Journal of Organizational Behavior Management

ISSN: 0160-8061 (Print) 1540-8604 (Online) Journal homepage: http://www.tandfonline.com/loi/worg20

A Paradigm Shift in Healthcare: An Open Door for

Organizational Behavior Management

David P. Kelley III & Nicole Gravina

To cite this article: David P. Kelley III & Nicole Gravina (2017): A Paradigm Shift in Healthcare:
An Open Door for Organizational Behavior Management, Journal of Organizational Behavior
Management, DOI: 10.1080/01608061.2017.1325824

To link to this article: http://dx.doi.org/10.1080/01608061.2017.1325824

Published online: 12 Jun 2017.

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Download by: [Eastern Michigan University] Date: 16 October 2017, At: 01:54
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT
https://doi.org/10.1080/01608061.2017.1325824

A Paradigm Shift in Healthcare: An Open Door for

Organizational Behavior Management
David P. Kelley III and Nicole Gravina
Florida Institute of Technology, Melbourne, Florida, USA

ABSTRACT KEYWORDS
The United States spends more money on healthcare each year healthcare; hospitals;
patient; value-based care
than any other country in the world (OECD, 2015). Despite high
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costs, the quality of healthcare is below average, resulting in a

society that is far from getting what it pays for. High costs
and poor quality have resulted in a recent paradigm shift from
traditional fee-for-service systems where hospitals and provi-
ders were paid by volume of patients to value-based care, to
where they are now paid by quality of care (Andel, Davidow,
Hollander, & Moreno, 2012). This shift has pressured organiza-
tions to improve quality of care at a rapid pace. This paper
seeks to assess how Organizational Behavior Management has
helped address the quality of healthcare thus far and discuss
avenues for future research and practice.

Healthcare is an industry where the primary function is diagnosis, treatment,

and prevention of disease, illness, and injury. The Organization for Economic
Cooperation and Development (OECD) consists of 34 countries and provides
yearly group healthcare statistics in an effort to promote policies that will
improve the economic and social well-being of people around the globe. In
the report from 2013, the United States spent an average of $8,713 per U.S.
resident on healthcare. To put this in perspective, this is almost 40% higher
than the next biggest spender in the OECD group (Switzerland) and over two
and a half times more than the average of all OECD countries (OECD, 2015).
Many variables influence these extremely high costs. One such variable
known to drive healthcare cost upward is the quality of care provided. A
recent study estimated that preventable medical errors could cost the U.S.
economy up to one trillion dollars annually (Andel, Davidow, Hollander, &
Moreno, 2012). In addition, another study suggests that these medical errors
cause over 250,000 deaths each year in the United States, making it the third
leading cause of death behind heart disease and cancer (Makary & Daniel,
2016). Over 25 years ago, it was estimated that the human toll of poor
healthcare was equivalent to 300 jumbo jets crashing every year (Andel
et al., 2012). One common and often preventable issue that arises in hospitals

CONTACT
2017 Taylor & Francis
 2 D. P. KELLEY AND N. GRAVINA

is patient falls. Approximately 320% of inpatients fall at least once during

their hospital stay (Quigley & White, 2013). Its estimated that a fall with no
serious injury results in additional hospital costs of $3,500, while a fall with
serious injury results in additional costs to hospitals of $27,000 (Wu, Keeler,
Rubenstein, Maglione, & Shekelle, 2010). High-quality care can be less
expensive if mistakes are avoided. A few programs, like the Hospital
Quality Alliance and value-based care, have attempted to address this topic.
In recent years, the Centers for Medicare and Medicaid Services (CMS)
has played a large role in addressing quality of care, as they provide health
payment coverage for over 30% of U.S. citizens and pay nearly one-third of
health expenditures in the United States (Department of Health and Human
Services, 2013). In 2011 CMS launched a program called Value-Based
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Purchasing (VBP) in an effort to improve the quality of care received by

patients in the United States and bend the cost curve for Medicare. This
program aimed to provide payment to hospitals based on the quality of care
for all Medicare and Medicaid covered patients. These metrics go beyond a
measure of preventable incidents and include additional measures such as
clinical processes of care, patient experience, outcomes, and efficiency.
As of 2017, VBP now reimburses hospitals based on measures in four
domains: clinical processes of care, and patient experience of care, outcomes,
and efficiency (United States Department of Health and Human Services, n.d.).
The Centers for Disease Control and Prevention (CDC) has reported a
decrease in multiple healthcare-associated infections over the last decade and
some of this could be attributed to VBP. For example, the CDC reported a 17%
decrease in surgical site infections (SSI) from 2008 to 2014 and an 8% decrease
in hospital-onset Clostridium difficile (C. difficile) from 2011 to 2014. No
progress has been seen in overall catheter-associated urinary tract infections
(CAUTI) from 2009 to 2014. Although these moderate improvements are
encouraging, it is unclear to what extent the VBP program has contributed
to bringing about these improvements (HAI Data and Statistics, 2016). More
important, much work can still be done to improve the quality of care being
provided in hospitals. Although Medicare and Medicaid only account for
about one-third of the population, it is likely that private insurance companies
will begin tying payment to quality as well (Shoemaker, 2011).
An increased focus on quality of care should lead to in an increased focus on
behavior change in hospital systems. Best practices have been developed for
prevention of certain events such as patient falls. Specific processes and beha-
viors such as fall prevention screenings and hourly rounds are thought to reduce
the likelihood of a patient fall from occurring (Quigley & White, 2013).
Following processes designed to keep patients safe is critical to patient safety
and quality of care. However, some reports suggest that core processes are
defective 50% of the time in healthcare, which may be a result of employees
not following those processes consistently (Resar, 2006). Improving the use of
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 3

best practices and process consistency in healthcare is a challenge uniquely

suited for the field of Organizational Behavior Management (OBM) as each
involves employee behaviors.
The field of OBM uses the scientific principles of behavior to better
understand how to train, change, and sustain the behavior of employees in
the workplace. OBM has shown successful results in multiple industries thus
far, including healthcare (e.g., Alavosius & Sulzer-Azaroff, 1990; Geller,
Eason, Phillips, & Pierson, 1980; Komaki, Heinzmann, & Lawson, 1980),
but is not a widely recognized intervention in healthcare. However, OBM has
made a considerable mark in terms of safety improvements, most often in
manufacturing, mining, and construction (Sulzer-Azaroff & Austin, 2000;
Tuncel, Lotlikar, Salem, & Daraiseh, 2006). When OBM researchers and
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practitioners focus on safety, they apply the principles of behavior analysis

to improve safety behaviors resulting in a decrease in worker injury. In a
literature review by Sulzer-Azaroff and Austin (2000), out of 33 total beha-
vioral safety studies reviewed, 32 resulted in substantial decreases in
employee injury rates. A more recent behavioral safety meta-analysis with
more stringent inclusion criteria found a reduction in injuries in 12 of the 13
studies evaluated (Tuncel et al., 2006). Yet, OBM has not infiltrated health-
care to improve quality of care in the same way that it has impacted safety in
manufacturing through behavioral safety, but the opportunity exists. In the
same way that critical behaviors can improve safety in manufacturing or
construction, there are these that can lead to improved safety for employees
and patients in healthcare. As healthcare has recently seen increased pressure
to improve quality of care while reducing costs, it is important to know how
OBM researchers and practitioners can make the biggest impact in the
healthcare industry. Thus, the purpose of this paper is to review and sum-
marize the OBM research, which has been conducted in hospital inpatient
settings and discuss strategies for OBM researchers interested in the health-
care industry. Because hospitals are currently motivated to improve their
scores in the domains tracked as part of value-based care, each domain will
be explained and the opportunities for OBM to contribute will be discussed.

Clinical processes of care

The VBP program measures hospitals on eight quality measures that fall
under five clinical areas where Medicare is focused on improving quality of
care (see Table 1). These measures make up the clinical processes of care
domain that account for 10% of the VBP score for each hospital. The five
clinical areas covered include acute myocardial infarction (AMI), pneumonia
(PN), surgical care improvement project (SCIP), healthcare-associated infec-
tions (HAIs), and preventative care (United States Department of Health and
Human Services, n.d.). Specific process measures are reported that influence
 4 D. P. KELLEY AND N. GRAVINA

Table 1. Clinical Processes of Care Domain.

Clinical area
Acute myocardial infarction
(AMI or heart attack)
Pneumonia (PN)
Surgical care improvement
project (SCIP)
Healthcare associated
infections (HAI)
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Measure
AMI patients were given fibrinolytic medication within 30 minutes of arrival
PN patients were given the most appropriate initial antibiotic(s)
Surgical patients who were taking heart medication called beta blockers
before coming to the hospital and who were kept on the beta blockers
during the period just before and after their surgery
Patients who got treatment at the right time (within 24 hours before or
after their surgery) to help prevent blood clots after certain types of
surgery
Surgical patients who were given the right kind of antibiotic to help
prevent infection
Surgical patients whose preventative antibiotics were stopped at the right
time (within 24 hours after surgery)
Surgical patients whose urinary catheters were removed on the first or

second day after surgery

Preventative Care Patients were assessed and given influenza vaccination
Note. Adapted from United States Department of Health and Human Services. Hospital Compare (n.d.).

each of these clinical areas. For example, under the AMI area, the process
measure reported is the percentage of heart attack patients given fibrinolytic
medication within 30 minutes of arrival (United States Department of Health
and Human Services, n.d.) because this is shown to improve patient out-
comes. Another example can be seen with HAIs. Recent survey data suggests
that on any given day, 1 in every 25 patients suffers from at least one HAI
(Magill et al., 2014). Each of these measures is under complete control of
hospital processes and caregivers behaving within these processes. As a result,
identifying strategies that increase the likelihood of consistently performing
well with these measures is vital to organizational success.
The majority of process measures under the clinical processes of care domain
are related to the speed and accuracy of medication delivery (see Table 1).
Suggestions for reducing medication errors such as performing independent
double-checks or limiting interruptions during medication administration can
be found in the healthcare literature, but these studies report these strategies are
only as effective as staff compliance with them (Anderson & Townsend, 2010).
Since OBM has strategies to create consistent and sustained behavior change, it
would be likely that OBM techniques could aid in improving compliance with
these processes.
However, to date, little known OBM research has been conducted to
address the caregiver behavior associated with these clinical processes. One
study conducted by Cunningham, Geller, and Clarke (2008) evaluated the
effects of a computerized provider order entry (CPOE) system (compared to
the traditional approach of hand-writing and hand-delivering orders) in a
hospital on compliance with medication-ordering protocols and the amount
of time until a patients first dose of antibiotics. The study looked specifically
at the percentage of complete compliance with medication orders and
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 5

percentage of first doses of antibiotics delivered within 240 minutes of

arrival. Results showed that CPOE orders had 59.8% complete compliance
compared to paper orders with 46.6% complete compliance. Additionally,
78.4% of antibiotics were delivered within 240 minutes when using CPOE
compared to paper orders at 55.1%. This study is a great example of how
OBM researchers can begin addressing some of the complex challenges
healthcare providers face in relation to clinical processes of care. Yet, more
work is needed to develop behavior change techniques to support compliance
with clinical processes of care. This could be an excellent avenue for OBM to
add value within the healthcare field.
Pinpointing the exact cost of measures associated with clinical processes of
care can be tricky. However, it has been suggested that the average cost for
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hospital-associated infections is roughly $15,275 per patient (Scott, 2009). A

large hospital might see over 30,000 inpatients each year. If 1 in 25 acquire a
hospital-associated infection, this would be approximately 1,200 patients and
cost approximately $18,330,000 annually (HAI Data and Statistics, 2016). If
OBM can help reduce infection rates by even 20%, this could help save the
hospital in this example 3.6 million dollars each year.

Patient experience of care

The patient experience of care domain accounts for 25% of hospitals overall VBP
score in 2016 (United States Department of Health and Human Services, n.d.).
This domain is based on the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey. This standardized survey is distributed
to adult patients post hospital stay to acquire feedback about their recent hospital
visit. The HCAHPS survey consists of eight domains that measure important
aspects of hospital quality (see Table 2). Each domain includes multiple questions
related to a specific area of quality. For example, one domain on the survey is
communication with nurses and is shown as the percentage of patients who
report that their nurses always provided clear communication. Three questions
contribute to the domain score: (a) nurses explained things in a way you could
understand, (b) nurses listened carefully to you, and (c) nurses treated you with
courtesy and respect.
Improving patient experience has received considerable attention, demon-
strated by the inception of the new peer reviewed Patient Experience Journal,
which began publication in 2014. One study published in this journal by
Morton, Brekhus, Reynolds, and Dykes (2014) sought to demonstrate the
impact of nurse leader rounds on patient experience for a large health
system. Specific behaviors that should be included in nurse rounds were
discussed, but no measures were provided regarding the frequency or con-
sistency of nurse leader rounds other than the start date of the initiative. In
addition, the data was trending in a positive direction in baseline, making it
 6 D. P. KELLEY AND N. GRAVINA

Table 2. Patient Experience of Care Domain.

Survey domain Measure
Communication with nurses Percentage of patients who reported that their nurses always
communicated well
Communication with doctors Percentage of patients who reported that their doctors always
communicated well
Responsiveness of hospital staff Percentage of patients who reported that hospital staff were always
responsive to their needs
Pain management Percentage of patients who reported that their pain was always well
controlled
Cleanliness and quietness of Percentage of patients who reported that the hospital environment
hospital environment was always clean and quiet
Communication about medicines Percentage of patients who reported that staff always explained
about medicines
Discharge information Percentage of patients who reported they were given information
about what to do during their recovery at home
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Overall rating of hospital Percentage of patients whose overall rating of the hospital was a 9 or
10 on a scale from 0 (low) to 10 (high)
Note. Adapted from United States Department of Health and Human Services (n.d.).

difficult to attribute improvements in the data to the intervention. Studies

like these may benefit from better behavioral measures as well as single
subject experimental design methodology. OBM researchers could work
collaboratively to provide expertise to strengthen the research methodology
used to evaluate interventions for improving patient experience scores over
time and build the knowledge base.
The recent and increased attention on patient experience coupled with a
lack of empirical data to support strategies for improvement shows a tre-
mendous opportunity for OBM to make a positive impact in the field of
healthcare. Although OBM has yet to address patient experience as it is
related to healthcare, multiple studies have been conducted addressing cus-
tomer satisfaction in other industries. Brown and Sulzer-Azaroff (1994)
systematically assessed the impact of service friendly behaviors including
customer satisfaction with three bank tellers. They found that providing
feedback to the tellers substantially improved the occurrence of these beha-
viors and also had a significant positive impact on customer satisfaction.
Basic feedback indicated that the tellers behaviors such as smiling, greeting,
and looking at the customer improved by 196%, 83%, and 30%, respectively.
Additionally, the study found a significant correlation between greeting the
customer and customer satisfaction. In another study, Slowiak, Madden, and
Mathews (2005) implemented an intervention package to improve telephone
customer service behaviors in a medical clinic environment. They found such
intervention consisting of task clarification, goal setting, feedback, and per-
formance contingencies was effective in increasing percentage of appropriate
greetings, tone of voice, and closing to end the call in four appointment
coordinators. Appropriate greeting usage for the group improved from an
average of 45.6% in baseline to 95.4% post intervention. Appropriate voice
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 7

tone improved from an average of 57.1% during baseline to 100% for all
participants following intervention. Standard closing of the call improved
from a group mean of 23.3% in baseline to 42.9% post intervention.
Slowiak (2014) used task clarification, goal setting, feedback, and perfor-
mance-contingent consequences to improve customer service behaviors of 20
full-time appointment coordinators at a medical clinic. Using an Applied
Behavior Analysis reversal design, the intervention produced an improvement
in the use of a standard greeting by 38% and improvement in speaking in an
appropriate tone of voice by 22%. Additionally, performance maintained
above baseline for both behaviors during a 5-month follow-up observation.
OBM interventions have been demonstrated to contribute to improve-
ments in customer service behaviors. It is likely that similar OBM interven-
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tions could be used to improve necessary behaviors in hospitals that impact

patient experience as measured by the HCAHPS survey. For example, there
may be opportunities for improved task clarification, goal setting, and feed-
back regarding specific behaviors thought to improve patient experience such
as necessary hourly rounds and bedside shift reports. Similar to studies
mentioned above, OBM could not only help select appropriate target beha-
viors, but also design systems to get clinical staff to engage in these leading
measures consistently.

Outcome
The outcome domain in VBP measures a broad spectrum of healthcare
activities that influence a patients well-being (see Table 3). This domain
includes mortality rates, infection rates, and safety indicators as measures
(United States Department of Health and Human Services, n.d.). The safety
indicators are part of a separate score called PSI-90 composite. A complete

Table 3. Outcome Domain.

Healthcare activity Measure
AMI 30-day mortality rate Rate indicates whether a patient with an AMI diagnosis died
within 30 days of their hospitalization
Heart failure (HF) 30-day mortality rate Rate shows whether a patient with a HF diagnosis died within
30 days of their hospitalization
PN 30-day mortality rate Rate shows whether a patient with a PN diagnosis died within
30 days of their hospitalization
AHRQ (PSI-90) patient safety for AHRQ PSI-90 is a composite of 8 underlying component
selected indicators (composite) indicators (see Table 5). Lower ratios indicate better quality
Central line-associated bloodstream Compares the actual number of CLABSIs with the predicted
infection (CLABSI) number of infections based on the baseline U.S. experience
Catheter-associated urinary tract Compares the actual number of CAUTIs with the predicted
infection (CAUTI) number of infections based on the baseline U.S. experience
Surgical site infection (SSI) Compares the actual number of SSIs from abdominal
hysterectomies or colon surgeries with the predicted number of
infections based on the baseline U.S. experience
Note. Adapted from United States Department of Health and Human Services (n.d.).
 8 D. P. KELLEY AND N. GRAVINA

list of PSI-90 measures can be found in Table 4. The outcome domain

accounts for 40% of a hospitals VBP score in 2016 (Centers for Medicare
& Medicaid Services, 2017). Healthcare research has shown that the use of
clinical best practices can significantly reduce 30-day mortality (Johansen
et al., 2010) and HAIs (Bizzarro et al., 2010). Almost 2 million patients
develop a HAI every year in the United States, with one-third of those
infections being CAUTI (Allegranzi et al., 2011). Not only is CAUTI one
of the most common infections found in hospitals, there are also an esti-
mated 13,000 deaths attributed to it each year in the United States and it
costs approximately $500 million annually to treat those infections (Scott,
2009). Despite these alarming results, the CDC has seen no improvement in
CAUTI rates between 2009 and 2014. Researchers have developed best
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practices for preventing CAUTI rates in hospitals (Saint, Gaies, Fowler,

Harrod, & Krein, 2014). Unfortunately, few studies have researched methods
for implementing and sustaining these practices in healthcare today.
To date, no OBM research has focused on improving 30-day mortality rates.
However, multiple studies have been conducted that directly influence infection
rates. Babcock, Sulzer-Azaroff, Sanderson, and Scibak (1992) trained five nurses to
distribute written comments regarding infection-control practices to their assis-
tants. Feedback delivery rates were initially low from nurse to assistant following
training. The trainer then met with each nurse weekly to set goals for using the
system, review individual feedback rates, and examine letters of appreciation.
Results showed that rates of feedback delivery increased from nurse to assistant
as well as infection-control practices in the treatment center as a result of the
intervention. In another study, infection-control nurses provided emergency room
nurses with individual biweekly performance feedback on the percentage of time
they wore gloves in situations where contact with bodily fluids was highly probable
(DeVries, Burnette, & Redmon, 1991). Results showed significant increases in
glove use in targeted areas of the emergency room.
Stephens and Ludwig (2005) used training, goal setting, and feedback to
target hand sanitizing behavior with seven Certified Registered Nurse
Anesthetists. Results showed an increase in hand sanitization behavior

Table 4. PSI-90 Composite.

Indicator Measure
PSI 03 Pressure ulcer rate
PSI 06 Latrogenic pneumothorax rate
PSI 07 Central venous catheter-related bloodstream infection rate
PSI 08 Postoperative hip fracture rate
PSI 12 Perioperative pulmonary embolism or deep vein thrombosis rate
PSI 13 Postoperative sepsis rate
PSI 14 Postoperative wound dehiscence rate
PSI 15 Accidental puncture or laceration rate
Note. Adapted from Fiscal Year (FY) 2016 Results for the CMS Hospital-Acquired Conditions (HAC) Reduction
program, 2015.
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 9

from 24% during baseline to 65% during intervention and maintained at 52%
following the removal of intervention. Precautionary behaviors, which were
never targeted, such as recapping needles with one hand, removing gloves
from the inside out, and glove use during waste removal increased as a result
of the intervention. Hinz, McGee, Huitema, Dickinson, and Van Enk (2014)
sought to assess the integrity of data from hand hygiene observations in a
neurovascular unit. Researchers found that when response effort for observa-
tions increased, compliance with audits decreased. In addition, as response
effort decreased, a significant increase in audit compliance was seen. These
studies are the closest OBM has come to influencing the outcome domain in
healthcare and show great promise for the positive impact OBM can have in
the industry. If similar levels of improvement can be obtained for a range of
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behaviors associated with mortality rates, infections rates, and safety, sub-
stantial health benefits for patients and costs savings for hospitals may be
realized.
OBM research has looked at improving worker safety in healthcare set-
tings. For example, a study conducted by Cunningham and Austin (2007)
sought to improve operating room safety by increasing the hands-free tech-
nique when passing sharp instruments during surgical procedures. The
researchers used goal setting, task clarification, and feedback with operating
room personnel and increased average percentage of safely passed sharp
instruments from 32% in baseline to 64% during treatment phase in the
inpatient setting. Nielsen, Sigurdsson, and Austin (2009) evaluated the effects
of video modeling on safe patient lifting with six nurses in a hospital setting.
The researchers introduced a video scoring system and five of the nurses
showed safety improvement following the scoring alone. Two of the partici-
pants received immediate feedback, which resulted in further safety
improvement.
Nielsen and Austin (2005) reviewed hospital-wide data and proposed
that four area hospitals focus on terms of safety. The annual injury rate for
hospital employees is 7.7 per 100 full-time employees. Based on these data,
the leading causes of injury were identified as overextension; slips, trips,
and falls; accidental needle punctures; and contact with bodily fluids. Not
only did the authors identify key behaviors to prioritize, interventions for
how to approach each were also proposed. Each intervention consisted of
creating a behavioral checklist involving observable behaviors, observation
of behaviors during natural work activities, and providing immediate
feedback on the occurrence of targeted behaviors or areas for improve-
ment. Although there seems to be a large opportunity in these areas, they
are focused on worker safety as opposed to patient safety. One may argue
that the two are inseparable, but different strategies and target behaviors
might emerge with a different outcome focus. The OBM research reviewed
in this section seems to yield promising results for improving safety in
 10 D. P. KELLEY AND N. GRAVINA

healthcare. More opportunity for OBM research exists to help hospitals

improve the overall safety of its patients and decrease preventable patient
mortality.
Cunningham and Geller (2012) recently developed and implemented a
needs assessment in a large rural medical center. The goal was to identify
patient-safety intervention targets by conducting a content analysis on safety
events reported over 17 months. The analysis identified the nine most
frequent safety events that occurred during the 17 month period of time.
Results from the content analysis showed that procedure/treatment variance
was reported most, while witnessed falls were associated with the least
effective management intervention. These findings resulted in the selection
of both patient safety events being targeted for intervention. The needs
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assessment proposed in the study may render particularly helpful for future
OBM researchers attempting to address some of patient safety challenges
hospitals face today.

Efficiency
Measuring the cost of care and recognizing hospitals that provide high-
quality care at lower costs is the purpose of the efficiency domain.
Medicare spending per beneficiary (MSPB) is the only measure in the
efficiency domain (United States Department of Health and Human
Services, n.d.). This measure looks at the amount of money spent on care
provided for each Medicare patient from 3 days prior hospital admission
through 30 days after discharge (see Table 5). This final measure contributes
25% to the VBP score for hospitals in 2016 (Centers for Medicare &
Medicaid Services, 2017). The MSPB measure is complex and is likely
influenced by many variables including overall quality of care provided
(Baicker & Chandra, 2004). One variable that can significantly influence
MSPB are hospital readmissions. When patients are discharged from the
hospital and encounter complications resulting in another hospital admission
within 30 days, MSPB increases. A recent report suggests that one in five
Medicare hospital patients return to the hospital within 30 days. This results
in a staggering cost of $12 billion to $15 billion dollars each year in Medicare
spending (Kenen, 2009). Recent studies have found that readmissions are

Table 5. Efficiency Domain.

Cost of care Measure
Medicare spending per Measure is based on an assessment of payment for services provided to a
beneficiary (MSPB-1) beneficiary during a spending-per-beneficiary episode that spans from
3 days prior to an inpatient hospital admission through 30 days after
discharge.
Note. Adapted from United States Department of Health and Human Services (n.d.).
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 11

typically preventable and may signify faulty transitional care processes or

inadequate patient plans following hospital discharge (Burke et al., 2016).
Several studies that deployed similar methods to the field of OBM have
been successful in reducing patients length of stay and also reduced overall
number of laboratory tests ordered (e.g., Calderon-Margalit, Mor-Yosef,
Mayer, Adler, & Shapira, 2005; Rotstein, Barabash, Noy, Wilf-Miron, &
Shani, 1996). Calderon-Margalit et al. (2005) conducted a study targeting
laboratory utilization in a university hospital. An intervention restricting the
use and frequency of identified emergency laboratory tests was implemented.
In addition, education to staff regarding misuse of laboratory tests and the
consequences involved were discussed along with the new restrictive policy.
Feedback on performance was sent to each unit leader following interven-
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tion. Results from the study showed an overall reduction in laboratory tests
by 19% in the year following the intervention. By reducing time spent in the
hospital, as well as unnecessary tests and procedures, medical costs can be
decreased.
To date, no OBM studies have been conducted that specifically address the
assessment or implementation of interventions targeting decreasing medical
spending. One study conducted by Clayton, Mawhinney, Luke, and Cook
(1997) focused on reducing overtime costs in a residential facility for indivi-
duals with developmental disabilities. The primary independent variable was
the delegation of managements control over budget decisions for smaller
organizational units to middle-level managers of those units. Results from the
study showed a significant decrease in overtime costs from $153,410 during
baseline to $76,264 during intervention. This was a yearly savings or cost
reduction of almost 50%. In another study conducted by Camden and
Ludwig (2013), researchers used normative and metacontingency feedback
to reduce absenteeism among 64 Certified Nursing Assistants (CNAs) across
three hospitals. Normative feedback included information on an individuals
current level of absenteeism as well as the groups absenteeism trends. The
metacontingency feedback included individualized data on how many extra
hours were worked as a result of that employees absenteeism. Results
showed that absenteeism improved from a mean of 0.24 days per week
during baseline to 0.13 days per week following intervention.
It is obvious from these studies that substantial gains in terms of cost
reduction can be accomplished using behavioral techniques offered by the
field of OBM. The unique science-based approach that OBM uses could play
an important role in identifying the root causes of some of these complicated
measures such as MSPB. Researchers interested in entering healthcare might
start by partnering with healthcare leaders to pinpoint critical caregiver
behaviors that reduce the chances of patients being readmitted to the hospital
within 30 days of discharge. Once these critical behaviors are identified,
OBM interventions can be implemented to initiate and sustain these
 12 D. P. KELLEY AND N. GRAVINA

behaviors over time. An additional route for researchers and practitioners

might be similar to the studies mentioned in this section. Finding other ways
to reduce costs may help hospitals offset some of the money lost due to poor
quality of care. By doing this, hospital administrators will have more time
and resources to focus on and improve quality of care.

Discussion
The field of healthcare is no doubt undergoing rapid change. Hospitals across
the country are facing continuous pressure to improve quality of care since
the introduction of VBP. While several studies have proven to be effective in
improving quality of patient care to some degree, the field of OBM has just
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scratched the surface of what can be accomplished in this industry.

Future OBM research in healthcare can go in multiple directions. First,
researchers might consider assessing interventions aimed at increasing com-
pliance and sustaining behaviors that positively impact the different domains
and measures discussed earlier. If the behaviors required to improve patient
safety differ from those to improve patient experience as measured via the
survey, then determining the type of interventions most effective for improv-
ing these behaviors on a large scale and sustaining them over time would
prove valuable to hospital administrators.
Additionally, OBM researchers might consider exploring different ways of
delivering feedback to caregivers regarding these complex metrics. Researchers
should seek to determine whether providing feedback to Registered Nurses
(RNs) regarding Medicare spending has an impact on their behavior.
Alternatively, providing feedback about the impact of nurses behavior toward
patients being immediately cared for may yield different results. More research
is needed to help clinical managers best deliver performance feedback while
trying to improve business outcomes.
Another possible direction for OBM researchers might be to determine
how these outcomes interact with one another. For example, it might be that
the current strategies to improve patient safety could decrease patient satis-
faction or increase costs or both. If this is the case, leaders might end up
moving the problem rather than solving it. Taking a scientific and systemic
approach to examining these variables and using repeated measures could
help uncover the answer to this question.
To this point, the discussion around the research that has been done
has been primarily at a local level, as well as future research yet to be
done. One thing that has not been mentioned is the impact that OBM
could have at a systems level, specifically regarding pay-for-performance
and leadership. The field of OBM has contributed to the research on
monetary incentives and performance-based pay (Allison, Silverstein, &
Galante, 1992; Bucklin, McGee, & Dickinson, 2003; Frisch & Dickinson,
 JOURNAL OF ORGANIZATIONAL BEHAVIOR MANAGEMENT 13

1990; Thurkow, Bailey, & Stamper, 2000). Although pay-for-performance

systems seem to be popular in healthcare, the impact of these systems
appears to be small or non-existent (Mehrotra, Sorbero, & Damberg,
2010). Future OBM researchers might consider assessing the current
state of pay-for-performance systems in healthcare and develop and test
behavioral solutions to make the systems more effective. Assessing pay-
for-performance systems can be done in multiple ways. First, researchers
might consider looking at the systems individual hospitals employ to
improve performance as a standalone organization. Alternatively,
researchers could assess the impact large-scale systems such as VBP had
on healthcare, in general.
In addition to pay-for-performance systems, OBM has also contributed to
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the research on leadership in organizational settings by examining it through

an operant lens (Komaki, 1998; Komaki, Minnich, Grotto, Weinshank, &
Kern, 2011; Mawhinney, 2006). By doing this, researchers are able to identify
the specific behaviors more likely to be demonstrated by high-performing
leaders. Through eight field studies, Komaki (1998) found that high-perform-
ing and effective managers monitored performance, provided consequences,
or did both. For example, one study compared the behavior of twelve
effective insurance managers and 12 ineffective insurance managers over a
7 month period. Results showed that effective managers collected perfor-
mance information significantly more often (M = 2.9%) than ineffective
managers (M = 2.0%). Additionally, results showed that effective managers
more frequently engaged in work sampling than ineffective managers
(t = 3.32, p = .002). Although the field is off to a good start in studying
leadership behavior in organizations, none of the studies have been con-
ducted on leaders in a healthcare environment. Future researchers may
evaluate the extent to which leaders in healthcare monitor work and provide
consequences and the impact these behaviors have on the outcomes dis-
cussed throughout this paper. This could provide insight for implementing
large-scale interventions to impact health outcomes and costs.
While this paper introduces many avenues for future researchers to
explore, several limitations should be noted. First, the amount of research
and journals in healthcare is vast and it is possible that not every study using
an OBM intervention in healthcare was reviewed. Second, the topics intro-
duced in this paper do not encompass everything important to healthcare at
this time. There are many other issues healthcare is facing today that OBM
could positively impact. Additionally, finding the opportunity to engage in
OBM activity in healthcare is no easy task.
Part of the reason finding opportunity to bring OBM services to healthcare
may be difficult is due to behavioral interventions being intensive and costly for
organizations. OBM researchers and practitioners must use assessments to
identify opportunities for substantial cost savings that warrant intensive and
 14 D. P. KELLEY AND N. GRAVINA

potentially costly interventions. In addition, incorporating technology, involving

leaders and training them on OBM tools, training internal data collectors who
collect behavioral data and provide feedback as part of their normal job duties,
and using systems tools can help constrain costs. Finally, individuals within the
organization can be trained or hired to provide OBM services (i.e., take a
full-time position within the organization), similar to other continuous improve-
ment approaches, which are more common in hospitals (e.g., lean six-sigma).
Internal consultants who are dedicated to using OBM tools to reduce costs
full-time may be more cost effective and efficient for hospitals.
Three strategies may help OBM practitioners get into influential positions
within a healthcare organization. The first strategy is to apply for the many
federal and private grants that have been written to address some of the topics
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discussed in this paper. By securing grant funding, healthcare organizations may

be more open to the idea of OBM research occurring within their facilities
operations. Published research will also increase the credibility and recognition
of OBM within the healthcare industry. A second strategy may be for OBM
practitioners to apply for open jobs in already established performance improve-
ment departments. Multiple departments exist within healthcare organizations
with the goal of improving organizational performance. Some of these depart-
ments include Operational Excellence, Organizational Effectiveness, and
Continuous Improvement. The science of behavior can be used to help each
of these departments achieve their goals and purpose. Finally, obtaining health-
care related training (e.g., Nursing degree or MBA in Healthcare) in addition to
OBM training, could open more doors for hospital-related work.
After reviewing some of the major challenges hospitals face today, there is
undoubtedly room for a field such as OBM to have a major impact. It is clear
from our review that OBM interventions may be well-suited to fill the
current gap existing between hospitals and the outcomes they are held
accountable to achieve. With healthcare being an industry that is unlikely
to go away, successful OBM research would likely draw a lot of positive
attention to the field of OBM in general. More research is needed to not only
demonstrate the impact of OBM interventions in healthcare, but also to
evaluate strategies for creating large-scale change in a cost-efficient way. As
noted above, healthcare impacts millions of people every year and plays an
enormous role in the U.S. economy. Successful OBM interventions would
have lasting positive effects on healthcare as an industry, the field of OBM in
general, and the population at large.

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