Creating Organizational Climates and Working Conditions that Foster Quality and Safety

On September 29, 2010, Ann McAlearney made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (2.4 MB). Free PowerPoint® Viewer (Plugin Software Help).

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Creating Organizational Climates and Working Conditions that Foster Quality and Safety

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Session Agenda

• Part 1: "High-Performance Work Practices in Healthcare: A Framework for Process Improvement Through People" (Andy Garman)
• Part 2: "Work Practices in Sharp Healthcare" (Nancy Pratt)
• Part 3: "Five Case Studies of High-Performance Work Practices in Healthcare" (Ann Scheck McAlearney)
• Part 4: Questions, Answers, & Discussion

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Session Learning Objectives

• Part 1: Participants will be able to identify high-performance work practices that are relevant to quality, safety, and efficiency goals in healthcare systems.
• Part 2: Participants will be able to analyze an example of adapting high-performance practices to the contexts of a particular leading system.
• Part 3: Participants will be able to describe how five high-performing healthcare systems use evidence-based workforce practices to improve their performance.

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Research Team Members and Co-Authors

Ohio State University

• Ann Scheck McAlearney, ScD, Associate Professor, Health Services Management and Policy (HSMP)
• Paula Song, PhD, Assistant Professor, HSMP
• Julie Robbins, MHA, Doctoral Student, HSMP

Rush University Medical Center

• Andrew Garman, PsyD, Associate Professor and Associate Chair, Dept. of Health Systems Management

Health Research and Educational Trust/AHA

• Megan McHugh, PhD, Director, Research

Agency for Healthcare Research and Quality

• Michael Harrison, PhD, Sr. Social Scientist, Organizations & Systems

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Advisory Panel Members

• Peter I. Buerhaus, Ph.D., RN, FAAN, Professor of Nursing, Vanderbilt University
• Myron D. Fottler, Ph.D., Dir. of Programs, U. of Central Florida
• Jane Grady, Ph.D., Asst. VP, Human Resources, Rush University Medical Center
• Stephen R. Grossbart, Ph.D., Corporate Quality Officer, Catholic Healthcare Partners
• Stephen R. Mayfield, DrHA, MBA, MBB, Sr. VP for Quality and Performance Improvement, & Quality Center Director, AHA
• Nicole Morin-Scribner, MBA, SPHR, Dir. Of Human Resources, St. Mary's Health System
• Nancy Pratt, RN, MS, Sr. VP, Clinical Effectiveness, Sharp HealthCare

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Slide 6. Research Goals

Research Goals

• To identify an HR practice or practice bundle with the potential to enhance the quality (safety, efficiency, patient-centeredness, equity, or efficiency) of health care.
• To develop recommendations for implementing that practice/bundle to enhance its dissemination and use within healthcare organizations.

Image: A dictionary with the word "research" highlighted is shown.

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Rationale for Study

• Evidence of lower quality of care, lapses in patient safety.
• Central to delivery of high-quality patient care is presence of capable workforce.
• Growing support for link between staffing patterns and patient outcomes.
• Innovative HR practices, also known as high-performance work practices (HPWPs) may represent an important and underutilized strategy to improve health care systems.

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Part 1: "High-Performance Work Practices in Healthcare: A Framework for Process Improvement Through People"

Presenter:  Andrew N. Garman, Psy.D.

Rush University Medical Center

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Introduction

• 'People strategy' is critical to success:
  • Personnel costs are single largest expense in health services delivery.
  • A stable, high-quality healthcare workforce is critical to efficient and effective health services delivery.
  • Many other human factors have also been found to influence patient perceptions as well as quality of care.

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How can these 'people practices' best be integrated?

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Research from other sectors may help

• High-Performance Work Practices (HPWPs):
  • Personnel practices associated with improved organizational performance.
  • Mutually reinforcing HR systems (or 'bundles') are likely to have greater impact.
  • Considerable research attention spanning the past 15 years.

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HPWP Logic Model

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Organizational Factors

Image: A flow chart showing the Inputs, Work systems, and Outputs is shown.

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The 'enabling' bundle: Organizational Engagement

• Conveying mission & vision
• Information sharing
• Performance-contingent reward / recognition
• Employee involvement in decision-making

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2. The "high leverage" bundle: Staff Acquisition & Development

• Rigorous recruiting
• Selective hiring
• Extensive training
• Career development / internal labor pools

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3. The "direct effect" bundle: Frontline empowerment

• Employment security
• Reduced status distinctions
• Teams / decentralized decision-making

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4. The "leadership" bundle: Leadership alignment and development

• Management training linked to organizational needs & goals
• Performance-contingent compensation for broader goals
• Development / continuity planning

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Part 2: "Work Practices in Sharp Healthcare"

Presenter:  Nancy Pratt, RN, MS
Senior Vice President
Clinical Effectiveness
Sharp HealthCare

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Part 3: Five Case Studies of High-Performance Work Practices in Healthcare

Presenter:  Ann Scheck McAlearney, Sc.D.
Associate Professor, Health Services Management and Policy, College of Public Health, The Ohio State University
Associate Professor, Pediatrics, College of Medicine, The Ohio State University

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Case Study Approach

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Site Selection Criteria

• Variability in organizational context (i.e., organization type, location, size).
• Variability in approach to selected HR practice(s) (i.e., degree of centralization; locus of control; integration of HR practice within operations).
• Identification of organizations known to have innovative and/or best practices.
• Potential for cases to serve as best practices examples worthy of attention and possible emulation by other healthcare organizations.

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Site Visit Process

• Five study site visits
• Semi-structured interviews held with key informants
• Rigorous analysis of interview data
• Organizational documents collected and reviewed, as appropriate (e.g., orientation materials, development plans)

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Key Informants Interviewed

• HR professionals
• Organizational leaders
• Clinical leaders
• Quality improvement professionals
• Information systems managers/directors
• Finance and accounting professionals
• Selected administrative and clinical personnel involved in HR practice (e.g., program participants)

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Interview Domains

• Organizational Structure
• History and Context of HR Practices
• HR Practice Selection, Adoption, Implementation, Operations, and Evaluation
• Business Case
• Impact on Patient Safety, Quality of Care
• HPWP Model Fit

Image: A magnifying glass is shown.

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Case Study Results

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Overview of Case Study Sites

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Variability in concept of "high-performance work practices"

• "Trying to identify practices in some evidence-based way that will help the organization achieve its goals."
• "To me, the biggest 'slice' would be communication—how much are you siloed—Do we have too many silos?"
• "It's that fusion and blend of our people and what they create for their customers. Engagement isn't just in one division."
• "Something becomes high performing if it has an infrastructure to sustain and to measure."
• "How one creates a culture of empowerment, one that permeates from the frontline through executive levels."
• "Achieves the outcome desired, standardized across systems to achieve goals."

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Defining "high-performance work practices" (continued)

• "'Best of breed' hiring people to do our work rather than consultants. Continuously evaluating performance against external metrics."
• "Goal alignment, role clarification, proper education around those things. What are the roles, expectations, how am I doing? Making sure everyone understands their role."
• "I think of it in terms of associate engagement—our two-way communication practices. We know that if our associates are engaged and satisfied, it means good patient care."
• "Ability to execute in a balanced way. Quality and safety being first, having strong financial performance, good relationships with associates and physicians, and operational excellence."

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Applying the Model of High-Performance Work Practices to Healthcare

Image: Three people sitting in an office are shown.

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HPWP Bundle #1: Organizational Engagement

• "There's not a meeting where the mission and vision aren't discussed or put in front of you in the same way."
  
• "Everyone anxious to drive a new culture within our system"
  
• "We hold each other accountable . to how we are going to behave."
  

*Note: Performance Contingent Compensation addressed in Bundle #4.

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HPWP Bundle #2: Staff Acquisition/ Development

• "If you teach values the right way, they know right away what we're all about and if they are going to fit in."
• "When in doubt, keep them out!"
• "If a team is involved in selection, there's more buy-in"
• "Our theory, we should focus most of our time with our high potentials"

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HPWP Bundle #3: Frontline Control/ Freedom to Challenge

• ". how one creates a culture of empowerment, one that permeates from frontline through executives, minimize hierarchy.
• "Being able to speak up and stop a procedure--there's training for that.that's been embraced."
• "Managers are completely empowered to work with doctors and housekeepers to ensure their unit works."

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HPWP Bundle #4: Leadership Alignment/ Development

• "Getting more and more true physician leaders over the past four years. leadership and training around patient safety."

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Explicit Link Between HPWP and Patient Safety, Quality of Care I

• Culture-based focus on safety, "just culture," or "patients first" has been credited with infusing quality improvement mindset and behavior throughout the organization:
  • "Staying here requires caring behaviors."
  • "Our goal is to make staff successful and skilled at their jobs, provide skills to help self-correct when an incident occurs."
  • "Looking through the lens of what through the system can be done to reduce errors and then looking at human error. If we punish people for making a mistake unjustly, they will not report."
  • Use of peer "Safety Coaches" at one site:
    • Percentage of employees who self reported "speaking up" and "completely expressing their concerns" increased from 17% to 42%
    • Safety coach observations went up from 1,000 to 2,750 after training.

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Explicit Link Between HPWP and Patient Safety, Quality of Care II

• Positive perception of link, but difficult to document:
  • Indirect measures: Focus on safety events and reporting "good catches" (near misses) resulted in 60-70% reduction in serious/sentinel events; reduced premiums for malpractice also noted.
• Organizing framework or process credited with linking HPWP and quality:
  • Process improvements due to Lean have resulted in improved clinical quality (e.g., infection rates).
  • Studer Group Pillars incorporated into many aspects of work life (e.g., performance).
• Use of scorecards credited for driving quality improvement:
  • We have a "graph that shows our balanced scorecard results. Direct correlation—trajectory slide that shows" this relationship.

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Common Themes Across Study Sites I

• Emphasis on culture, "just culture," "culture of safety," culture change:
  • Described as a "journey," driven by leaders.
• Use of standardized metrics/ scorecards tied to strategic goals, tied to workforce performance.
• Use of external frameworks/resources very helpful:
  • Examples: Studer Group, Baldrige, Lean, Nurse Magnet.
• Business case not well articulated but widely supported.

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Common Themes Across Study Sites II

• Use of standardized, recognizable "tools" and approaches, evolved as needs change
  • Example: "Right from the Start"
• Strong belief in link between HPWPs and quality, but pursued more as a "leap of faith," but other benefits recognized
  • Employee engagement, recruitment, confidence/trust
  • Strong employee pride

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Critical Success Factors for HPWP Implementation, Use

• Strong, committed, and involved leadership
• Emphasis on "organizational culture"
  • Deliberate effort: includes articulation of vision, rigorous gap analysis, and recognition that change is not overnight ("journey")
• Use of an organizing framework/model, e.g. Baldrige, Studer Group, Lean
• Communication!!

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Common Challenges of HPWP Implementation, Use

• Physician involvement: level of engagement and buy-in varies
• Unionized employees

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Next Steps

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What's Next?

• Expansion of study through AHRQ to look specifically at the role of HPWPs in efforts to reduce healthcare-associated infections.
• Scan of active research in HAIs.
• Additional case studies (4 new, 2 expanded):
  • New selection criteria.
  • Comparison cases.

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Final Thoughts

• There is huge potential for HPWPs in healthcare organizations.
• More study is needed:
  • Investigation of more organizations.
  • Consideration of different initiatives.
  • Alternative organizational samples.
  • Quantitative analyses.
• We are delighted we have been able to begin this research.

Slide 43

Any Questions?

Andrew Garman
Nancy Pratt
Ann Scheck McAlearney

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Supplemental Information

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Related Publications

• Garman, A., McAlearney, A.S., Song, P., Harrison, M., McHugh, M. 2009. "High-Performance Work Practices in Healthcare Management: An Evidence-Based Review and Synthesis." Proceedings of the Sixty-Ninth Annual Meeting of the Academy of Management.
• McAlearney, A.S.; Garman, A.; Song, P; McHugh, M.; Robbins, J.; Harrison, M. 2010. "Supporting Those Who Dare to Care: Five Case Studies of High-Performance Work Practices in Healthcare." Best Paper Proceedings of the Seventieth Annual Meeting of the Academy of Management.
• McHugh M., Garman A., McAlearney A., Song P., and Harrison M. Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals. Health Research & Educational Trust, Chicago, IL. March 2010.