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known as “response generalization.”36 This line of OBM research informed an intervention to decrease injuries from sharps among surgical team members during operations by increasing the use of a “hands-free” method for exchanging sharp instruments.37 The intervention package, which included task clarification, pre-intervention feedback, goal setting, and weekly intervention feedback, led to dramatic increases in the use of this injury-reduction technique from 32 to 64 percent). Whereas these examples of OBM research targeted the safe behavior of caregivers, each of these interventions indirectly advanced patient safety. Patient safety cannot be separated from caregiver safety.38 An OBM Approach to System Change A behavioral approach also can be useful in evaluating the impact of system change. For example, a systematic, behavior-based evaluation of a gradual, voluntary CPOE implementation found that CPOE medication orders were safer and more efficient compared to the standard paper-based ordering method.16 However, OBM may be needed to increase CPOE use. For example, a number of strategies were evaluated to increase the use of CPOE among physicians. These included a) presenting evidence in support of CPOE use; b) rewarding CPOE use with small trinkets; c) providing individual access to computers; d) adding clinical decision support; e) instigating relevant peer pressure; and f) providing financial compensation for the extra time required to become proficient with the CPOE system. The financial compensation strategy was found to be most effective in the short term, increasing CPOE use from 35 to 57 percent. After financial compensation was discontinued, though, CPOE use declined to 42 percent after several months but did not fall to baseline levels.39 The maintenance of CPOE use following the withdrawal of the financial incentive probably occurred because some physicians experienced intrinsic or natural reinforcement. However, the lack of peak maintenance raises the concern that external consequences of a financial incentive may over-control or over-justify the behaviors targeted for intervention, reducing self-persuasion or the influence of intrinsic consequences. 7 OBM for Patient Safety In one study,40 providing feedback to caregivers on their frequency of hand washing led to an increase in hand washing following patient contacts (from 63 percent at baseline to 92 percent post-intervention). The impact of this intervention was significantly greater than adding an emollient hand washing agent to the environment. A number of other OBM intervention studies have demonstrated significant increases in hand washing among caregivers.41, 42, 43 The intervention programs varied substantially among these studies, but all included a behavior-based feedback component. Moreover, nonbehavioral attempts to increase hand washing among caregivers suggest that hand-hygiene interventions targeting attitude change, intentions, or self-reported practice are likely to fail at altering actual behavior.44 Other examples of OBM interventions targeting patient safety include the following: • A quota system (antecedent strategy) for emergency patients’ admission to internal medicine departments resulted in reduced length of stay with no difference in outcomes.45 • Education, discussion, and feedback on proper laboratory tests reduced the overall number of tests ordered without any decrement in patient outcomes.46 • Standardizing the handoff communication procedure using antecedent reminders and feedback improved patient satisfaction, medication administration record-keeping, completion of cardiac enzyme regimens, and patient transportation without a cardiac monitor, thereby making an additional 67.5 hours of nursing time available each month.47 This is not an exhaustive review, yet the OBM approach to patient safety certainly appears promising. However, additional field research in this domain is clearly needed. A Disconnect Between OBM and Health Care Management Methodological Distinctions Health care has been noted as being resistant to importation of ideas from other disciplines.48 This tendency has been
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