The Hawthorne Effect

The Hawthorne effect refers to modification of an individual’s or group’s behavior in

response to their awareness of being observed. This effect was originally claimed to have

had a positive impact on electric plant workers’ productivity in response to lighting

changes, in which productivity increased with any change in lighting. The result was

attributed to workers’ awareness of being studied.

We discuss the Hawthorne effect in the hospital setting, as reported in the Harvard

Business Review in March 2017. The report identifies a unique form of the Hawthorne

effect in hospitals during unannounced hospital inspections. In this case, patient survival

rates during the inspection week were compared to average survival rates before and after

the inspection. It is hypothesized that clinicians and other hospital workers changed their

attitude toward patient needs and improved patient care while being watched, which

resulted in a 6% increase in patient survival rates as compared to non-inspection times.

The inspections are done by the Joint Commission, a U.S. health care regulatory

organization that ensures hospitals comply with patient safety standards. The inspection lasts

a week, and is required for hospitals to maintain accreditation. During the inspection week,

hospital employees typically receive emails making them aware that a Join Commission

inspection is under way.

The study analyzed data from 1984 US hospitals during 2008-2012 and matched inspection

weeks to hospitalization data for 1.7 million patients. It was discovered that mortality rates

decreased from 6.4% to 5.9%, which amounted to a relative 6% decline in mortality.

Furthermore, mortality rates returned to previous values immediately after inspection week.

The reporters of the study claim that this is a statistically significant effect, and if
extrapolated to a yearly horizon, could save thousands of peoples’ lives. The study proposes

(but does not provide evidence) several reasons for the apparent decrease in patient

mortality while hospital was under inspection: increased hand hygiene and infection control

practices, raised clinicians’ awareness of operational deficiencies, improved focus and

vigilance. All this, the authors of the study claim, may have positive impact on patient care,

and suggest hospitals to adhere to these changes as part of their regular practices. The study

concludes that the Hawthorne effect is real and can uniquely account for the small relative

reduction in patient mortality.

Although the report provides an observational study supporting the Hawthorne effect, I

believe it lacks scientific and statistical rigor. It does not isolate and investigate specific

factors that resulted in better patient care, nor does it causally connect them to awareness of

being observed. Furthermore, implementing permanent changes in hospital’s hygiene

routines and other infection control practices by means of micromanagement may result in

additional stress to hospital workforce and eventually lead to worsened patient care. Also,

even if the Hawthorne effect in hospitals exists, the benefits may be short lived, as workers

could eventually adjust to the new norm of being constantly observed. Therefore, the

suggested long-term extrapolation may not be valid. Furthermore, since the apparent

positive impact results in a very small decrease in mortality, other extraneous long-term

effects may reverse any benefits even if Hawthorne effect persisted on such time scales.

Essentially, there could be a cost associated with increased benefits to patients, but such cost

may only be revealed over a period much longer than 1 week. Thus, the practical

implications of improving patient care as suggested in the report are based on too many

assumptions that have not been scientifically investigated.

https://hbr.org/2017/03/when-clinicians-know-theyre-being-watched-patients-fare-better