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How High-Performance Work Systems Drive Health Care Value: An Examination of Leading

Process Improvement Strategies Julie Robbins, MHA; Andrew N. Garman, PsyD; Paula H. Song, PhD; Ann Scheck

McAlearney, ScD, MS

Background: As hospitals focus on increasing health care value, process improvement strategies have proliferated, seemingly faster than the evidence base supporting them. Yet, most process improvement strategies are associated with work practices for which solid evidence does exist. Evaluating improvement strategies in the context of evidence-based work practices can provide guidance about which strategies would work best for a given health care organization. Methods: We combined a literature review with analysis of key informant interview data collected from 5 case studies of high-performance work practices (HPWPs) in health care organizations. We explored the link between an evidence-based framework for HPWP use and 3 process improvement strategies: Hardwiring Excellence, Lean/Six Sigma, and Baldrige. Results and Conclusions: We found that each of these process improvement strategies has not only strengths but also important gaps with respect to incorporating HPWPs involving engaging staff, aligning leaders, acquiring and developing talent, and empowering the front line. Given differences among these strategies, our analyses suggest that some may work better than others for individual health care organizations, depending on the organizations’ current management systems. In practice, most organizations implementing improvement strategies would benefit from including evidence-based HPWPs to maximize the potential for process improvement strategies to increase value in health care.

Key words: health care, high-performance work systems, human resources management, process improvement, qualitative, quality of care, workforce

Author Affiliations Division of Health Services Manage- ment and Policy, College of Public Health (Ms Robbins and Drs Song and McAlearney), and Department of Pe- diatrics, College of Medicine (Dr McAlearney), The Ohio State University, Columbus; and Department of Health Systems Management, Rush University Medical Center, Chicago, Illinois (Dr Garman).

Correspondence: Julie Robbins, MHA, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave, Cunz Hall, 2nd Floor, Columbus, OH 43202 (robbins.11@ buckeyemail.osu.edu).

This work was supported by the Agency for Healthcare Research and Quality (AHRQ) through the 2008 ACTION Network Task Order 5, HHSA #290200600022. The content is solely the respon- sibility of the authors and does not represent the official views or recommendations of AHRQ or the Department of Health and Human Services.

The authors have no conflicts of interest.

The authors appreciate the participation of all of their study sites and key informants, as well as the collaborative efforts of their research team members. They thank Emily K. Knecht, Sarah M. Roesch, and Trevor Young, all of whom were affiliated with The Ohio State University during the study, for their dedicated re- search assistance.

DOI: 10.1097/QMH.0b013e31825e88f6

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How HPWSs Drive Health Care Value 189

H ospitals, particularly those in the United States, are under considerable ongoing pressure to increase health care value: improving safety and quality while also

controlling or reducing costs. Associated with this pressure, organizational process improvement strate- gies have proliferated, with most strategies designed to help hospitals achieve greater value. Yet, there has been scant, robust, independent research con- ducted to compare the efficacy and cost-effectiveness of these programs1; as such, managers often must rely on their own judgment and that of their peers to de- cide which options to pursue.

A useful strategy for assessing and prioritizing process improvement approaches is to consider their component parts as they relate to practices for which the evidence base is clearer. Implementation of process improvement strategies typically involves and/or is supported by management and human resources practices (eg, education, training, eval- uation); therefore, having a greater understanding of these work practices may, by extension, help managers identify process improvement opportuni- ties that will be most helpful within their unique contexts.

In this article, we use an evidence-based model of high-performance work practices (HPWPs) as a framework for analyzing and comparing 3 improve- ment approaches commonly used in health care or- ganizations: Lean/Six Sigma, Baldrige, and Hard- wiring Excellence. Our study extends the literature on health care organizational improvement by pro- viding an objective framework for comparing process improvement approaches and the management prac- tices required to support their implementation. More practically, this study provides guidance to managers considering the potential fit of these approaches with respect to their ability to attain improvement goals within their own organizational contexts.

BACKGROUND

Process improvement strategies

For the purposes of this research, we de- fine “process improvement strategies” as system-

atic, organization-wide programs that are adopted to improve quality and/or efficiency. We spec- ify “adopted” to identify strategies that are im- ported from outside rather than developed internally and more organically. “Organization-wide” indicates strategies for which all members of the organiza- tion could conceivably play a direct role (discipline- specific strategies such as Magnet Recognition2 for nursing are thus excluded). Finally, the emphasis on improving quality and/or efficiency creates a narrower focus than the more general concept of “organizational transformation”1; this thus excludes institution-wide efforts that may have a less direct effect on quality and/or efficiency (eg, employee en- gagement initiatives). Of the process improvement strategies currently deployed in health care settings, 3 were identified—by practitioner colleagues as well as recent reviews1—to be particularly widespread in their current use and serve as the focus of this ar- ticle: Hardwiring Excellence, Lean/Six Sigma, and Baldrige.

Hardwiring Excellence

The “Hardwiring Excellence” model (also referred to as the Studer model or the StuderGroup model) is a leadership and management approach described in the book Hardwiring Excellence3 and in sub- sequent books and other materials published by author/consultant Quint Studer. Hardwiring Excel- lence is motivated by a philosophy that organizations “can create momentum for change by engaging the passion of their employees” and focusing on the core business of healthcare—serving patients.3 A recent analysis of Hardwiring Excellence identified numer- ous empirically grounded theoretical underpinnings to its principles, including motivation and feedback, management by objectives, evidence-based manage- ment, and organizational learning,4 providing further indirect support for the utility of the model.

Lean/Six Sigma

Originally developed in a manufacturing environ- ment, Six Sigma and Toyota Production Systems’ Lean technologies (Lean) are process improvement strategies that have been implemented in health

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care settings to improve operational efficiency and, increasingly, quality and safety.5-7 Although they use different techniques, both Lean and Six Sigma have similar goals of improving quality and efficiency, are based on a philosophy of employee empowerment, and rely on the use of robust operational data to fo- cus performance efforts.8,9 The approaches, which originated in industry, are not associated with a specific provider or consulting firm, although there are some widely recognized programs supporting their use (eg, the Six Sigma black belt certifica- tion offered by the American Society for Quality10). Effective adoption of these approaches is described as requiring a change in organizational culture in which leaders fully commit to the philosophy, em- power employees (eg, through training support and reduced hierarchy), and foster a shared sense of purpose.8,9

Baldrige

The Baldrige Performance Excellence Program, op- erated by the National Institute of Standards and Technology of the US Department of Commerce, is a program that promotes quality management through education and recognition.11 The program provides assessment and consultation support for organiza- tions interested in adopting quality management principles. It also operates an annual awards program that recognizes excellence across the 7 focal areas that the Baldrige criteria measure: leadership; strate- gic planning; customer focus; measurement, analysis and knowledge management; workforce focus; opera- tions focus; and results.11 Several noteworthy studies of the Baldrige model have found significant positive relationships between its implementation and orga- nizational outcomes.12,13

Although all of the approaches under considera- tion have seen widespread use within health care, research assessing their impacts has been limited, making it difficult for managers to make informed de- cisions about which process improvement strategies will yield the greatest benefits to their own organi- zations. Thus, examining the relationships between these process improvement strategies and an exist- ing evidence-based framework may provide insights

that can inform efforts to select and implement these approaches.

High-performance work practices in health care

High-performance work practices are management and human resources practices such as selective hir- ing, employee development and involvement, and incentive compensation, that, when implemented as a system, can have a positive impact on orga- nizational outcomes. Other than a few noteworthy exceptions,14-16 most research on HPWPs has been conducted either outside of health care or included health care organizations as one of many industries studied. Recently, Garman and colleagues17 com- pleted a comprehensive literature review to develop a health care–specific model of HPWPs. The model is composed of 4 subsystems—engaging staff, align- ing leaders, acquiring and developing talent, and em- powering the front line—and includes 15 associated practices, summarized in Table 1.

McAlearney and colleagues18 recently completed a case study analysis to provide preliminary sup- port for the “fit” of this model to describe HPWPs in health care organizations. In conducting this re- search, a potential relationship between HPWPs and the process improvement strategies health systems were deploying started to become apparent. This re- lationship suggests that an understanding of a health system’s existing work practices can assess the ex- tent to which a given process improvement strategy is likely to yield greater relative success. We examine this question in greater depth in the present analysis we report in this article.

METHODS

The research presented in this article uses the con- ceptual framework of the health care HPWP model described earlier17 to evaluate the potential relation- ship between process improvement strategies and HPWPs in 3 steps: (1) a review of literature descrip- tions of process improvement strategies; (2) anal- yses of data from a larger exploratory qualitative

How HPWSs Drive Health Care Value 191

Table 1

HPWP MODEL SUBSYSTEMS AND WORK PRACTICESa

HPWP Subsystem Focus Work Practices

1. Engaging staff Fostering employee awareness and personal commitment to work, supporting the accomplishment of organizational goals

Communicating mission/vision Information sharing Employee involvement in decisions Performance-driven rewards/recognition

2. Aligning leaders Influencing leaders’ capabilities to run and evolve the organizational as a whole

Leadership training linked to organizational goals

Succession planning Performance-contingent rewards

3. Acquiring and developing talent

Building the quality of the workforce Rigorous recruiting Selective hiring Career development Extensive training

4. Empowering the front line

Motivating and supporting the front line to influence the quality and safety of care provided

Employment security Employment safety Reduced status distinctions Teams/decentralized decisions

Abbreviation: HPWP, high-performance work practice. aAdapted with permission from Garman et al.17

case study of HPWPs in 5 health care organizations selected on the basis of their reputations as well- managed health systems; and (3) comparison areas of overlap between process improvement strategies and HPWPs.

Human subjects approval for this research study was obtained through the Behavioral and Social Sci- ences Institutional Review Board of The Ohio State University.

Review of process improvement literature: Identifying areas of “expected overlap”

In the first step of our analysis, we conducted a conceptual review of the process improvement liter- ature to identify areas of expected overlap between the practices in the HPWP model and those in each of the process improvement approaches. We used the evidence-based model of HPWPs of Garman and colleague17 in health care as a framework for analyz- ing and comparing the 3 process improvement ap- proaches.

This conceptual review was structured to iden- tify areas of expected overlap between the 4 HPWP subsystems—engaging staff, aligning leaders, acquir- ing and developing talent, and empowering the front line—and each improvement approach. To perform this review, we used original and/or peer-reviewed sources to identify the specific work practices asso- ciated with each of the process improvement ap- proaches and then compared each of those with HPWP model practices.9,10,19-21 We defined these ar- eas of overlap between HPWPs and the process im- provement approaches as “expected overlap,” given the conceptual nature of our review.

Analyses of case study data on HPWPs in health care organizations: Identifying evidence for areas of “observed overlap”

In the second step of our evaluation, we conducted secondary analyses of key informant interview data from 5 case studies of health care organizations that

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had been conducted to assess HPWPs in health care. We conducted these analyses to identify areas of overlap between HPWPs and process improvement strategies used in these 5 health care organizations, as described further later.

Source of primary case study data

The 5 organizations had been selected to partic- ipate in our original study of HPWPs on the ba- sis of external recognitions for these organizations’ innovative management practices. Potential sites had been identified through objective criteria, including recognition as Baldrige award winners, recognition as being among Fortune magazine’s “Best Places to Work,” and through recommendations from a project advisory committee composed of health system hu- man resources executives. Of the 5 study sites, 3 had implemented Hardwiring Excellence practices, 3 were actively using Lean/Six Sigma, and 1 had re- ceived the Baldrige award (use of the different organi- zational improvement approaches was not mutually exclusive). We provide more detailed information about the organizations, their major workforce initia- tives, and their reported use of process improvement frameworks in Table 2.

Primary data collection process

Key informant interviews were the primary data source for the HPWP study. Interviews had been con- ducted with a total of 67 key informants (10-16 per site) and were held during 1- to 2-day site visits to each of the case study organizations. At each site, we interviewed a broad range of informants, including chief executives (n = 4), human resources leaders and staff (n = 24), operations and nursing leaders (n = 12), leaders focused on quality and/or service (n = 12), fi- nance leaders and staff (n = 7), and other relevant staff such as planning executives and culture change leaders (n = 8). To ensure consistency in the data col- lection process, we used a semistructured interview guide that focused primarily on the four HPWP sub- systems and their links to organizational outcomes. There were no direct questions asked about the pro- cess improvement strategies used by these organi- zations, but interviewees did comment about these

strategies in the course of their comments describing their HPWPs and their quality improvement efforts.

Primary analyses of case study data

All interviews had been recorded and transcribed verbatim. Interview transcripts were then coded by 2 research assistants trained in qualitative techniques. To ensure consistency and reliability in the coding process, the research team developed a “coding dic- tionary” that identified codes and associated defini- tions. Initial codes were developed on the basis of questions asked in the interview guide; new codes were added as themes emerged in the data.22 To en- sure consistent application of the codes, coders met periodically to review coding decisions, to revise and develop new code definitions as needed, and to re- solve any discrepancies.23 We used the qualitative data analysis software Atlas.ti, Version 6, to support this coding process.22

Secondary analyses of case study data

The original coding dictionary included codes for each of the 15 work practices that were part of the HPWP model, and these were applied to any quote describing or referencing that work practice. Simi- larly, the coding dictionary also included codes for each of the 3 process improvement strategies that were applied to any quotes that specifically ref- erenced Hardwiring Excellence, Lean/ Six Sigma, and/or Baldrige. For this study, we reviewed a sub- set of the data that had associated codes for one of the improvement approaches and at least one HPWP practice.

We completed a systematic secondary analysis in which we analyzed quotes associated with each of the 15 HPWPs and those associated with each of the 3 process improvement approaches to identify areas of overlap. We defined these areas of over- lap as “observed overlap,” given the evidence we found of a relationship between the HPWPs and the process improvement approaches under study. Wherever possible, we analyzed the content of these quotes to provide a description of the relation- ship between HPWPs and the process improvement approaches.

How HPWSs Drive Health Care Value 193

Table 2

DESCRIPTION OF HPWP CASE STUDY SITES

Site Focus of HPWP Initiative Process Improvement

Approaches in Use

Site 1 Pursuit of “cultural transformation” Internally developed Large, urban multisite academic health center

Emphasis on practices to reinforce values and engage employees

Operational benchmark-driven

∼8000 FTEs Site 2 Integrated human resources strategy focused on

accountability and goal alignment Hardwiring Excellence (past)

Large, urban, multisite health system

Strong employee engagement components (eg, extensive communication, rewards/recognition)

∼15 000 FTEs “Just culture” initiative Site 3 Broad leadership initiative to retool processes for

better alignment and performance Hardwiring Excellence

Large, urban, multisite health system

Internally branded platform focused on goal alignment and consistent internal communication

Lean/Six Sigma

∼15 000 FTEs Strong employee engagement components (eg, extensive communication, rewards/recognition)

Baldrige

Site 4 Getting the “right people” identified as a central tenet of the organization’s quality/safety efforts

Lean/Six Sigma

Urban “safety net” hospital

Extensive training

∼5500 FTEs Site 5 Emphasis on “patients first” culture” Hardwiring Excellence

Rural multisite health system ∼3500 FTEs

Strong employee engagement components (eg, extensive communication, rewards/recognition)

Abbreviations: FTE, full-time equivalent; HPWP, high-performance work practice.

Comparison of expected and observed overlap between HPWPs and process improvement strategies

As the third step in these analyses, we compared findings about expected areas of overlap from our conceptual review of the literature with the results of our secondary data analyses in which we sought evi- dence for areas of observed overlap. We next present the results of these comparisons and further describe our findings about evidence for a relationship be- tween HPWPs and process improvement strategies.

RESULTS

An integrated summary of our analysis of areas of expected and observed overlap between the HPWP

subsystems and each process improvement approach is presented in Table 3. We discuss more detailed findings from our assessment of these areas of overlap by process improvement approach.

Hardwiring Excellence

On the basis of our review of Hardwiring Excel- lence principles, tools, and practices,3 we expected strong overlap with the engaging staff, aligning lead- ers, and acquiring and developing talent HPWP sub- systems; these were largely observed in practice. More broadly, the Hardwiring Excellence “pillars,” which refers to 5 goal areas—service, quality, peo- ple, finance, and growth—were found to be a highly resonant organizing framework for the implementa- tion of all of these work practices.

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Table 3

EXPECTED AND OBSERVED OVERLAP BETWEEN HPWP SUBSYSTEMS, HPWPS, AND PROCESS IMPROVEMENT APPROACHESa

Process Improvement Approaches

HPWP Subsystem HPWP Practices Studer Lean/Six Sigma Baldrige

1. Engaging staff Communicating mission/vision X X X Information sharing X X X Employee involvement in decisions X X Performance-driven rewards/recognition X X X

2. Aligning leaders Leadership training linked to organizational goals X X Succession planning Performance-contingent rewards X X X

3. Acquiring and developing talent

Rigorous recruiting Selective hiring X X Career development Extensive training X X X

4. Empowering the front line

Employment security Employment safety X X Reduced status distinctions X Teams/decentralized decisions X X

Abbreviation: HPWP, high-performance work practice. aShaded “X” indicates expected overlap between HPWP practice and process improvement strategy. Nonshaded “X” indicates observed overlap from case studies

Several of the core Hardwiring Excellence principles—Commit to Excellence, Communicate at All Levels, Recognize and Reward Success, Build In- dividual Accountability, and Align Behavior with Goals and Values—are designed to engage employ- ees and foster commitment to broader organizational goals. The recommended actions related to these principles focus on leader behavior to clearly articu- late and communicate organization vision and goals, openly share information about organizational per- formance, and implement practices that link indi- vidual performance to the achievement of organiza- tional goals—practices that are very similar to those in the engaging staff HPWP subsystem. In addition, Hardwiring Excellence recognizes that leaders play a critical role in modeling desired behavior and moti- vating employees and therefore includes a focus on leader training and development—an HPWP align- ing leaders practice. These engaging staff and align- ing leaders HPWPs were observed in the form of

systematic mechanisms for “cascading” communica- tion, widespread use of employee teams to inform leadership decisions and set behavioral standards for employees, robust performance management sys- tems tied to organizational goals, and highly visible rewards and recognitions.

Two important HPWPs—performance-contingent rewards for managers and performance-driven re- wards and recognition for staff—are not specifically addressed in Hardwiring Excellence but were ob- served in our case studies. Several case study sites of- fered management and staff bonuses that were linked to both organizational performance and robust re- wards/recognition programs.

We also expected overlap between Hardwiring Ex- cellence and the HPWP acquiring and developing talent subsystem that focuses on building the qual- ity of the workforce. Similar to the HPWP model, Hardwiring Excellence includes a strong focus on recruitment, selection, and training and includes

How HPWSs Drive Health Care Value 195

the following: establishment of behavioral standards, a focus on attracting and/or retaining “high per- formers,” and an emphasis on establishing a strong employer-employee “fit” in the hiring and social- ization processes.3 These workforce practices were in evident in our case study organizations; specifi- cally, we found application of behavioral standards in selection and performance review, peer interview- ing, structured “on-boarding” initiatives, and robust training and education initiatives related to organi- zational goals (eg, a “corporate university,” tuition assistance). On the contrary, “career development” is a practice in this HPWP subsystem that did not overlap with Hardwiring Excellence principles or practices.

Finally, we did not expect, nor did we observe, overlap between Hardwiring Excellence principles and the empowering the frontline HPWP subsystem. While Hardwiring Excellence recognizes the impor- tance of frontline employees to organizational suc- cess, its overall emphasis is on developing leaders to have the skills necessary to change organizational culture and motivate employees in support of orga- nizational goals.3

Our detailed findings regarding the 4 HPWP model subsystems and Hardwiring Excellence are sum- marized and presented, along with representative quotes from key informants, in Table 4.

Lean/Six Sigma

Developed primarily as a tool for process im- provement, Lean/Six Sigma was designed to en- courage employees to identify operational problems and then empower them to develop and implement solutions.8,9 Given this frontline focus, we expected considerable overlap between Lean/Six Sigma and the HPWP engaging staff and empowering the front- line subsystems.

With respect to engaging staff, leadership practices that create a strong culture of shared value and link individual efforts to larger organizational strategy are important to “enable” successful Lean/Six Sigma implementation9,19,23 We observed overlap between Lean/Six Sigma and HPWP engaging staff subsys-

tem practices in several ways among our case study sites. First, Lean/Six Sigma implementation was of- ten tied to organizational mission and strategy from both a communications standpoint (eg, “we are im- proving our processes so that we can better fulfill our mission”) and as a mechanism for prioritizing projects and resource allocation. Furthermore, those sites that had implemented Lean/Six Sigma had com- mitted to “transparency” and were actively sharing unit- and project-level performance data. Consistent with the HPWP empowering the frontline subsys- tem, leader behavior to create an environment that is “open and safe” for employees to speak up regardless of status has been identified as a factor for successful Lean/Six Sigma implementation.9,19,23 We observed these practices in our case study sites, especially in the use of employee-empowered problem-solving teams and in policies and practices that sought to reduce status distinctions by requiring employees to “check [their] badges at the door.”

We both expected and observed some overlap be- tween Lean/Six Sigma and the HPWP acquiring and developing talent subsystem. Studies have found that having the “right” people who “fit with the orga- nizational culture”10 and that strong “people sys- tems” (eg, recruitment, selection, and training) are key to securing the appropriate workforce for suc- cessful Lean/Six Sigma implementation.19,23 On the basis of these findings, we expected overlap between HPWP selection and training practices. While we did not find evidence that our case study sites’ selection practices were linked to Lean/Six Sigma implemen- tation, we did find evidence of robust employee ed- ucation and training that focused on communicating the importance of Lean/Six Sigma to improving qual- ity and developing technical skills.

Finally, studies have found that practices that link leader compensation to improvement outcomes are an important factor for successful Lean/Six Sigma implementation,9,19,23 a practice that is consistent with the HPWP aligning leaders subsystem in con- cept. In our cases study sites, although Lean/Six Sigma project outcomes were often considered in leader/manager performance reviews, they were not specifically linked to compensation. For example,

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Table 4

OVERLAP BETWEEN HPWP SUBSYSTEMS AND “HARDWIRING EXCELLENCE”

Overlap

HPWP Subsystem Expected Observed Representative Quotes

1. Engaging staff Leaders articulate vision and mission, share information, foster 2-way exchange with employees

Goal/reward alignmentEmployee service teams

Goal/reward alignment

Widespread use of “pillars” as framework to communicate vision and goals

Goal/reward alignmentIndividual performance evaluation linked to organizational goals

Cascading communication

Creative reward and recognition programs

“We convey our mission and vision in a number of ways, but the primary one is our Pillars of Excellence.”

Goal/reward alignment“We use ‘high performance’ in every communication . . . we set up goals under each of those pillars to communicate the heck out of them.”

“We bring 1400 [leaders] off-site . . . and we spend a full day there. . . . the CEO . . . goes through our report card, pillar by pillar and talks about where we are hitting our measures, where we are not, and what we need to be doing.”

“We have pillar performance bonuses . . . each employee can receive $600 [if we meet all our organizational goals.]”

2. Aligning leaders

Emphasis on leader development

Use of rewards/recognition to motivate leader behavior

Extensive leadership training

“Pillar” bonus for leaders

“[we do ‘Hardwiring Excellence’ training”] to reduce leader variation by letting people know what the expectations are for leaders and [do] some skill-building as well.”

“[our leader] ‘must-haves’ are modeled right off Quint Studer.”

3. Acquiring and developing talent

Emphasis on employee “fit,” starting with selection through 90-d on-boarding; follow-up at intervals

Focus on leader recruitment and development

Emphasis on fit through peer interviews, behavioral standards, 90-d on-boarding

“Our [interview guide is] aligned with the pillars of excellence, the behaviors of the organization and the values of the organization.”

“We meet annually with each staff person and let them know whether they are a high-, middle-, or low-performer. We [ask the high performers], is there anything we can do different to keep them here? Middle performers we give one thing to work on to become a higher performer, and the low performers, they either need to x, y, and z by next month or week, or we’ll be having this conversation again.”

4. Empowering the front line

Not a primary focus Not a primary focus

Abbreviation: HPWP, high-performance work practice.

How HPWSs Drive Health Care Value 197

the “executive sponsor” of each Lean/Six Sigma project was formally held accountable for results in his or her performance evaluation, but this was not tied to compensation or bonuses.

We present our detailed findings regarding the 4 HPWP model subsystems and the Lean/Six Sigma process improvement approach, along with repre- sentative verbatim quotes from key informants, in Table 5.

Baldrige

Although the Baldrige criteria do not prescribe specific work practices, they do delineate standards that provide a framework for organizations seeking performance excellence. In our analysis of expected overlap, we found strong alignment between these standards and all 4 HPWP subsystems. Similarly, in our case study data, we found that pursuit of the Baldrige award had been a galvanizing force for sys- tematic HPWP implementation and quality improve- ment. As one interviewee noted, “The Baldrige pro- cess is one of the elements of not only how you put an organizational structure together, but then how you use that structure to be focused.” At the same time, we noted extensive implementation of innova- tive HPWPs in all study sites, while our case study interviewees did not often attribute these directly to pursuit of the Baldrige award, creating a challenge for our secondary analyses. Nonetheless, we present a summary of our analysis of expected compared with observed overlap between HPWPs and the Baldrige framework.

Baldrige standards that relate to the HPWP em- ployee engagement subsystem include those that re- quire leaders to articulate and promote the organi- zation’s vision and mission, to share information to help employees do a better job, and to “foster frank, 2- way communication” throughout the organization.11

These engagement HPWPs were evident within our Baldrige award case study site. We also observed many information sharing practices, largely initiated in conjunction with pursuit of the Baldrige award (eg, an annual off-site meeting for all staff, routine leader- ship briefings, and formal mechanisms to “cascade”

information). Finally, the Baldrige standards empha- size the importance of linking individual recognition and rewards, including compensation, to organiza- tional performance, a practice that is consistent with both the HPWP engaging staff and aligning leaders subsystem work practices. In our study, the Baldrige case study site had implemented a performance- based bonus; however, it was not clear whether its implementation was linked directly to pursuit of the Baldrige award.

We found clear alignment between the HPWP ac- quiring and developing talent subsystem and the “workforce” components of the Baldrige criteria. “Workforce” is 1 of 6 major focus areas for Baldrige, and organizations applying for the award must demonstrate and provide a detailed plan for how they will recruit, hire, and train new members of the work- force to meet organizational strategic objectives.11 In addition, Baldrige criteria require organizations to demonstrate a focus on facilitating career progression within the organization11 and require that organiza- tions demonstrate a focus on “knowledge manage- ment” through the implementation of learning and development programs. The Baldrige organization we studied had robust and integrated training pro- grams, including offerings in many subject areas and delivering training through different mechanisms (eg, a corporate university, tuition reimbursement, classroom-based learning, and e-learning). Further- more, this organization had developed internal lead- ership development programs for promising clinical bedside staff. Although we did not find direct evi- dence that any single practice was directly related to—or created as a result of—the Baldrige process, there was a strong perception among interviewees at this site that Baldrige provided an integrative frame- work and focus for the organization.

In terms of empowering the front line, Baldrige is the only 1 of the 3 improvement approaches con- sidered in this article that explicitly addresses the HPWPs of “employment safety,” or the ability to speak up without fear of repercussions, and “em- ployment security,” or stable employment. While there is no specific standard for employment safety, Baldrige requires a general emphasis on creating a

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How HPWSs Drive Health Care Value 199

“safe, trusting, and cooperative environment.” For security practices specifically, the Baldrige work- force standards require organizations to demonstrate how they will “manage to prevent workforce re- ductions and minimize the impact of workforce re- ductions if they become necessary.”11 In our study, several informants had described widespread use of employee teams and culture change initiatives de- signed to create a “culture of safety” in which all employees feel comfortable speaking up. Moreover, interviewees in the Baldrige-winning organization did discussed the organization’s commitment to avoiding layoffs. However, similar to the analyses of Baldrige compared with the other HPWP subsystems we reported earlier, our case study informants did not directly attribute these employment safety and security work practices to the Baldrige process.

One particularly interesting finding from our anal- ysis of HPWPs within the Baldrige-winning orga- nization involved their concurrent use of multiple process improvement approaches. For instance, this organization had used several practices from Hard- wiring Excellence for employee engagement (ie, pil- lars framework for alignment of individual and or- ganizational performance goals and then Lean/Six Sigma for empowering performance improvement teams.)

We present our detailed findings about the overlap of the Baldrige framework with the 4 HPWP subsys- tems and the individual HPWPs, along with repre- sentative quotes from interviewees, in Table 6.

DISCUSSION

In this analysis, we sought to examine the relation- ships between a model of HPWPs previously iden- tified as relevant to health care and 3 widely used process improvement strategies to (a) identify impor- tant differences in the management and/or human resources practices associated with these strategies and (b) provide a framework that could be used to in- form an organization’s decisions about improvement strategies, based on evidence-based management fac- tors. Through our literature review and analysis of

case study data, we conclude that the models dif- fer enough to suggest that leaders may find a given process improvement strategy to be a better fit for their specific organization’s needs and may be able to assess their evaluation of fit based on their organiza- tion’s current portfolio and quality of work practices.

While each of these approaches has been recog- nized for its potential as a “transformation” strategy for an organization, their value as such has not been systematically evaluated.1 Although our study was not conducted as an evaluation of these improve- ment approaches, our results do indicate that there is a strong fit between the 3 improvement approaches and an evidence-based model of HPWPs that is linked to quality outcomes in health care. Thus, from a research perspective, these findings provide preliminary theoretical and empirical insight about the potential value of these widely used health care improvement approaches. More practically, our analysis offers insight into each of the improvement approaches, including a comparison of the relative focus and merits of each strategy.

The results of our analyses suggest that these pro- cess improvement strategies differ in ways that will render them a stronger or weaker fit for a given or- ganization, based in part on the current management practices of that organization. For example, for or- ganizations in which structures are relatively hierar- chical, this design may lead the organization to fa- vor the Hardwiring Excellence approach because of the strong emphasis on leader and manager behav- iors. Conversely, organizations that have a particu- larly strong emphasis on frontline empowerment or operational improvement may find Lean/Six Sigma to be a better fit. In addition, while we found that the Baldrige standards are the most inclusive in terms of their alignment with HPWPs, they are also the least prescriptive of the 3 improvement strategies and may be most useful for organizations that have strong internal leadership and support for human resources and organizational development. Alterna- tively, Baldrige may provide a useful “umbrella” framework for guiding concurrent implementation of other improvement approaches (eg, Hardwiring Ex- cellence and Lean/Six Sigma).

200 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 21, ISSUE 3, JULY–SEPTEMBER 2012

Table 6

OVERLAP BETWEEN HPWP SUBSYSTEMS AND BALDRIGE

Overlap

HPWP Subsystem Expected Observed Representative Quotes

1. Engaging staff

Leaders articulate vision and mission and share information

Organization fosters 2-way exchange with employees

Annual off-site meeting for all staff

Online dashboards for sharing real-time performance information

Employee bonuses

“[Through Baldrige] we truly got our workforce rowing in the right direction.”

“That commitment of going through the [Baldrige] process really made us a far more effective and productive workforce. I mean to have all fifteen thousand people being able to say the same thing . . . you walked through the halls here and you felt that they all got it. They’re all talking in the same terms.”

2. Aligning leaders

Linking leader compensation to goals

Extensive leader development

Cascading goals and aligned accountabilities

Performance bonuses

“What [my leader] has on her performance targets are written so that by me doing my work, I’m supporting what she’s doing and so on, down the line. It sounds so logical, but we weren’t operating in that fashion [before Baldrige].”

“We have the nursing leadership academy which really targets [all clinical team members] who might be future leaders.”

“We have a bonus program here and it starts at the manager level . . . . We align them with the performance indicators. It does work well.”

3. Acquiring and developing talent

Standards address recruitment, hiring, placement, retention, and systematic focus on career progression

Use of behavioral standards, peer interviewing

Employee referral bonuses

“We have twelve behavioral standards in the organization we’ve created through the [Baldrige process], through our teams . . . . [We had a team] that created a whole behavioral interviewing guide that’s aligned with both pillars of excellence, the behaviors of the organization and also the values of the organization.”

“We have an employee referral bonus program and that was just recently revamped. But we want to reward our own employees. We feel like they’re our best assets. They are the best witness to somebody who might be to the caliber that we need on our team.”

4. Empower- ing the front line

Emphasis on “open culture” and safe, trusting environment

Standards for workforce empowerment and decision making

Collaborative decision-making valued

Organization emphasizes employment security

“We push decision making down and [have] a lot of collaborative practice teams with multi-disciplinary groups. We do probably more communication and decision making than most organizations.”

“Our organization is about employment security as it relates to—if we look at what we’re doing right now, we’re doing everything to avoid lay-offs. And it is about doing the right decision making and protecting and securing our employees.”

Abbreviation: HPWP, high-performance work practice.

How HPWSs Drive Health Care Value 201

In terms of the specific HPWPs we studied, we found that the engaging staff subsystem, in particu- lar, had a high degree of relevance across all 3 process improvement strategies. To us, this underscores how essential this subsystem and its component prac- tices are to these process improvement strategies in particular and perhaps to all organizational improve- ment efforts. The centrality of this subsystem to or- ganizational effectiveness and performance was also emphasized by comments from members of our prac- titioner advisory panel who participated in the devel- opment of the HPWP model17 and who viewed this subsystem as enabling all other work practices in the HPWP model. If this is indeed the case, then the en- gaging staff subsystem could be useful for explaining interorganizational differences in degrees of success with respect to process improvement efforts.

Limitations

Our research has several important limitations. First, in terms of the field research, although we had a robust sample of key informants, the total num- ber of organizations that had implemented each im- provement strategy was limited because not all 5 of the organizations in the study were implementing each of the improvement strategies we examined. For Baldrige, in particular, our interview data relied on multiple interviews conducted at a single orga- nization. While we are confident that the results we report are valid across this organization, this study limitation makes it impossible to fully tease out the effects of the Baldrige strategy versus organization- specific effects. A second key limitation relates to our study methodology. Our secondary analyses of these case study data meant that we were relying on informants to make associations between the HPWP model and the process improvement strategies rather than directly responding to questions about these strategies. While this approach strengthens our con- fidence in the evidence we found, we recognize that we were unable to target and interview key infor- mants who might have been particularly informa- tive with respect to the issues we considered in this study.

CONCLUSIONS

Our study suggests that given the strengths and limitations of these popular process improvement strategies with respect to their incorporation of HP- WPs, some may work better than others for individ- ual health care organizations, depending on the or- ganizations’ current management systems. In prac- tice, most organizations implementing these strate- gies would benefit from considering their relation- ships to evidence-based HPWPs in order to maximize their potential to increase value in health care.

REFERENCES

1. Vest JR, Gamm LD. A critical review of the research litera- ture on Six Sigma, Lean and StuderGroup’s Hardwiring Ex- cellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implement Sci. 2009;4:35.

2. American Nurses Credentialing Center. ANCC Magnet Recognition Program. American Nurses Credentialing Cen- ter Web site. http://www.nursecredentialing.org/Magnet.aspx. Accessed December 8, 2011.

3. Studer Q. Hardwiring Excellence. Gulf Breeze, FL: Fire Starter Publishing; 2003.

4. Spaulding AC, Gamm LD, Griffith JM. Studer unplugged: iden- tifying underlying managerial concepts. Hosp Top. 2010;88: 1-9.

5. Eldridge NE, Woods SS, Bonello RS, et al. Using the Six Sigma process to implement the Centers for Disease Control and Pre- vention guideline for hand hygiene in 4 intensive care units. J Gen Intern Med. 2006;21:S35-S42.

6. Fairbanks CB. Using Six Sigma and Lean methodologies to improve OR throughput. AORN J. 2007;86:73-82.

7. Womack JP, Miller D. Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement; 2005.

8. Arnheiter ED, Maleyeff J. The integration of Lean management and Six Sigma. TQM Magazine. 2005;17:5-18.

9. Dahlgaard JJ, Dahlgaard-Park SM. Lean production, Six Sigma quality, TQM and company culture. TQM Magazine. 2006;18:263-281.

10. American Society for Quality: Six Sigma Black Belt Certifica- tion. American Society for Quality Web site. http://prdweb. asq.org/certification/control/six-sigma/index. Accessed De- cember 8, 2011.

11. National Institute of Standards and Technology. Baldrige National Quality Program: 2011-12 Health Care Crite- ria for Performance Excellence. http://www.nist.gov/baldrige/ publications/hc_criteria.cfm. Accessed January, 2012.

12. Foster JJ, Pitts W. Implementation of an insulin therapy proto- col: applying the Baldrige approach. Am J Health Syst Pharm. 2009;66:1035.

202 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 21, ISSUE 3, JULY–SEPTEMBER 2012

13. Goldstein SM, Schweikhart SB. Empirical support for the Baldrige Award framework in US hospitals. Health Care Man- age Rev. 2002;27:62.

14. Harley B, Allen BC, Sargent LD. High performance work systems and employee experience of work in the service sector: the case of aged care. Br J Ind Relat. 2007;45: 607-633.

15. Harmon J, Scotti DJ, Behson S, et al. Effects of high- involvement work systems on employee satisfaction and service costs in veterans’ healthcare. J Healthc Manage. 2003;48:393-405.

16. West MA, Guthrie JP, Dawson JF, Borrill CS, Carter M. Reduc- ing patient mortality in hospitals: the role of human resource management. J Organ Behav. 2006;27:983-1002.

17. Garman AN, McAlearney AS, Harrison MI, Song PH, McHugh M. High-performance work systems in health care manage- ment, part 1: development of an evidence-informed model. Health Care Manage Rev. 2011;36:201-324.

18. McAlearney AS, Garman AN, Song PH, McHugh M, Robbins J, Harrison MI. High-performance work systems in health care management, part 2: qualitative evidence from five case stud- ies. Health Care Manage Rev. 2011;36:214-226.

19. Liker JK, Morgan JM. The Toyota way in services: the case of Lean product development. Acad Manage Perspect. 2006;20:5-20.

20. Miles MB, Huberman AM. Qualitative Data Analysis: An Ex- panded Sourcebook. Thousand Oaks, CA: SAGE Publications; 1994.

21. Glaser BG, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. New Brunswick, NJ: Al- dine Transaction; 1967.

22. Atlas.ti. 6.0 ed. Berlin, Germany: Scientific Software Devel- opment GmbH; 2009.

23. Coronado RB, Antony J. Critical success factors for the suc- cessful implementation of Six Sigma projects in organisations. TQM Magazine. 2002;14:92-99.