Natural experiments have been around for a long time in public health research. They are defined as observational studies in which an event or situation occurs allows for the seemingly random assignment of study subjects to different groups to be leveraged to try to answer a specific question. Importantly, natural experiments are used when the traditional method of a prospective, randomized, controlled study is not feasible, due to financial, logistical, or ethical reasons. Perhaps Ralph Waldo Emerson had natural experiments in mind when he said, "All life is an experiment. The more experiments you make the better."
Perhaps the greatest natural experiment of all was that of the founders of the United States, who designed a form of government that they referred to as an experiment. For example, Thomas Jefferson said, "I have no fear that the result of our experiment will be that men may be trusted to govern themselves without a master." Notably, still to this day, politicians refer to the American system of government as an experiment!
Susanna Galli and colleagues conducted just such a natural experiment, which they discussed in a Harvard Business Review article (see also their working paper "Incentives, Peer Pressure, and Behavior Persistence"), "Incentives Don't Help People Change, but Peer Pressure Does". Galli and her team took advantage of a particular set of circumstances to try and answer the age-old question on whether financial incentives can be used to help change behavior. They studied the impact of a one-time employee incentive bonus on hand hygiene compliance at one California hospital. Hand hygiene is one of the most effective ways of preventing the spread of infections in the hospital setting.
The California hospital used a team of "secret shoppers" to directly monitor hand hygiene compliance over a 90 day period. Employees received biweekly progress reports on hand hygiene compliance. If a specific target was achieved by the end of the 90 days, all employees would a one-time $1,200 bonus. Uniquely, California is one of a growing number of states that employ what is known as a "corporate practice of medicine law" that prohibits hospitals from directly employing physicians. Instead, hospitals form contracts with medical groups that employ the physicians. As a result of this situation, physicians would not be eligible for the one-time $1,200 bonus. At the same time, however, the hospital's hand hygiene compliance, and most importantly, the ability of the hospital to achieve the target performance that would trigger the one-time bonus, was highly dependent on physician hand hygiene compliance.
Hospital employees (nurses, allied health professionals, etc) came up with creative ways to encourage physicians to comply with good hand hygiene practices. For example, employees who observed physicians that demonstrated good hand hygiene practices would send celebratory emails and hand-written notes to the individual physicians. Conversely, employees would send reminders and "nudge" emails to physicians who failed to practice good hand hygiene.
On average, hospital employees significantly improved their hand hygiene compliance at the end of the 90-day intervention period. They met their target and received the monetary bonus. Unfortunately, however, improved hand hygiene was short-lived, as compliance slowly fell towards historical levels and in some cases even lower levels!
Again, physicians weren't eligible for the bonus incentive. However, hand hygiene compliance improved slowly but significantly in physicians too. More importantly, the improvements continued even after the 90-day intervention period. In summary, then, providing a financial incentive certainly changed behavior for the better, but the improved behavior was short-lived. Peer pressure resulted in similar degrees of improvement in behavior, though the improvements were sustained beyond the intervention period.
I've talked about this study in the past (see "Wash Your Hands!"), particularly in the concept of extrinsic motivation versus intrinsic motivation. What's important to realize here is that so-called natural experiments are frequently used in the management literature to answer questions that may not be amenable to traditional methods of research. As suggested by Emerson, "all life is an experiment."
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