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objective of OBM is the institutionalization of contingencies needed to support the desired 5 behavior in the absence of intervention agents.29, 30 Ideally, the intervention techniques become part of the organization’s day-to-day practices. Several factors are critical for behavioral maintenance, including: a) educating and training; b) involving indigenous personnel in customizing and delivering an intervention process; c) developing organizational structure to monitor the intervention process and outcome; d) providing ongoing social and organizational support; and e) generating “self-rules” that individuals can use to motivate their own intervention-relevant behavior.18, 29, 30 Behavior is also maintained within an organization when influenced by natural (or intrinsic) contingencies. Thus, when a particular behavior’s natural consequences are rewarding, external contingencies (e.g., feedback from another source) are not necessary for motivation. This occurs, notably, when physicians learn how to use CPOE and eventually find it more efficient and reliable than ordering prescriptions by hand. However, it often takes time to experience the intrinsic qualities that reinforce a behavior. People need to engage in a behavior fluently to experience its inherent, beneficial consequences. This means that external contingencies are often necessary to motivate the initiation of a target behavior. Organizational Applications for Large-Scale Change The OBM perspective has informed an innovative people-based patient safety approach to health care,31 which strategically integrates behaviorism and humanism in the design of interventions to benefit patient safety. This comprehensive approach to patient safety is based on the following evidence-based guidelines, which are derived from applied and experimental behavior analysis (see Geller17 for a comprehensive description and analysis of these guidelines): • Target observable behavior. • Focus on external factors to explain and improve behavior. • Direct with antecedents and motivate with consequences. • Focus on positive consequences to motivate behavior. • Design interventions with consideration of internal feelings and attitudes. • Apply the scientific method to improve intervention. • Use theory to integrate information, not to limit possibilities. Safety-Related OBM Research in Health Care Settings Intervening to Improve the Safety of Health Care Workers Several successful applications of OBM in health care settings, based on the seven guidelines listed above, provide the foundation for designing interventions to initiate and maintain behaviors relevant for patient safety.31 In one example, various feedback schedules were investigated to determine which best supported the acquisition and maintenance of three healthcare routines: feeding, positioning, and transferring physically disabled patients.32 All feedback schedules were effective at increasing and maintaining the target behavior, but densely scheduled feedback produced more immediate behavior change. 6 In another study,33 an intervention that combined goal setting with interpersonal reviews of behavior-based feedback increased nurses’ use of behavioral feedback to promote infection control practices in a head injury treatment center. A different study of infection control found that applied performance feedback increased nurses’ use of sterile gloves in potentially infectious situations in an emergency room.34 OBM techniques—specifically, training, goal setting, and feedback—also helped increase nurse anesthetists’ compliance with procedures (i.e., hand sanitizing) to reduce the probability of accidental exposure to blood-borne pathogens.35 Hand sanitizing increased from 24 percent at baseline to 65 percent during the intervention and was maintained at 52 percent following withdrawal of the intervention. Additionally, nontargeted precautionary behaviors increased as a result of the intervention, including recapping needles with one hand (from 45 to 61 percent); removing gloves from the inside out (from 61 to 93 percent); and wearing gloves when discarding waste (from 31 to 52 percent). This impact on nontargeted behavior suggests a spread of OBM influence, a phenomenon
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