should have a professional look and tone, with extra effort taken to ensure that its underlying rationale is clearly communicated.

Recognize accomplishments. Any time an individual reaches a designated milestone, that accomplishment should be recognized and communicated to all stakeholders, including how long it took to reach it and (if possible) the value achieved.

Ensure the right motivators are used for the right set of employees. As was described earlier, individuals generally fall within one of the four categories of gamers. It’s important to understand that using the wrong motivator can cause an employee to lose any motivation to participate in the initiative. For instance, points and badges tend to be most valued by creator and competitor personality types, and not so much by collaborators or explorers. Therefore, if the game requires high-achievement to succeed, it may be off-putting to the socializers in the group.

There also is a fine line between managing and micromanaging. When games become laborious to maintain, or statistics are tracked on too many items, it can seem that management is simply trying to track and control individuals, rather than promoting enhanced behavior.

Case Example: Application of Gamification in Health Care

A healthcare organization recently employed a gamification strategy when it implemented a new instrument-tracking system within its surgical sterile-processing department. A component of this project required relabeling trays with a special barcode that the system could read. This task involves a completely manual, labor-intensive process, which, if not done correctly, would result in wasted resources and rework. However, by gamifying the process, leaders were able to ensure that employees were fully engaged and attuned to the minutiae of their work.

At the end of each project period, employees were scored on the numbers of trays they labeled accurately, and the employee who labeled the most trays received a gift certificate redeemable at the hospital gift shop and coffee with the department director. The project clearly appealed to users exhibiting competitive personalities, but the recognition, intricacy of the process, and sense of being part of a team effort also appealed to users with other personality types.

An important feature of the game was the inclusion of a system for tracking the users who labeled trays, allowing the supervisor to determine who labeled which trays and the individuals’ accuracy ratios, and creating a trail of accountability if something went wrong.

Other areas that are conducive to gamification include supply chain management and patient and staff scheduling. In the supply chain, the focus might be on utility items, where the gamification objective would be to lower costs by reducing printing, electricity use, and software licensing. In patient scheduling, staff could be rewarded for their ability to reduce time between patient appointments. Without sacrificing the patient experience or accuracy, game dynamics can build awareness that staff must keep patient care process moving. And regarding staff scheduling, gamification can focus on right-sizing staffing to meet shifting requirements based on various factors.

A Promising New Tool for Promoting Change

Gamification is being hailed as a new tool in a healthcare leader’s toolbox that can assist in improving employee engagement and productivity and ultimately lead to waste and cost reductions. Any organization that is contemplating implementing gamification should, at a minimum, understand the expectations and preferences of the staff it intends to engage, recognize the behaviors and waste it wishes to change, understand what motivates each staff member at an individual level, and define how success will be measured.

Gamification should not be seen as a panacea, and like most improvement tools, the effectiveness of the results rests largely on how it is implemented. The long term benefits of gamification remain to be seen, and only time can tell whether desirable behavior changes that are achieved through its early application in health care will be sustainable over the long term. Yet there are compelling reasons to believe gamification can positively transform organizations, and as organizations throughout the country begin to implement gamification techniques, the body of evidence to support this belief will grow. At the very least, therefore, healthcare finance leaders should monitor trends in the use of gamification in health care and stay attuned to developments, including promising applications that could benefit their own organizations. The conversation has only just begun.

---

Brian D. Washburn, MHA, PMP, LSSBB, 
is a health systems engineer, Mayo Clinic, Rochester, Minn.

Footnotes

a. Williams, R., “Why Financial Incentives Don’t Improve Performance,” Psychology Today, Nov. 28, 2015.

b. See, “Luis van Ahn: Games With a Purpose,” CITP Lecture Series, Princeton University, Center for Information Technology Policy, Oct. 8, 2008.

c. Hamari, J., Koivisto, J., Sarsa, H., “Does Gamification Work? A Literature Review of Empirical Studies on Gamification,” Proceedings of the 47th Hawaii International Conference on System Sciences, Jan. 6-9, 2014.  

d. Markets qand Markets, Gamification Market by Solution (Consumer driven and Enterprise driven), Applications (Sales and Marketing), Deployment Type (On-Premises and Cloud), User Type (Large Enterprise, SMBs), Industry and Region—Global Forecast to 2020, February 2016.

e. Biro, M., “5 Ways Leaders Win at Gamification tTechnology,” Forbes Contributors blog, Sept. 15, 2013.

f. Institute for Healthcare Quality Improvement, UNC School of Medicine, “90-Day Action Plan (Example),” 2016.

g. Kim, A.J., “Beyond Player Types: Kim’s Social Action Matrix,” 2017, amyjokim.com.