Creating Organizational Climates and Working Conditions that Foster Quality and Safety

Slide presentation from the AHRQ 2010 conference.

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).

Slide 1

Slide 1. Creating Organizational Climates and Working Conditions that Foster Quality and Safety

Creating Organizational Climates and Working Conditions that Foster Quality and Safety

Slide 2

Slide 2. Session Agenda

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

Slide 3

Slide 3. Session Learning Objectives

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.

Slide 4

Slide 4. Research Team Members and Co-Authors

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

Slide 5

Slide 5. Advisory Panel Members

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

Slide 6

Slide 6. Research Goals

Research Goals

  1. 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.
  2. 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.

Slide 7

Slide 7. Rationale for Study

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.

Slide 8

Slide 8. Part 1: High-Performance Work Practices in Healthcare: A Framework for Process Improvement Through People

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

Slide 9

Slide 9. 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.

Slide 10

Slide 10. How can these people practices best be integrated?

How can these 'people practices' best be integrated?

Image: 20 different charts and company logos are shown.

Slide 11

Slide 11. Research from other sectors may helpp

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.

Slide 12

Slide 12. HPWP Logic Model

HPWP Logic Model

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

Slide 13

Slide 13. Organizational Factors

Organizational Factors

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

Slide 14

Slide 14. The enabling bundle: Organizational Engagement

The 'enabling' bundle: Organizational Engagement

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

Slide 15

Slide 15. 2. The high leverage bundle: Staff Acquisition and Development

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

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

Slide 16

Slide 16. 3. The direct effect bundle: Frontline empowerment

3. The "direct effect" bundle: Frontline empowerment

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

Slide 17

Slide 17. 4. The leadership bundle: Leadership alignment and development

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

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

Slide 18

Slide 18. Part 2: Part 2: Work Practices in Sharp Healthcare

Part 2: "Work Practices in Sharp Healthcare"

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

Slide 19

Part 19. Part 3: Five Case Studies of High-Performance Work Practices in Healthcare

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

Slide 20

Slide 20. Case Study Approach

Case Study Approach

Image: An office meeting table is shown with empty chairs.

Slide 21

Slide 21. Site Selection Criteria

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.

Slide 22

Slide 22. Site Visit Process

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)

Image: Four people walking, pulling suitcases is shown.

Slide 23

Slide 23. Key Informants Interviewed

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)

Slide 24

Slide 24. Interview Domains

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.

Slide 25

Slide 25. Case Study Results

Case Study Results

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Slide 26

Slide 26. Overview of Case Study Sites

Overview of Case Study Sites

SiteSize/StructureRecognitionsMajor Workforce Initiatives
1Large urban, multi-site health system, Midwest ~15,000 FTEsFortune "Best Places to Work," Nurse Magnet (2 sites)
  •  Focus on "Just Culture" for patient safety
  • "Right from the Start" for selection/onboarding; emphasis on culture and fit
  • Extensive information sharing, recognition and rewards
  • Aligned accountabilities, performance contingent compensation
2Large urban, multi-site health system, Pacific ~15,000 FTEsBaldridge, Nurse Magnet (2 sites)
  • Focus on "Just Culture" for patient safety
  • Internally branded platform for goal alignment/ communication
  • Behavioral standards, used for selection/performance
  • Organizing framework= Baldrige, Studer Group "Pillars," Lean for process excellence
3Urban "safety net" hospital, Mountain ~5,600 FTEsNone, to date
  • "Right People" Strategy widely embraced
  • Lean used as platform for improvement, HR considered a "value stream"
  • Focus on "Talent Plus" for recruiting
4Rural multi-site health system, Northeast ~3,400 FTEsDavies award for EHR implementation
  • "Patients First" culture
  • Organizing framework= Studer Group "Pillars"
  • Extensive information sharing, focus on leadership development

Slide 27

Slide 27. Variability in concept of high-performance work practices

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."

Slide 28

Slide 28. Defining high-performance work practices (continued)

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."

Slide 29

Slide 29. Applying the Model of High-Performance Work Practices to Healthcare

Applying the Model of High-Performance Work Practices to Healthcare

Image: Three people sitting in an office are shown.

Slide 30

Slide 30. HPWP Bundle #1: Organizational Engagement

HPWP Bundle #1: Organizational Engagement

Common PracticesUnique Innovations
Conveying Mission, Vision, Values
  • Culture change focus
  • Structured framework, e.g., "pillars"
  • Incorporated from orientation- performance management
  • Use of "behavioral" standards
  • Annual "sign off" on mission as part of performance review
  • Feedback from new employees at 90 days regarding "fit"
Information Sharing
  • Large gatherings
  • Std. communication, cascading, intranet
  • Report cards widely used as vehicle for communication
  • Safety messages on screensaver
  • Use of "affinity" groups for cross-campus sharing
Employee Involvement in Decisions
  • Use of employee councils or committees, e.g., nursing
  • Inter-professional "rounding"
  • "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.

Slide 31

Slide 31. HPWP Bundle #2: Staff Acquisition/ Development

HPWP Bundle #2: Staff Acquisition/ Development

Common PracticesUnique Innovations
Rigorous Recruiting
  • Sites perceived as highly attractive employers
  • Competitive pay
  •  Incentives for peer-referral
Selective Hiring
  • Consider cultural "fit"
  • Selection, onboarding one process
  • Use of "behavioral" standards
  • Peer/ employee developed standards
  • Use of fit-oriented tool/process (T+)
Extensive Training
  • Starts with orientation, continues
  • Use of large, leader and staff forums
  • Robust "corporate university" or formal relationships with local universities
  • Use of "simulation lab" to identify/address gaps for new grad nurses
Career Development
  • Leadership dev. for high potential managers
  • Mentoring programs
  • Subsidies for conferences
  • "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"

Slide 32

Slide 32. HPWP Bundle #3: Frontline Control/ Freedom to Challenge

HPWP Bundle #3: Frontline Control/ Freedom to Challenge

Common PracticesUnique Innovations
Employment Security
  • None reported layoffs, most have long tenure, low turnover
  • Emphasis on redeployment


Reduced Status Distinctions
  • All articulate support for "speaking up," but recognize challenges
  • Shared governance
  • Use of multi-level "accountability team"
  • Use of trained/ empowered "safety coaches" on each unit
  • Employee/management "service teams" for key issues
Teams/ Decentralized Decisions
  • Manager empowerment
  • Use of report card for accountability at division/ unit level
  • Use of employee "innovation teams" to generate ideas for strategic growth
  • ". 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."

Slide 33

HPWP Bundle #4: Leadership Alignment/ Development

Common PracticesUnique Innovations
Management training linked to organization needs
  1. Leadership development for promising mid-level managers
  2. Management training curriculum
  1. Emerging leader program to develop management skills among promising non-management employees
  2. Physician leadership coaching
Succession Planning
  1. Leaders charged with identifying potential successors
  1. Use of formal "talent management" system to surface
Performance-contingent compensation
  1. If used, tied to scorecard results
  2. Most have for executives, some for management
  • "Getting more and more true physician leaders over the past four years. leadership and training around patient safety."

Slide 34

Slide 34. Explicit Link Between HPWP and Patient Safety, Quality of Care I

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.

Slide 35

Slide 35. Explicit Link Between HPWP and Patient Safety, Quality of Care II

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.

Slide 36

Slide 36. Common Themes Across Study Sites I

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.

Slide 37

Slide 37. Common Themes Across Study Sites II

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

Slide 38

Slide 38. Critical Success Factors for HPWP Implementation, Use

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!!

Slide 39

Slide 39. Common Challenges of HPWP Implementation, Use

Common Challenges of HPWP Implementation, Use

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

Slide 40

Slide 40. Next Steps

Next Steps

Image: A row of dominos falling is shown.

Slide 41

Slide 41. What's Next?

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.

Slide 42

Slide 42. Final Thoughts

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

Slide 43. Any Questions?

Any Questions?

Andrew Garman
Nancy Pratt
Ann Scheck McAlearney

Slide 44

Slide 44. Supplemental Information

Supplemental Information

Image: An open book is shown.

Slide 45

Slide 45. Related Publications

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.
Current as of December 2010
Internet Citation: Creating Organizational Climates and Working Conditions that Foster Quality and Safety. December 2010. Agency for Healthcare Research and Quality, Rockville, MD.