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High-performance work systems in health care management, Part 2: Qualitative evidence from five case studies

Ann Scheck McAlearney

Andrew N. Garman

Paula H. Song

Megan McHugh

Julie Robbins

Michael I. Harrison

Background: A capable workforce is central to the delivery of high-quality care. Research from other industries suggests that the methodical use of evidence-based management practices (also known as high-performance work practices [HPWPs]), such as systematic personnel selection and incentive compensation, serves to attract and retain well-qualified health care staff and that HPWPs may represent an important and underutilized strategy for improving quality of care and patient safety. Purpose: The aims of this study were to improve our understanding about the use of HPWPs in health care organizations and to learn about their contribution to quality of care and patient safety improvements.

Key words: health care, human resources, organizational development, patient safety, qualitative, quality of care

Ann Scheck McAlearney, ScD, MS, is Associate Professor, Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus. E-mail: [email protected]. Andrew N. Garman, PsyD, MS, is Associate Professor and Associate Chair, Department of Health Systems Management, Rush University Medical Center, Chicago, Illinois. Paula H. Song, PhD, is Assistant Professor, Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus. Megan McHugh, PhD, is Director, Research, Health Research and Educational Trust/AHA, Chicago, Illinois, and Research Assistant Professor, Institute for Healthcare Studies and Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chigaco, Illinois. Julie Robbins, MHA, is Research Associate, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus. Michael I. Harrison, PhD, is Sr. Social Scientist, Organizations and Systems, Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Washington, DC.

Funding source: Agency for Healthcare Research and Quality.

The content of this article is solely the responsibility of the authors and does not represent the official views or recommendations of the Agency for Healthcare Research and Quality (AHRQ) or the Department of Health and Human Services.

An earlier version of this article received a ‘‘Best Paper’’ designation from the Health Care Management Division of the Academy of Management and was accepted for presentation at the 70th Annual Academy of Management Meeting in Montreal, Canada, in August 2010. Highlights of these results were also presented at the 2010 AcademyHealth Meeting in Boston, Massachusetts, in June 2010.

DOI: 10.1097/HMR.0b013e3182100dc4 Health Care Manage Rev, 2011, 36(3), 214Y226 Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Methodology/Approach: Guided by a model of HPWPs developed through an extensive literature review and synthesis, we conducted a series of interviews with key informants from five U.S. health care organizations that had been identified based on their exemplary use of HPWPs. We sought to explore the applicability of our model and learn whether and how HPWPs were related to quality and safety. All interviews were recorded, transcribed, and subjected to qualitative analysis. Findings: In each of the five organizations, we found emphasis on all four HPWP subsystems in our conceptual modelVengagement, staff acquisition/development, frontline empowerment, and leadership alignment/ development. Although some HPWPs were common, there were also practices that were distinctive to a single organization. Our informants reported links between HPWPs and employee outcomes (e.g., turnover and higher satisfaction/engagement) and indicated that HPWPs made important contributions to system- and organization-level outcomes (e.g., improved recruitment, improved ability to address safety concerns, and lower turnover). Practice Implications: These case studies suggest that the systematic use of HPWPs may improve performance in health care organizations and provide examples of how HPWPs can impact quality and safety in health care. Further research is needed to specify which HPWPs and systems are of greatest potential for health care management.

A growing body of evidence drawn from a breadth of industries suggests that the systematic use of evidence-based management practicesVsometimes

identified as ‘‘high-performance work practices’’ (HPWPs)V is associated with significant differences in organizational outcomes such as quality and efficiency (e.g., Combs, Liu, Hall, & Ketchen, 2006). Although most research on HPWPs has been conducted in other industries, a com- prehensive review of research into these systems of man- agement practice concluded that many of these practices could also be relevant to health care settings (Garman, McAlearney, Harrison, Song & McHugh, 2011). However, actual field use of the practices, as well as their com- plementarities and outcomes, has yet to be explored.

This study seeks to improve our understanding of HPWP use in health care through case studies of five high- performing U.S. health care organizations that were selected based on the recognition they have received for their man- agement practices and outcomes. We were particularly in- terested in exploring links between these systems of management practices and organizational performance in the areas of quality of care and patient safety.

High-Performance Work Practices

Evidence-based human resource (HR) or management prac- tices that may contribute to organizational performance have been commonly labeled HPWPs (U.S. Department of Labor, 1993). Furthermore, collections of HPWPs used together are often referred to as high-performance work sys- tems or subsystems (see Garman et al., 2011). Most defi- nitions of HPWPs (e.g., Baker, 1999; Becker & Gerhart, 1996; Becker & Huselid, 1998; Truss, 2001) include an emphasis on attraction, selection, development, and reten- tion of personnel, with some definitions also including emphasis in the areas of employee involvement/decision latitude (e.g., Harel & Tzafrir, 2001; Truss, 2001), and leadership practices such as linking training to organiza-

tional needs and use of succession planning/internal labor markets (Macky & Boxall, 2007).

Implementing HPWPs may offer a promising approach to improving the quality, safety, and financial performance of organizations. A recent meta-analytic review of studies from manufacturing and service industries by Combs et al. (2006) found significant associations between HPWPs and financial measures across industries as well as sectors (i.e., manufacturing and services), and another recent literature synthesisfoundassociations between a range of HR practices and performance (Harris, Cortvriend, & Hyde, 2007). Nu- merous healthcare-specific studies have found associations between health care outcomes and management factors such as supervision (MacDavitt, Chou, & Stone, 2007), employee involvement (Harmon et al., 2003), and use of quality-focused incentives (Beaulieu & Horrigan, 2005). Significant associations have also been found between HPWPs and occupational safety across different sectors (Lauver, 2007; Zachratos, Barling, & Iverson, 2005).

Adapting HPWPs to Health Services Settings

Although many of the individual HPWPs have been adopted in health care settings, there are very few published evaluations of these practices within the context of a work system. In one such study, West, Guthrie, Dawson, Borrill, and Carter (2006) found a significant association between several HPWPs and patient mortality in a study of 52 Na- tional Health Service hospitals. Similarly, in a study of 146 Veterans Affairs Centers, Harmon et al. (2003) found a significant association between employee involvement and both employee satisfaction and service costs.

Rationale for This Study

Given the paucity of current research in health care orga- nizations about the potential linkage between HPWPs and

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quality of care and patient safety, many questions remain. For instance, little is known about how HPWPs might support health care workers’ abilities to impact quality of care and patient safety, nor how the use of HPWPs can affect overall organizational performance in health care. Moreover, scant practical information is available about how innovative HPWPs are used in health care orga- nizations. We initiated this exploratory study to improve our understanding about the use and potential impacts of HPWPs in health care organizations.

Conceptual Framework

The conceptual framework used in this study is based on the literature review reported in Garman et al. (2011)

and the logic model presented in Figure 1. This cross- industry review, based on 114 articles and white papers, utilized realist review methods adapted from Pawson (2006) to construct a model that was then reviewed through sev- eral iterations with an advisory panel of executives and management scholars.

The resulting model contained work practices grouped into four subsystems: (1) staff engagement, (2) staff acquisition/development, (3) frontline empowerment, and (4) leadership alignment/development. The model also described how these subsystems may interact with one another and may affect organizational and employee outcomes, thus providing an organizing framework by which to inquire about work practices in health care settings.

Figure 1

Conceptual model of how HPWP subsystems affect employee and organizational outcomes

Note: HPWP = high-performance work practice.

216 Health Care Management Review JulyYSeptember & 2011

Methods

Case Study Methodology

We used qualitative methods of data collection and analysis to conduct case studies of purposively selected exemplary organizations and make comparisons among them (Maxwell, 2005; Yin, 1994). This qualitative methodology enabled the collection of rich information about the multiple facets of HPWP adoption and implementation in health care organizations from the perspectives of a variety of key informants (Crabtree & Miller, 1999; Miles & Huberman, 1994). Our primary source of data collection was through key informant in- terviews, the majority of which were conducted in per- son. In addition, our case studies included document collection and review, especially in the areas of commu- nications practices related to the HPWPs in use, and reports of impacts potentially related to the implementa- tion and use of the HPWPs (e.g., orientation materials and development plans). Finally, members of our re- search team toured at least one health care facility in four of the five organizations studied to gather impres- sions of the work environment. We obtained human subjects approval through the institutional review boards of the authors, and all study participants were assured that their voluntary responses would remain anonymous.

Identification of HPWP Organizations

Because we could conduct only a limited number of case studies, we chose to investigate delivery systems that were known for exemplary ‘‘people practices’’ and high- quality outcomes. Our reasoning was that these leading organizations were particularly likely to provide good illustrations of the potential contributions of HPWPs to quality and safety and that reports about the con- tributions of HPWPs in these exemplary organizations might stimulate adoption of HPWPs by other care pro- viders. In addition we sought to ensure variation among the organizations on factors such as size, geographic lo- cation, and type of delivery system. We were also in- terested in finding variation in organizations’ approaches to specific HR practices, such as the degree of centrali- zation of HR management and its integration into busi- ness operations.

We initially identified potential case study sites by seeking health care organizations that were known to have a commitment to ‘‘people practices’’ and innovations be- nefiting their workforces. Because our study was exploratory in nature and we were interested in learning from inno- vative organizations, we did not establish strict a priori selection criteria. Instead, we used an iterative process in which we sought references to best practice sites in both

published and trade literature, solicited referrals from known experts in this field, and asked for suggestions from members of a project advisory panel.

The five organizations ultimately selected each had potential to serve as best practice examples worthy of attention and possible emulation by other health care organizations and were characterized by the organizational diversity needed for our exploratory study. These organ- izations and/or their component hospitals had won numerous awards for their organizational and/or workforce innovations, including the Malcolm Baldrige Award, Fortune ‘‘Best Companies to Work For,’’ Magnet desig- nation, Planetree recognition, Pebble Project, HIMSS Davies Award, and the University HealthSystem Con- sortium’s Quality Leadership Award. No organization that we contacted refused to participate in our study. Table 1 provides more detailed information about the organizations studied and their workforce initiatives.

Key Informant Interviews

Across the five case study sites, we interviewed 67 key informants. Interviews lasted from 30 to 60 minutes, with the great majority conducted in person. All interviews were recorded and transcribed verbatim.

To ensure consistency in data collection, interviewers used a semistructured interview guide including open- ended questions and probes (McCracken, 1988; Miles & Huberman, 1994), which was pilot tested prior to roll- out. The following nine major domains were covered in the interviews: (1) history and context of using HPWPs, (2)organizational structure and involvement of HR/organizational development, (3) selection and adop- tion of HPWPs, (4) implementation of HPWPs (includ- ing barriers and facilitators), (5) operations associated with use of HPWPs, (6) business case for use of HPWPs in health care organizations, (7) evaluation of HPWPs, (8) impact of HPWPs on patient safety and quality of care, and (9) recommendations and lessons learned.

A handout providing explanations and definitions of the HPWPs for this study was given to each key in formant prior to our detailed discussion about organiza- tional examples of HPWPs during the interview process to help ensure consistency of understanding about defi- nitions and this conceptual framework (Figure 2). To minimize the likelihood that interviewees would sim- ply accept the validity of the model at face value, in- terviewers were careful to identify the model as a preliminary framework based on research from other in- dustries, which may or may not have relevance to health care. Interviewees were then asked whether they could identify activities in their own organizations associated with any of the practice definitions and also whether there were any practice areas in their organization that appeared to be missing from the model or practice areas

Cases of High-Performance Work Systems 217

that were in the model but not applicable in their organization.

Analyses

We used the constant comparative method of qualita- tive data analysis (Glaser & Strauss, 1967) and common approaches to code the data (Constas, 1992; Miles & Huberman, 1994), including holding periodic conversa- tions with research team members about code definitions and emerging patterns within the data. Additional conver- sations with professional colleagues, our project advisory panel, and an ongoing literature review helped us to con- ceptualize, validate, compare, and extend findings, where appropriate (Glaser & Strauss, 1967). To support our cod- ing process, we used the qualitative data analysis software Atlas.ti, Version 6 (Scientific Software Development, 2009).

Findings

Our investigation of the use of HPWPs in five health care organizations reputed to have best practices permitted us to investigate whether our preliminary logic model could be appropriately applied to HPWP use and enabled us explore whether and how HPWP use in health care organizations could be linked to quality of care and organizational per- formance. We report these results here.

Key Informants Interviewed

We interviewed 67 informants across the five case study sites (7Y16 per site). We aimed to interview individuals with similar roles across each site to obtain perspectives from participants in commensurate positions. Our multiple key informants included HR professionals, organizational

Table 1

Case study site descriptions

Site Major workforce initiatives

Site 1: large, urban, multisite academic health center; ~8,000 FTEs

Focus on three areas: reinforcing values, soliciting employee feedback, and leadership development

Established a ‘‘Work Culture Committee’’ that includes COO, CFO, and VP of HR

Site 2: large, urban, multisite health system; ~15,000 FTEs

Creation of a ‘‘just culture’’ for patient safety Comprehensive, internally branded program for selection/on-boarding focused on culture and fit

Extensive process for formal information sharing, e.g., large group meetings, talking points for managers to share with direct reports, and plans for cascading information down throughout the organization

Widespread use of individual and team recognitions and rewards Highly structured performance management system with aligned accountabilities, performance-contingent compensation

Site 3: large, urban, multisite health system; ~15,000 FTEs

Creation of a ‘‘just culture’’ for patient safety Internally branded platform for goal alignment and internal communication Use of Studer Group ‘‘Pillars’’ (Studer Group, 2010) and Baldrige processes as organizing framework for strategy and implementation

Site 4: urban ‘‘safety net’’ hospital; ~5,500 FTEs

Leadership committed to a strategy of getting the ‘‘right people’’ Lean project used as platform for organizational improvement; HR identified as a ‘‘value stream’’

Use of external product (objective assessment test) for strategic personnel selection

Site 5: rural multisite health system; ~3,500 FTEs

Creation of a ‘‘patients-first’’ culture Use of Studer Group ‘‘Pillars’’ as organizing framework for strategy and organizational improvement

Extensive process for formal information sharing, e.g., large group meetings, talking points for managers to share with direct reports, plans for cascading information down throughout the organization

Note. FTE = full-time equivalent: COO = chief operating officer; CFO = chief financial officer; VP = vice president; HR = human resource.

218 Health Care Management Review JulyYSeptember & 2011

leaders, clinical leaders, quality improvement professio- nals, information systems managers/directors, finance and accounting professionals, and select administrative and clinical personnel involved in HR practices (Table 2).

Application of HPWP Model to Health Care Management

We organized our case study findings across sites using the framework of our HPWP logic model (Figure 1). We

sought to determine the extent to which practices in each of the four HPWP subsystems (listed in Figure 2) were present in the organization studied and sought to identify practices that were distinctive to each location. Table 3 summarizes our findings across sites. The column in Table 3 labeled ‘‘Common Practices’’ lists HPWP practices found in multiple organizations, whereas the column labeled ‘‘Distinctive Practices’’ lists practices that occurred only in a single organization. We discuss these findings by subsystem in the following sections.

Figure 2

Handout providing explanations and definitions of HPWPs

Note. HPWP = high-performance work practice.

Cases of High-Performance Work Systems 219

HPWPs in staff engagement. The four practices comprising the staff engagement subsystem of HPWPs were found in each of the sites visited. The first prac- tice, ‘‘communicating mission, vision and values,’’ was emphasized in each organization; many sites structured efforts to convey mission, vision, and values using an organizing framework (e.g., the ‘‘pillars’’ model propagated by the Studer Group). Use of this practice was also com- monly associated with recent culture change efforts. As one HR director noted, ‘‘Everyone is anxious to drive a new culture within our system,’’ and this effort involved emphasizing the mission, vision, and values. Furthermore, in all five sites, we found employee-focused messages about the mission and vision reinforced throughout the organization, with particular emphasis on HR-related activities,suchasnew-employeeorientationandincorporation into performance management systems. One vice president (VP) of HR reported, ‘‘There’s not a meeting where the mission and vision aren’t discussed or put in front of you in some way.’’

The practice of ‘‘information sharing’’ was also found across all sites, especially in the widespread use of large, formal gatherings to share information with all employ- ees. Across several organizations, interviewees discussed the practice of ‘‘cascading,’’ by which directors were responsible for communicating information to managers, managers to supervisors, supervisors to frontline staff, and so forth, to ensure that information was cascaded down throughout the organization. All organizations made use of report cards showing quality of care or pa- tient safety metrics through newsletters and bulletin boards that were accessible to all employees. Distinctive information-sharing approaches included placing patient safety messages on all computer screensavers at one or- ganization (e.g., messages about the importance of hand hygiene), designated use of functional groups (e.g., ser- vice line leaders and HR liaisons) for cross-campus shar- ing of information in another organization, and posting of report cards in a high-visibility public area (outside the cafeteria).

The third practice, ‘‘employee involvement in deci- sions,’’ was also present in each of the five organizations. Members of three organizations described extensive use of employee councils or committees (e.g., nursing and interprofessional) to collect and use employee opinions; two organizations had systems in place for involving employees from all levels in leading and/or participating in process improvement projects. Examples of distinctive practices included the use of peer ‘‘safety coaches’’ at one site and, for a site that had deployed Lean processes, having a stated goal that every employee, including se- nior leaders, participate in a Lean project.

The fourth practice, ‘‘performance-driven reward and recognition,’’ was commonly found in the use of individual and team recognition programs tied to organizational val- ues and goals or to organizational balanced scorecard re- sults. As one HR VP explained, ‘‘Like it or notVwhen you tie management bonuses to achieving some objective, you can be sure it is going to get done.’’ The case study orga- nizations also typically recognized and rewarded long-term employment (e.g., 10 and 25 years). Distinctive examples in this area included one organization in which employees earned a ‘‘free shopping’’ trip that included a cash bonus based on their tenure with the organization and an orga- nization where senior executives held an ‘‘Emmy Awards’’Y type ceremony to recognize employees.

HPWPs in staff acquisition/development. The second HPWP subsystem includes the four practices of ‘‘rigorous recruiting,’’ ‘‘selective hiring,’’ ‘‘extensive train- ing,’’ and ‘‘career development.’’ In each of the five orga- nizations, examples of rigorous recruiting were cited in relation to the goal of being perceived as a highly attractive employer. Examples of this practice included communica- tions about competitive compensation and benefits, along with provision of information about awards programs and positive employee engagement scores. Respondents in sev- eral sites noted that their organization had pursued close relationships with local schools to effectively create ‘‘feeder systems’’ for the organization.

Table 2

Key informants interviewed

Function Executive/Vice President Director/Manager Nonmanagement Total

Chief executive 4 4 Human resources 10 11 3 24 Nursing/Operations 8 3 1 12 Quality/Service 6 5 1 12 Finance 5 2 0 7 Other (e.g., communications, and planning) 6 1 1 8 Total 39 22 6 67

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Table 3

High-performance work practices identified, by HPWP subsystem

Dimension Common practices Distinctive practices

Subsystem 1: Staff Engagement

Communicating Mission, Vision, Values

Culture change focus Annual ‘‘sign off’’ on mission as part of performance reviewStructured framework for

consistent communication (e.g., use of Studer Group pillars)

Feedback from new employees at 90 days regarding ‘‘fit’’

Employee-focused messages regarding mission/vision reinforced throughout human resource functions, e.g., new employee orientation and performance management systems

Information Sharing

Use of large, formal gatherings Safety messages on all computer screensaversStandardized communication

‘‘talking points,’’ cascading, increasing use of intranet

Use of functional groups, e.g., service line leaders and liaisons, for cross-campus sharingUse of report cards as

communication vehicle Employee Involvement in Decision-Making

Use of employee councils or committees, e.g., nursing and interprofessional

Interprofessional ‘‘rounding’’

Use of employees from all levels to lead and/or participate in improvement projects, e.g., Lean projects and peer safety coaches

Use of peer ‘‘safety coaches’’ Goal is to have every employee participate in a Lean project

Performance-driven Reward and Recognition

Individual and team recognition programs tied to organizational values and goals, scorecard results

Spot bonuses (team and individual)

Organizations also recognized and rewarded long-term employment, e.g., 10 and 25 years

‘‘Free shopping’’ trip to local mall tied to tenure

Pins for good deeds, tenure ‘‘Emmy Awards’’ to recognize employees

Subsystem 2: Staff Acquisition and Development

Rigorous Recruiting Positioning sites (e.g., through award programs, communicating employee engagement scores) to be perceived as highly attractive employers

Close relationships with local schools as ‘‘feeder systems’’

Communicating competitive compensation and benefits

Selective Hiring Assessing cultural ‘‘fit’’ Peer/employee-developed standardsSelection and on-boarding as one

integrated process Use of ‘‘behavioral standards’’ in selection

Extensive Training Starts with orientation, continues Use of ‘‘simulation laboratory’’ to identify/address clinical skills gaps for new-graduate nurses

Use of large leader and staff forums

Paying for certifications in addition to degrees

Robust ‘‘corporate university’’ or formal relationships with local universities

Tuition reimbursement programs Career Development Leadership development for

high-potential managers Physician leadership academy

Mentoring programs Leadership coaching as part of the on-boarding process

Subsidies for conferences Use of some career ladders (e.g., for nurses)

Physician development programs

(continues)

Cases of High-Performance Work Systems 221

With respect to selective hiring, all sites emphasized the importance of ensuring that new employees had the right ‘‘fit’’ with the organizational culture. One HR director sum- marized this HPWP in explaining his organization’s phi- losophy: ‘‘When in doubt, keep them out!’’ In practice, selective hiring commonly involved creating an integrated process for selection and on-boarding and often involved the use of ‘‘behavioral standards’’ in the selection process. As one HR VP noted of this integrated process, ‘‘If you teach values the right way, they know right away what we are all about and if they are going to fit in.’’ Another opportunity to promote the practice of selective hiring involved the use of team interviewing and greater employee involvement in the

hiring process. As one HR director explained, ‘‘If a team is involved in selection, there’s more buy-in.’’

Each of the organizations had examples of the practice of extensive training, often starting with new-employee orien- tation and continuing into the employee development process. Three of the five organizations used large leader and staff employee forums as part of the trainingcomponent of employee development, and several had a robust ‘‘corpo- rate university’’ and/or formal relationships with local universities to support the training process. Furthermore, all study sites included tuition reimbursement programs, with reimbursement tied to student performance, although not always aligned with specific hospital needs. Distinctive

Table 3

Continued

Dimension Common practices Distinctive practices

Subsystem 3: Frontline Empowerment

Employment Security

Emphasis on employment continuity; redeployment instead of layoffs

None reported layoffs; most have long tenure, low turnover

Employment Safety All articulate support for ‘‘speaking up’’ but recognize challenges

Use of trained/empowered ‘‘safety coaches’’ on each unit (e.g., crew resource training)

Emphasis on communication, safety

Team communication training (e.g., AIDET: acknowledge, introduce, duration, explanation, thank you); Crucial Conversations

Reduced Status Distinctions

Shared governance Use of multilevel ‘‘accountability team’’ Employee/management ‘‘service teams’’ for key issues

Teams/ Decentralized Decision-Making

Manager empowerment Use of employee ‘‘innovation teams’’ to generate ideas for strategic growthUse of report cards for

accountability at division/unit level

Subsystem 4: Leadership Alignment/ Development

Leadership Training Linked to Organizational Goals

Leadership development for promising midlevel managers

Emerging leader program to develop management skills among promising nonmanagement employeesManagement training curricula

Program for physicians with ‘‘bad behaviors’’Succession Planning Leaders charged with

identifying potential successors

Use of formal ‘‘talent management’’ systems to surface and develop high potentials

Performance- Contingent Rewards

Where used, tied to scorecard results

Spot bonuses

Most sites had performance management systems linking individual accountabilities to organizational objectives; accountabilities used as basis for performance review and/or compensation

Most sites have performance- contingent compensation for top executives, some for all managers

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approaches to this HPWP included the use of a ‘‘simulation laboratory’’ for new nursing graduates that could help organizations to identify and address new nurses’ clinical skills gaps, and tying pay increases to the completion of certifications and/or degrees.

Career development as a HPWP commonly involved providing subsidies for conference attendance and offering leadership development programs and classes for high- potential managers. As one HR director noted, ‘‘Our theory: We should focus most of our time on high potentials.’’ Additional approaches to this HPWP included providing formal mentoring programs and using some career ladders (e.g., for nurses). In several organizations, there was progress in new physician leadership development programs; one organization had recently developed a physician leadership academy. Another organization reported offering leader- ship coaching to all new leaders, as they had found that the leaders who used coaches during their on-boarding process were more likely to be successful in their roles.

HPWPs in frontline empowerment. The frontline empowerment subsystem is characterized by four dis- tinct practices: ‘‘employment security,’’ ‘‘employment safety,’’1 ‘‘reduced status distinctions,’’ and ‘‘use of teams/ decentralized decision making.’’ In the area of employ- ment security, all organizations emphasized the impor- tance of employment continuity, and several explained how they responded to changing workforce needs through strategic redeployments instead of layoffs. Although none of the sites reported having a formal no-layoffs policy, none reported having had any layoffs either, and all re- ported that their workforces were characterized by low turnover rates and long tenure among employees.

With respect to employment safety, informants from each organization articulated examples of support for employees to ‘‘speak up’’ but also recognized that there were challenges associated with this practice. The em- phasis at all five organizations was on communication and patient safety. As one HR director described, the organization promotes the ability of employees ‘‘being able to speak up and stop a procedureVthere’s training for thatIthat’s been embraced.’’ Distinctive examples of this HPWP included team training on addressing patient safety concerns (e.g., Crew Resource Management), the use of trained and empowered safety coaches on each unit, and the widespread use of team communication training (e.g., AIDET [acknowledge, introduce, duration, explanation, thank you] and Crucial Conversations).

The practice of creating reduced status distinctions was also evident in all five sites, with the most common ex-

amples relating to shared governance. As one organiza- tion’s VP for operations explained, the organization’s goal was to ‘‘Icreate a culture of empowerment, one that permeates from the frontline through executives, mini- mizes hierarchy.’’ One distinctive example involved using a multilevel ‘‘accountability team’’ to set and track goals. The HR director described how ‘‘We hold each other accountableIto how we are going to behave.’’ Another distinctive approach involved the use of employee/ management ‘‘service teams’’ to resolve key issues.

The fourth practice of using teams/decentralized deci- sion making was typically described as involving empower- ment of midlevel managers and direct supervisors. A chief nursing officer at one exemplar site explained that ‘‘man- agers are completely empowered to work with doctors and housekeepers to ensure their unit works.’’ Most sites used report cards to move accountability to the division or unit level, thus using information sharing to support the practice of decentralized decision making. One innovative organi- zation had committed to decentralizing the performance improvement process and called on deployed employee ‘‘innovation teams’’ for suggestions about how to drive strategic growth in the organization.

HPWPs in leadership alignment/development. The fourth HPWP subsystem of leadership alignment/ development includes the three HPWPs of ‘‘leadership training linked to organizational goals,’’ ‘‘succession plan- ning,’’ and ‘‘performance-contingent rewards.’’ Each of the organizations had examples of leadership training linked to organizational goals;however, eachorganization’s approach was considerably different. An approach that was common across all organizations involved the use of organization- wide management meetings for educational purposes, but sites varied as to whether these meetings were considered mandatory. All sites also had new manager training pro- grams; however, only two of the five organizations had formal leadership development programs at higher levels in the organization. One innovative organization developed an emerging leader program that targeted promising non- management employees and offered training in manage- ment skills. On the physician side, two of the organizations were especially focused on opportunities to promote man- agement training for physicians. As one HR director ex- plained, the organization had worked toward ‘‘getting more and more true physician leaders over the past four yearsI leadership and training around patient safety.’’

The practice of succession planning was also identified as a concern within each of the organizations as they at- tempted to plan for the future. In all five organizations, existing leaders were routinely encouraged to identify po- tential successors, although some organizations had more formal processes in place than others. Distinctive ap- proaches involved the use of formal ‘‘talent management’’ systems to surface and develop high potentials (e.g.,

1 Multiple interviewees across several of the organizations felt that the practice of

protecting employees from repercussions for speaking up should be distinguished

from the practice of safeguarding employment for all employees. To address this

we added the practice ‘‘employee safety’’ to refer to the former and narrowed our

original definition of ‘‘employee security’’ to refer to the latter.

Cases of High-Performance Work Systems 223

using both peer and superior nominations to direct high potentials to multilevel leadership academies) and regular communications about promotion opportunities that were disseminated across individual hospitals, the health system (if appropriate), and functional areas.

The final HPWP, performance-contingent rewards, where used, was tied to overall organizational performance (e.g., tied to scorecard results). All sites had performance management systems that linked individual account- abilities to organizational objectives, and these account- abilities were used as basis for performance review and/or compensation. Four of the five sites had performance- contingent compensation for top executives; in the one site that did not, several interviewees said they thought it would be useful to implement.

Linking HPWPs and Quality and Safety

In general, respondents across all of our case study sites strongly believed that their workforce practices did impact quality and safety outcomes. However, their organizations did not gather and analyze data that could provide evidence of direct links between HPWPs and care quality or safety. Several sites had reportedly been able to document impacts for specific initiatives, but none had systematically gathered and analyzed data on the broader impacts of investments in HPWPs. For instance, at one site, an initiative to reduce safety events through improved reporting resulted in an estimated 60%Y70% reduction in serious/sentinel events; more distally, this decrease was believed to contribute to reduced premiums for malpractice insurance. At another site, the use of peer safety coaches had reportedly increased the percentage of employees who self-reported ‘‘speaking up and completely expressing their concerns,’’ with a docu- mented increase from 17% to 42% after implementation of the organization’s safety coach program.

Beyond quality and safety impacts, respondents at all of the case study sites noted that their workforce prac- tices had other benefits that may have contributed in- directly to improvements in quality and patient safety. These suggested benefits included increased employee en- gagement, enhanced market differentiation (to improve recruitment success and customer attraction), and in- creased employee pride in the organization.

The Role of Management in HPWPs

Two findings from the study are particularly relevant to the managerial role: the contribution of organizational culture to quality and performance and the importance of senior leadership support for HPWP implementation.

Consensus about the importance of organizational culture to ensure focus. Key informants across sites emphasized the importance of organizational culture in

the creation of a unified, organizational approach to qual- ity, safety, and, ultimately, organizational performance. All of the sites reported that that they have sought to improve quality and safety by creating an organizational culture or mindset (e.g., ‘‘patients first,’’ ‘‘culture of safety,’’ and ‘‘just culture’’) that focuses on quality and safety. High- performance work practices were often described in terms of efforts to support the development of this culture.

Despite the lack of hard data regarding organizational- level quality (or financial) impacts, informants across sites widely credited their organization’s focus on culture and frontline empowerment with gains in quality and safety. Beyond documented quality and safety effects, informants at all the sites recognized that their HPWPs had other benefits that may contribute to quality/safety, as suggested previously, and recognized the importance of organizational culture.

Consensus about the importance of a strong commitment from senior leadership. Informants in all sites emphasized the importance of strong commitment from organizational senior leadership as a facilitator of HPWP implementation and use. Numerous comments and examples emphasized the strong commitment of senior leaders to the HPWP, and this commitment was evidenced by reports of the time spent, the effort expended, and the enthusiasm of senior leaders. Interestingly, this commitment was not neces- sarily tied to involvement with traditional HR functions (e.g., compensation and benefits) but instead was related to the emphasis on the more strategic HPWPs of interest in our study. For instance, several of the organizations had de- signated a senior-level leader to drive organizational im- provement initiatives that were related to HPWPs, but these senior-level leaders were not responsible for HR.

Discussion

Support for HPWP Use in Health Care Organizations

Findings from our case studies offer support for the pres- ence of HPWPs in exemplary health systems and provide examples of how HPWPs are applied in health care or- ganizations. Our finding that the four HPWP subsystems in our model were present in all five exemplar organizations also helps confirm the face validity of our model.

Informants in all case study organizations agreed that HPWPs were critical drivers of organizational success. Par- ticularly interesting was the emphasis placed on the staff engagement subsystem across all five organizations, with nearly all respondents able to describe how their orga- nizations paid particular attention to the importance of systematic communication about the alignment of manage- ment practices to mission, vision, goals, and objectives.

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Our findings support the view that methodical adop- tion of a system of HPWPs may indeed be linked to both employee outcomes (e.g., decreased turnover and higher satisfaction/engagement) and organization-level outcomes (e.g., fewer ‘‘never events,’’ lower agency costs, and lower turnover costs). Notably, across all sites, attributions of a link between HPWPs and organizational outcomes were more intuitive than metric based. Nonetheless, in several health systems, there were reports of modest associations between HPWPs and measures related to improvement, such as employee satisfaction. Our findings of substantial variation in HPWP use across the five organizations sug- gest a need for further investigation into which sets of practices may be the most important for supporting efforts to improve care quality and patient safety.

Limitations of This Study

A major limitation of this study is our inability to defi- nitively link HPWP use to favorable employee outcomes or to improvements in quality of care or patient safety. Furthermore, our decision to select sites for intensive study based on their exemplary people practices made it impossible for us to compare best work practices to other types of work practices.

In addition, without comparisons among organizations with a diverse range of HPWPs, it is difficult to conclude with certainty that specific HPWPs or HPWP subsystems are critical to either employee or organizational outcomes. Although participants at all five sites were able to provide numerous illustrations of connections between HPWPs and quality/safety practices and outcomes, and several sites produced data showing how a specific HR practice or prac- tices produced favorable results, the links were typically not rigorously tested. Future research can move beyond the limitations of this study by using larger and more di- verse samples that permit contrasting HR practices and allow for quantitative analyses of associations between HPWPs and specific clinical and organizational outcomes.

Practice Implications

Findings from this study have several important implica- tions for practice, particularly as they relate to managerial roles. The consistent finding across sites concerning the importance of a strong commitment by senior leadership underscores how important it is for leaders at all levels to be full participants in the improvement efforts of their organizations. The words and actions of senior leaders set the direction for the rest of the organization; if important goals around quality and safety are not a regular part of those communications, they are likely to receive less atten- tion. This, in turn, may lead to slower progress toward those goals. Senior leadership commitment also creates the foundation for our second consensus finding about the

importance of organizational culture. Leaders create orga- nizational culture over time, through the systematic rein- forcement of specific actions (Schein, 2010). To the extent that leaders are consistent and systematic in creating a culture supportive of common goals, they are also enabling the organization’s capacity to implement other HPWPs.

Conclusions

The findings from this research are promising for both practitioner and academic audiences. From a practitioner perspective, our findings highlight the potential impor- tance and impact of HPWPs in health care organizations and provide direction about practices for these organi- zations to consider. More specifically, our findings can help managers understand how HPWPs can support health care organizations’ strategic goals to improve quality of care and patient safety in health care. From an academic per- spective, these findings lay the groundwork for future re- search into a more definitive link between HPWPs and health care quality outcomes. Additional investigations will likely provide further insight as to which of the prac- tices will have the highest leverage for improving quality and safety in health care.

Acknowledgments

We greatly appreciate the help of all study participants, as well as the research assistance provided by Emily K. Knecht, Maria Jorina, and J. Phil Harrop, all of whom were affiliated with The Ohio State University during the study. Ethi- cal approval for this research study was obtained through the Behavioral and Social Sciences Institutional Review Board of The Ohio State University. We are especially grateful to the Agency for Healthcare Research and Quality that funded this research through the 2008 ACTION Network Task Order #8, HHSA# 290200600022.

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