Case Study 3 Barriers to an Effective QI Effort District Hospi

Case Study 3 Barriers to an Effective QI Effort
District Hospital is a 260-bed, public, general acute care
hospital owned by a special tax district . Its service area
includes five communities with a total population of 180,000 in
a southeastern coastal state in one of the nation's fastest-
growing counties. It is one of three hospitals owned by the
special tax district. The seven other hospitals in District
Hospital's general service area make the environment highly
competitive. District Hospital has a wide range of services and
the active medical staff of 527 repre- sents most specialties. The
emergency department (ED) is a major source of admissions.
Last year, 26,153 patients visited the ED and 3,745, or 14.3%,
were admitted. This was 42% of total hospital admissions. Some
admissions were sent to the ED by private physicians and some
came by ambulance, but most were self-referred. The hospital
chief executive officer, W.G. Lester, noted that the number of
visits to the ED was decreasing. Over a 3-year period, they had
declined from a high of 29,345 to the current low of 26,153.
Only part of this reduction seemed attributable to competition.
Lester was also concerned about an increasing number of
complaints concerning the quality of ED services. The
complaints related to waiting time, poor attitudes of physicians,
and questions about the quality of care. Investigation found that
many complaints were justified, the causes of these problems
were difficult to discern. Registered nurses (RN) employed in
the ED want a larger role in triaging and treating patients, but
the dominance of ED physicians limits the RNs' duties and
frustrates other staff, as well. This is manifested among RN
staff by high turnover, low morale, and difficulty in re-
cruitment and retention. Another factor is the emergency
medical technician (EMT) program started in the county a few
years ago. The EMTs are an important community medical
resource and are very influ- ential in deciding the hospital to

which patients in ambulances will be transported. It will be
necessary for District Hospital, through the ED physicians, to
participate actively in training and managing the EMT program
if District Hospital is to receive its share of emergency pa-
tients. ED physicians have refused to participate in teaching or
directing the program, however. In fact, they often alienate the
EMTs. Lester is concerned, too, that the position of full -time
director of emergency medicine at District Hospital has been
vacant for 4 years. Residency programs in emergency medicine
are producing physicians who are seeking positions with higher
salaries and better working condi- tions than those available at
District Hospital. There has been little turnover among the six
physicians who staff the ED; they include one general surgeon
(retired from private practice), two internists, and three non-
U.S.-trained medical graduates with specialties in family
practice. The ED physicians seem to lack a clear commitment to
District Hospital . All of them contract separately w ith the
hospital to provide ED services. District Hospital bills ED
patients and collects the physicians' fees: moneys above the
guaranteed minimum are paid to them pro rata. They participate
in District Hospital's fringe benefits and are covered by its
professional liability insurance policy. One ED physician, Dr.
Balck (the retired surgeon), recognizes the progress being made
nationally in emergency medicine. She made several
unsuccessful attempts to move District Hospital in the same
direction. With great effort, she instituted programs on
intradepartmental education and mandatory attendance at
approved courses in emergency medicine. Quality related
activities, however , are done perfunctorily. Also, she has tried
to obtain full recognition The members of the PSO seem
satisfied with the situation. Its executive committee does not
understand the changing status of emergency medicine. As
evidence of its unwillingness to grant full recognition to the
department, the PSO has consistently denied the ED's requests
of the ED and its work by other members of the PSO. for full
departmental status.

Week 6 Case QuestionsDesign and Control in Quality
Improvement Initiatives
Chapter 11, Case 3: “Barriers to an Effective QI Effort”
Questions:
1. Use the principles of QI from Chapters 7 and 8 to outline a
basic effort to improve quality in the ED.
2. Identify some control measures that Lester could use.
© 2016 Laureate Education, Inc. Page 1 of 1
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
214 JulyYSeptember & 2011
Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized
reproduction of this article is prohibited.1

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
Cases of High-Performance Work Systems 215
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
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
group
reports, and
plans for cascading information down throughout the
organization
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

group
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.
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.
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
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)
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
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 organizati ons 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 forme r
and narrowed our
original definition of ‘‘employee security’’ to refer to the latter.

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, organizati onal 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.
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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