A Guide for Hospitals
The purpose of this guide is to provide hospital leaders and human resources staff a basic description of four high-performance work practices (HPWPs) that can help improve an organization's capacity to effectively attract, select, hire, develop, and retain and deploy personnel in ways that best support a high-performing health care system. It also offers approaches and recommendations for implementing HPWPs in their organizations.
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Contents
Acknowledgments
Introduction
HPWP Category 1: Organizational Engagement Practices
HPWP Category 2: Staff Acquisition and Development Practices
HPWP Category 3: Frontline Empowerment Practices
HPWP Category 4: Leadership Alignment/Development
Facilitating the Adoption of High-Performance Work Practices
Conclusion
Organizational Assessment
Resources
Acknowledgments
The Health Research & Educational Trust (HRET), an
affiliate of the American Hospital Association (AHA), is dedicated to
transforming health care through research and education. The research and
publication costs for this guide were funded by the Agency for Healthcare
Research and Quality (Contract No. HHSA290200600022, Task Order No. 5).
We appreciate the work of the following contributors who
served as advisors to this project:
Peter I.
Buerhaus, Ph.D., RN, FAAN
Professor of
Nursing
Vanderbilt University
Myron D.
Fottler, Ph.D.
Director of
Programs
University of Central Florida
Jane Grady,
Ph.D.
Assistant
Vice President, Human Resources
Rush University Medical Center
Stephen R.
Grossbart, Ph.D.
Corporate
Quality Officer
Catholic Healthcare Partners
Stephen R.
Mayfield, Dr.H.A., M.B.A., M.B.B.
Senior Vice
President for Quality and Performance Improvement
Quality
Center Director
American Hospital Association
Nicole Morin-Scribner,
M.B.A., SPHR
Director of
Human Resources
St. Mary's Health System
Nancy Pratt,
RN, M.S.
Senior Vice
President, Clinical Effectiveness
Sharp HealthCare
Contact Information; Michael Harrison, AHRQ. E-Mail: Michael.Harrison@ahrq.hhs.gov.
The authors of this report are responsible for its content.
The authors and investigators have all provided assurances to AHA and AHRQ that
they did not have any affiliations or financial involvement that created a
conflict of interest with respect to any of the material or conclusions
presented in this publication. Funding of the Guide by the Agency for
Healthcare Research and Quality in the U.S. Department of Health and Human
Services was provided to collect and disseminate employment practices that have
yielded high quality outcomes. The contents of the Guide should not be
interpreted as mandatory national standards of clinical practice or quality
health care.
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Introduction
There is ample evidence indicating the need to improve
health care quality. Health care organizations have been investing significant
resources to implement systems and processes to improve care quality, but must
pursue these efforts strategically in order to maximize their effectiveness
within an environment of growing resource constraints.
A considerable amount of information suggests that workforce
practices may represent an important and underutilized resource for supporting
quality improvement activities in health care organizations. The availability
of a stable, capable health care workforce has been shown repeatedly to be
critical to the efficient and effective delivery of health services. Although researchers are still
investigating links between workforce
practices and care quality, the
findings so far suggest
that several practices hold the potential to positively affect organizational
outcomes.
The purpose of this guide is to provide hospital leaders and
human resources staff a basic description of four high-performance work
practices (HPWPs) that can help improve an organization's capacity to
effectively attract, select, hire, develop, and retain and deploy personnel in
ways that best support a high-performing health care system. It also offers
approaches and recommendations for implementing HPWPs in their organizations. These
HPWPs fall into four categories.
- HPWP Category 1: Organizational Engagement Practices:
Practices that ensure all
employees' awareness, understanding, and personal stake in the organization's
vision, including its current level of success in pursuing that vision.
- Communicating
mission, vision, and values.
- Sharing
performance information.
- Involving
employees in key decisions.
- Tracking
and rewarding performance.
- HPWP Category 2: Staff Acquisition and Development Practices:
Practices that build the quality
of the organization's workforce through attention to attracting, selecting, and
developing staff.
- Rigorous
recruiting.
- Selective
hiring.
- Extensive
training.
- Career
development.
- HPWP Category 3: Frontline Empowerment Practices:
Practices that affect the ability
and motivation of frontline staff to improve the quality of care that their
teams provide.
- Employment
security.
- Reduced
status distinctions.
- Teams/decentralized
decisionmaking.
- HPWP Category 4: Leadership Alignment and Development Practices:
Practices that develop leaders and
align behavior with organizational goals.
- Linking
management training to organizational needs.
- Planning
succession.
- Tracking
and rewarding performance.
These numerous HPWPs can be facilitated by the following
actions, which will be expanded upon in a later section of this guide:
- Commit to an organizational culture that focuses on quality and
safety.
- Engage senior leadership support.
- Involve the human resource department in strategic planning.
- Identify opportunities for shared learning.
- Hire human resources professionals with training and experience
in HPWPs.
- Involve employee representatives.
- Monitor progress.
The implementation recommendations presented below were
distilled from a review of peer-reviewed and gray literature covering health care
and other industries, and from findings from case studies of five health care
organizations that have been recognized for their successful workforce
practices (e.g., Fortune magazine's "Best Companies to Work For,"
Baldrige National Quality Award). A checklist for readers to document and
assess the extent to which HPWPs are used in their organizations is available
later in this guide.
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HPWP Category 1: Organizational Engagement
Practices
Organizational engagement practices are designed to enhance
employees' awareness and personal stake in the organization's vision and its
current level of success in pursuing that vision. Four HPWPs fall under the
heading of Organizational Engagement.
1. Communicating
Mission, Vision, and Values
Description
Practices that communicate the organization's scope and
purpose to employees and clarify their role in supporting that purpose.
Implementation Recommendations
- Incorporate the organization's mission and values into new
employee orientation.
- Incorporate the organization's values into performance reviews;
have employees "sign off" on the mission as part of their annual review.
- Discuss mission and values at the start of all internal meetings;
discuss management decisions in the context of mission and vision; present the
organization's mission on the first slide for presentations.
2. Sharing Performance
Information
Description
Practices that communicate organizational performance and
other information affecting employees' jobs and job performance.
Implementation Recommendations
- Hold town hall meetings and other open forums to provide
overviews of organizational and departmental performance.
- Share performance "report cards" regularly and widely.
- Communicate news to employees through multiple channels (e-mail
and voicemail bulletins, intranet, newsletters).
- Monitor the effectiveness of communication strategies designed to
reach different audiences.
3. Involving Employees
in Key Decisions
Description
Practices supporting employees' ability to influence the "decisions
that matter."
Implementation Recommendations
- Create employee councils or committees and empower them to
influence key decisions.
- Hold town hall meetings and other open forums during which staff
can interact with leadership.
- Develop suggestion systems.
- Use a quality/process improvement model that empowers employees
to implement system improvements (e.g., Baldrige National Quality Award
criteria, Lean training).
4. Tracking
and Rewarding Performance
Description
Policies and practices that provide formal
rewards/recognition for employees' success in achieving organization-supportive
goals.
Implementation Recommendations
- Provide recognition awards to individuals and/or teams that are
tied to actions supporting the organization's mission and vision. Criteria for
individual awards should consider employees' contribution to teams.
- Award spot bonuses when employees go "above and beyond" in demonstrating
the organization's values.
- Provide annual bonuses based on organizational performance using
balanced scorecards.
Organizational Engagement in Action
Several years ago, an
academic medical center in the Midwest launched a large project focused on
integrating the organization's mission, vision, and values (MVV) into the work
and culture of the organization. The project, led by the organization's chief
operating officer, was adopted because of the belief that strong MVV can lead
to greater employee engagement and better organizational outcomes. The goal of
program during the first year was simply MVV awareness. All employees received
an hour of training on the organization's MVV, and the training was
incorporated into new employee and manager orientations. A survey of employees
following these trainings showed that the trainings were effective in
increasing awareness of the MVV.
The
second year of the program focused on engagement. The HR department developed
several tools for managers to increase the focus on MVV within their
departments and to foster an environment in which the values would flourish. Specifically,
managers were instructed on how to establish goals for employees that align with the organization's MVV and
to incorporate MVV into the annual performance reviews. The goal of the third
year of the project was adoption. Each month, the HR department developed
events and programs that focused on a different core value of the organization.
For example, "collaboration" was a value selected for one month, and the HR
department arranged for employees to create large greeting cards to show
appreciation for the work done by different teams.
The
project is overseen by a Work Culture Committee that includes the CEO, CFO, and
vice president of HR, and two positions were added to support the project. Progress
of the project is tracked through a periodic staff survey that consists of a
single question, "Would you rather work at this hospital than any other
hospital in the area?" Since the start of the project, the percentage of
employees who responded affirmatively to the question has steadily increased. Results
also indicate a strong correlation between employees' positive responses to the
question and their ability to identify their performance goals and how these
relate to the organization's goals.
Leaders
of the Work Culture project offered three recommendations for implementing the
project at other sites:
- Engage
senior executives. Grassroots activities are important, but rolling them out
and maintaining them organizationwide requires high-level support.
- Coordinate
timing so that the initiative does not conflict with other significant efforts.
If executives and employees are focused on other projects (e.g., electronic
health record implementation), it will be difficult to get their attention.
- "Slow
and steady wins the race." Incremental change brings small steps that lead to
steady progress.
|
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HPWP Category 2: Staff Acquisition and
Development Practices
The four HPWPs in this category focus on building the
quality of the organization's workforce through attention to attracting,
selecting, and developing staff.
1. Rigorous
Recruiting
Description
Activities and outcomes associated with outreach to attract
new employees.
Implementation Recommendations
- Identify your strengths as an employer. Survey your employees to
learn the reasons they choose to work with you rather than other employers, and
search for ways to further strengthen those attributes.
- Use your strengths to proactively cultivate the image of your
organization as a highly desirable place to work. This could be accomplished
through, for example, communicating the mission-driven focus of your staff,
quality of work life you offer, attractive benefits, flexible working
arrangements, competitive pay (e.g., 50th percentile for most jobs, 65% for managers, 75% for hard-to-fill positions).
- Develop highly efficient and targeted strategies for recruitment
for your high-volume and hard-to-fill positions, such as nurses and
pharmacists. For example, form partnerships with local schools and develop
special pages on your Web site for recruitment of hard-to-fill positions.
- Continuously evaluate your recruiting systems against industry
best practices. For example, review best recruiting practices offered by the
American Society for Healthcare Human Resources Administration (ASHHRA).
2. Selective Hiring
Description
Practices associated with ensuring that open positions are filled
with the highest quality candidates available from the applicant pool.
Implementation Recommendations
- Use prescreening tools for high-volume applicant positions.
- Adopt validated selection tools (e.g., objective assessments,
behavior-based interviewing) that tie selection to the knowledge, skills, and
attitudes that directly contribute to quality, safety, and other performance
goals.
- Assess candidates' fit within the culture of the organization
through peer interviewing and team selection processes.
3. Extensive Training
Description
Activities involving a more-than-mandated, more-than-typical
investment in developing staff in order to achieve greater organizational
effectiveness.
Implementation Recommendations
- Develop internal conferences and workshops around organizational
goals and skill development needs.
- Encourage continuing education activities that are aligned with
organizational goals through organizational sponsorships, and hold attendees
accountable for "bringing back" what they learn to their parts of the
organization.
- In areas where skills are not present in-house, consider bringing
in outside speakers, rather than (or in addition to) sending individuals out to
conferences.
4. Career Development
Description
Practices that focus on identifying career opportunities and
pathways for current employees, as well as providing training to support those
opportunities. Practices related to career development also include an emphasis
on internal labor pools for filling open positions.
Implementation Recommendations
- Emphasize opportunities to develop and recruit from within.
- Encourage flexibility to move within the organization to
departments or units that best fit employees' interests and skills.
- Provide educational support (e.g., tuition assistance) for
employees to pursue career paths within your organization.
Staff Acquisition and Development Practices
in Action
Five years ago, a large
safety net hospital launched a system transformation to improve quality. One
component of that transformation involved matching the right people to the
right positions. The organization's CEO and other senior leaders embraced
concepts from the book Good to Great, which holds that it is easier to
teach, correct, or remediate skill gaps than it is to address talent or
attitudinal gaps. Based on a strong recommendation from the head of a leading
firm in a non-medical service industry and with the help of an outside firm,
the organization adopted a talent assessment and selection process for new
recruits and applicants requesting a promotion.
The structured selection
process represented a significant change from hiring based solely on clinical
skills, training, credentials, and experience. The process involves a
systematic interview, which assesses candidates' abilities in several behavioral
areas (for example, ability to manage change and difficult situations or
ability to build relationships), with the goal of selecting people who will
support the desired culture of the organization. The selection system is
managed by an external provider, who monitors the protocol to ensure that the
process provides valid predictions for areas of importance to the organization.
Fifteen people within the
organization have been trained to conduct the structured interviews for
entry-level and managerial positions, and two consultants lead the interviews
for director-level and above positions. Retention rates among those who were
hired under the new process are higher than those who were not. To further
evaluate the process, the organization is now investigating the links between
their selection process and both absenteeism and patient satisfaction.
Although the organization
has now embraced the new selection process, it has created some challenges. The
interviews have to be scored, which adds 1 to 2 weeks to the hiring process.
Also, a hiring manager might not be able to select his or her top candidate if
the candidate does not score well on the interview. There is an appeal process
that will, in some cases, allow the manager to "override" the decision. There
are also concerns that the interview may not be culturally sensitive.
Organizations considering the adoption of a formal selection process should
always consider evidence of validity prior to implementation and involve
end-users in the implementation process. |
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HPWP Category 3: Frontline Empowerment
Practices
The three HPWPs in this category are those that most
directly affect the ability and motivation of frontline staff, clinicians in
particular, to influence the quality and safety of their care.
1. Employment
Security
Description
Policies and practices that ensure employees
greater-than-mandated security in their positions.
Implementation Recommendations
- Develop a commitment to preventing the need for layoffs, and
pursue organizational policies that provide for alternatives.
- Set policies that protect employees from repercussions for "speaking up" about
quality and safety concerns.
- Train staff on methods that will support and empower staff to
speak up when they observe potential problems with quality and safety.
- Reinforce appropriate examples of speaking up and supporting
patient safety by communicating and disseminating the examples.
2. Reduced Status
Distinctions
Description
Practices that emphasize egalitarianism across employee
roles.
Implementation Recommendations
- Have managers and organization leaders model openness and
availability to receive feedback from employees.
- Discourage the use of formal titles in team conversations (e.g.,
use first names).
- Provide training and policies that encourage teamwork and minimize
hierarchy.
3. Teams/Decentralized
Decisionmaking
Description
Practices of formalizing/defining employee roles according
to teams and providing those teams (and the individuals in them) greater
latitude in decisionmaking related to how their work is organized and
completed.
Implementation Recommendations
- Implement shared governance and staff practice councils.
- Hold regular team huddles to discuss current status and concerns.
- Provide opportunities for teams to participate together in
training.
- Involve members of departments/units in setting performance goals
and metrics.
- Consider employees' contribution to teamwork in performance
reviews.
Frontline Empowerment Practices in Action
Lean/Toyota Production
System (TPS) is well recognized as an effective approach to reducing waste and
inefficiency in health care. Lean is also an example of several HPWPs,
including the decentralization of decisionmaking and the reduction of status
distinctions.i
A safety net hospital in a
large metropolitan area selected Lean as its primary method of quality
improvement, integrating it into 15 areas of the organization, including human
resources, finance, and clinical care. Senior executives of the organization,
particularly the CEO, are strong supporters of Lean and described waste as
disrespectful because it squanders scarce resources, makes employees do work
with no value, and makes patients endure processes with no value.
The hospital has a Lean
department that employs 8 facilitators. With guidance from an outside
consultant (a "sensei"), the facilitators oversee approximately 120 rapid
improvement events (RIEs) per year within the organization. During an RIE, a
team of 8 to 10 staff spend a week focused on improving a particular process or
area. They spend the first 2 days mapping out the current process and
identifying possible improvements. By the third day, the team implements the
improvements; on the fourth day they turn the improvements into standard work;
and on the fifth and final day they report the results to executive staff.
Frontline employees and
executives work together on the RIE teams, which helps reduce status
distinctions within the organization. Frontline staff find RIEs to be
empowering because they serve as a vehicle for expressing ideas and
implementing change. Through the RIE process, the teams develop production
boards and matrices that they then post on the walls. The postings facilitate
communication and transparency about the changes occurring.
At this organization, 200
staff received additional Lean training and have earned the designation of "black
belt." The black belts are tasked with developing an idea for improvement every
other month and are expected to generate $30,000 in
cost savings each year. The CEO reviews monthly reports on their progress, and
this accountability creates considerable competition around finding ways to
eliminate waste.
Surveys
of employee engagement at this organization show that staff who are involved in
RIEs are more engaged than those who have not participated. The organization
estimates that it has saved more than $27 million through improvements
resulting from applications of Lean since the inception of the program.
i The
origins of Lean stem from the work of W. Edwards Deming, who called for
improvements in quality by focusing on improving the production process,
building quality into the product at the forefront instead of relying on later
inspections. Taichi Ohno of Toyota adopted and extended Deming's work for the
design of their manufacturing process, the Toyota Production System (TPS). The
TPS is focused on establishing a customer-focused environment, making
continuous improvements, correcting problems as they arise, and eliminating
waste. "Lean" was a term developed in the 1980s to describe the TPS.
Lean/TPS has been described
as a philosophy, a management strategy, and a set of tools or practices. As a philosophy, Lean calls for
bringing value to the customer and eliminating waste in the production process.
The Lean management strategy is focused on streamlining processes to reduce
cost and improve the quality and timeliness of products. Lean practices range
from material flow in a factory, to equipment design, to human resource
practices. Overall, the goal of Lean/TPS is to produce the desired amount of
product at the highest level of quality, using as few resources as possible.
|
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HPWP Category 4: Leadership Alignment/Development
The three HPWPs in this category are those that develop
leaders and align behavior with organizational goals.
1. Linking Management Training to Organizational Needs
Description
Practices involving the alignment of leadership development
resources with the strategic direction of the organization.
Implementation Recommendations
- Use corporate goals to prioritize training, assessment, and
feedback programs provided to managers.
- Use new or existing leadership forums as vehicles to provide
opportunities for skills development in areas of organizational need.
- Enlist managers to help employees connect their work to the goals
and vision of the organization. Encourage managers to make sure their employees'
goals align with the organization's goals.
2. Planning Succession
Description
Proactively identifying and planning for future leadership
needs.
Implementation Recommendations
- Use talent assessments to identify employees with potential for
promotion before the need arises.
- Require managers to create career development plans for the
individuals reporting to them.
- Provide support for the development of high-potential future
leaders through mechanisms such as mentoring programs, stretch assignments, and
job rotations.
3. Tracking and Rewarding Performance
Description
Policies and practices that provide formal
rewards/recognition for leaders' success in supporting organizational goals.
Implementation Recommendations
- Provide annual bonuses based on objective measures of
organizational performance.
- Support the appropriate use of incentives by implementing
balanced scorecards that are relevant to the individual leader's scope of work.
- Provide other mechanisms for recognizing leaders who have modeled
support of the organization's mission and goals through their own actions.
Leadership Development in Action
Executives at a large
not-for-profit health system recognized that identifying and developing leaders
is key to achieving organizational goals. They implemented several education
and training strategies, one of which was a leadership development series.
Every quarter, all department managers, directors, and even leaders above that
level—1400 people in all—participate in a day of learning. The day begins with
an address by the CEO focusing on the system's performance indicators and
highlighting progress toward meeting performance targets. New leaders are
introduced, and then a speaker gives a presentation aligned with the
organization's goals. The afternoon includes exercises that reinforce the
messages conveyed by the speaker, and at the end of the day, leaders are asked
to integrate the learning into their departments' action plans. There is an
accountability grid with measurable outcomes that the leaders are expected to
achieve by the end of the quarter, and leaders are accountable to their
supervisors for progress toward these outcomes.
In addition, the
organization offers leadership boot camps, which are smaller workshops for new
leaders and leaders who need or want additional training in a given area, for
example, in building relationships with employees or in hiring new employees.
Approximately 1,000 leaders attend a boot camp each year, and the camps range
in size from 10 to 40 attendees. All of the presentations and tools from the
leadership development series and the boot camps are available on the
organization's intranet. The boot camp sessions are advertised on the site. |
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Facilitating the Adoption of High-Performance Work Practices
Findings from the literature review and case studies suggest
that several actions can facilitate the adoption of HPWPs. We offer the
following recommendations for the adoption of HPWPs:
- Commit to an organizational culture that focuses on quality and safety. Use
HPWPs to support that culture.
- Engage senior leadership support. Ensure that top and mid-level leaders
are involved in the planning and implementation of HPWPs and that they
reinforce the purpose and importance of HPWPs in communications with employees.
- Involve the human resources department in strategic planning. Implementation
of HPWPs should be tied to the strategic decisionmaking process of the
organization from the beginning. The best way to accomplish this goal is for HR
to have a direct voice in strategic planning.
- Identify opportunities for shared learning. Help the people who are
accountable for HPWP implementation find colleagues at other organizations that
have implemented such practices successfully. Sources for these contacts could
include professional associations (e.g., American Society for Healthcare Human
Resources Administration, State hospital associations) and other shared
learning collaboratives.
- Hire human resources professionals with training and experience in
HPWPs. Make sure your organization has a critical mass of professionals who
have the training and experience to understand, implement, and evaluate these
best practices.
- Involve employee representatives. Ensure that both senior leaders and
labor representatives understand the purpose and goals of HPWPs, and involve
both groups in overseeing their implementation.
- Monitor progress. Include a review of HPWP implementation progress along
with organizational progress on quality, safety, and efficiency goals.
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Conclusion
Health care organizations invest considerable resources to
improve quality and other dimensions of organizational performance. To cope
with growing resource constraints, systems must make strategic choices about
which improvement initiatives to pursue and how best to implement these
initiatives. Personnel requires the single largest expense associated with
health services delivery, so strategic management of human resources can help organizations
leverage multiple opportunities to promote quality improvement and improve
performance.
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