Assessing the usefulness of instant feedback and the Hawthorne effect: an audit of time indexes of EMS missions in Tehran


Effect Modifier, Epidemiologic
Emergency Medical Services
Hawthorne Effect
Management Audit

How to Cite

Saberian P, Mousaeinezhad N, Hasani-Sharamin P, Mohammadi H, Jamshididana M, Baratloo A. Assessing the usefulness of instant feedback and the Hawthorne effect: an audit of time indexes of EMS missions in Tehran . Australasian Journal of Paramedicine [Internet]. 2021Apr.11 [cited 2021May13];18. Available from:



It has been well established that if a person is aware that they are being monitored their commitment and effort will be maximised (the Hawthorne effect), which then leads to efficiency increase and optimal workflow.


Our aim was to evaluate the efficacy of instant feedback and the Hawthorne effect of this intervention on pre-hospital time indexes during emergency medical service (EMS) missions.


This is a cross-sectional auditing study on the missions of the Tehran EMS Center (performed over a 12-month period) in three phases: pre-intervention, instant feedback, and monitoring without feedback. The measured time indexes were the different parts of mission times. To collect data, a pre-prepared checklist was set up. For the first phase, data were extracted from the database of the Tehran EMS Center. In the second and third phases, the data were entered into the relevant forms for each mission by the researcher and executive colleagues.


The data of 229,847 missions were analysed. In the instant feedback phase, compared to the pre-intervention phase, the mean activation time, response time, scene time, transfer time and hospital delay time were decreased. When we compared the mean time indexes in the monitoring phase compared to the instant feedback phase, we saw that the average activation time, response time and transfer time were increased but they were still less than that in the pre-intervention phase. However, the scene time and hospital delay time were not changed compared to the instant feedback phase but were lower than that in the pre-intervention phase.


Auditing was effective in reducing the total time of missions and this effect was largely maintained in the monitoring phase under the Hawthorne effect.


Mock CN, Jurkovich GJ, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma Acute Care Surg 1998;44:804-14.

Pittet V, Burnand B, Yersin B, Carron P-N. Trends of pre-hospital emergency medical services activity over 10 years: a population-based registry analysis. BMC Health Serv Res 2014;14:380.

Sullivan F, Williams KA, Jason Rhodes MPA E-C. An overview of prehospital emergency medical services. R I Med J 2013;96:24.

Mehmood A, Rowther AA, Kobusingye O, Hyder AA. Assessment of pre-hospital emergency medical services in low-income settings using a health systems approach. Int J Emerg Med 2018;11:53.

Canto JG, Zalenski RJ, Ornato JP, et al. Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2. Circulation 2002;106:3018-23.

Baratloo A, Rahimpour L, Abushouk AI, et al. Effects of telestroke on thrombolysis times and outcomes: a meta-analysis. Prehosp Emerg Care 2018;22. :472-84.

Studnek JR, Artho MR, Garner Jr CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med 2012;30:51-6.

Anderson PD, Suter RE, Mulligan T, et al. World Health Assembly Resolution 60.22 and its importance as a health care policy tool for improving emergency care access and availability globally. Ann Emerg Med 2012;60:35-44. e3.

Coyle RM, Harrison H-L. Emergency care capacity in Freetown, Sierra Leone: a service evaluation. BMC Emerg Med 2015;15:1-9.

Dinh MM, Bein K, Roncal S, et al. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury 2013;44:606-10.

Tien HC, Jung V, Pinto R, et al. Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma. Ann Surg 2011;253:1178-83.

Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma Acute Care Surg 2002;52:420-5.

Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med 2013;28:376.

Reichard AA, Marsh SM, Moore PH. Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehosp Emerg Care 2011;15:511-7.

Eva KW, Regehr G. Effective feedback for maintenance of competence: from data delivery to trusting dialogues. CMAJ 2013;185:463-4.

Kidwai AS, Abujudeh HH. Radiologist productivity increases with real-time monitoring: the Hawthorne effect. J Am Coll Radiol 2015;12:1151-4.

Leonard KL, Masatu MC. Changing health care provider performance through measurement. Soc Sci Med 2017;181:54-65.

Hagel S, Reischke J, Kesselmeier M, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2015;36:957-62.

Croskerry P. The feedback sanction. Acad Emerg Med 2000;7:1232-8.

Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? Can J Emerg Med 2001;3:271-6.

Gilmore WS. Emergencies of pregnancy. Emergency medical services: clinical practice and systems oversight, 2 volume set. 2014;13:312.

Campbell JP, Maxey VA, Watson WA. Hawthorne effect: implications for prehospital research. Ann Emerg Med 1995;26:590-4.

Mangione‐Smith R, Elliott MN, McDonald L, McGlynn EA. An observational study of antibiotic prescribing behavior and the Hawthorne effect. Health Serv Res 2002;37:1603-23.

Offenstadt EMMLB. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intens Care Med 2006;32:2088.

McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol 2014;67:267-77.