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

2. 2 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

3. 3 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.

4. 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 4

5. 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 5

6. 6 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; and, 2.To develop recommendations for implementing that practice/bundle to enhance its dissemination and use within healthcare organizations.

7. 7 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

8. 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

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 9

10. How can these ‘people practices’ best be integrated? 10

11. 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 11

12. HPWP Logic Model

13. ' Quality of candidate pools Quality of hires System reliability / resilience - Staff resources - Staff effectiveness Capacity for continuous system improvement HPWP Subsystem #3: Frontline Empowerment Employment security Reduced status distinctions Teams / decentralized decision-making Teams / decentralized decision-making HPWP Subsystem #2: Staff Acquisition & Development Rigorous recruiting Rigorous recruiting Selective hiring Selective hiring Extensive Training Extensive Training HPWP Subsystem #1: Staff Engagement HPWP Subsystem #1: Staff Engagement Information sharing Information sharing Performance- driven reward/ recognition Performance- driven reward/ recognition Employee involvement in decision-making Employee involvement in decision-making Communicating mission & vision Communicating mission & vision HPWP Subsystem #4: Leadership Alignment & Development Leadership training linked to organizational goals Leadership training linked to organizational goals Performance-contingent rewards Performance-contingent rewards Succession planning Employee Outcomes Higher retention Higher engagement Higher resilience Higher skills Higher social exchange/ relational coordination Higher general well- being Organization-level Outcomes Higher quality Higher safety Higher efficiency Career develop- ment Career develop- ment Organizational Factors Factors influencing HPWP adoption: Senior leadership support HR involvement with strategic planning Capabilities of the implementers Higher number of network affiliations Factors influencing HPWP impact & sustainability Quality of the local labor market Financial condition Continued leadership support StaffingCare processes Outcomes 13

14. ' Quality of candidate Pools - Pool size - Applicant quality Quality of hires (capabilities) -Experience -Capacity to learn -Motivation -Loyalty System reliability / resilience Staff resources - Staffing adequacy - Staffing stability Staff effectiveness - Quality focus - Communication - Problem-solving Capacity for continuous system improvement - Motivation to learn - Capacity to learn - Freedom to 'challenge the system' Staff acquisition & development Rigorous recruiting Selective hiring Extensive Training Leadership alignment & development Management training linked to organizational needs Performance contingent compensation Succession planning Employee Outcomes Lower turnover Higher satisfaction / engagement Lower burnout Higher general well-being Organizational performance Fewer "never events" Lower malpractice costs Innovation adoption Lower agency costs Lower turnover costs Career develop- ment Exogenous Factors Factors influencing HPWP adoption: Senior leadership support HR involvement with strategic planning Capabilities of the people charged with implementation Lower union density Higher number of network affiliations Financial condition / slack resources Factors influencing HPWP impact & sustainability Higher quality of the local labor market Continued leadership support Staffing Care system Outcomes Frontline control & freedom to challenge Employment security Reduced status distinctions Teams / decentralized decision-making Organizational engagement Information sharing (organizational) Performance- contingent Incentives Employee involvement in decision-making Conveying mission & vision 1.The ‘enabling’ bundle: Organizational Engagement  Conveying mission & vision  Information sharing  Performance-contingent reward / recognition  Employee involvement in decision-making

15. ' Quality of candidate Pools - Pool size - Applicant quality Quality of hires (capabilities) -Experience -Capacity to learn -Motivation -Loyalty System reliability / resilience Staff resources - Staffing adequacy - Staffing stability Staff effectiveness - Quality focus - Communication - Problem-solving Capacity for continuous system improvement - Motivation to learn - Capacity to learn - Freedom to 'challenge the system' Staff acquisition & development Rigorous recruiting Selective hiring Extensive Training Leadership alignment & development Management training linked to organizational needs Performance contingent compensation Succession planning Employee Outcomes Lower turnover Higher satisfaction / engagement Lower burnout Higher general well-being Organizational performance Fewer "never events" Lower malpractice costs Innovation adoption Lower agency costs Lower turnover costs Career develop- ment Exogenous Factors Factors influencing HPWP adoption: Senior leadership support HR involvement with strategic planning Capabilities of the people charged with implementation Lower union density Higher number of network affiliations Financial condition / slack resources Factors influencing HPWP impact & sustainability Higher quality of the local labor market Continued leadership support Staffing Care system Outcomes Frontline control & freedom to challenge Employment security Reduced status distinctions Teams / decentralized decision-making Organizational engagement Information sharing (organizational) Performance- contingent Incentives Employee involvement in decision-making Conveying mission & vision 2. The ‘high leverage’ bundle: Staff Acquisition & Development  Rigorous recruiting  Selective hiring  Extensive training  Career development / internal labor pools

16. ' Quality of candidate Pools - Pool size - Applicant quality Quality of hires (capabilities) -Experience -Capacity to learn -Motivation -Loyalty System reliability / resilience Staff resources - Staffing adequacy - Staffing stability Staff effectiveness - Quality focus - Communication - Problem-solving Capacity for continuous system improvement - Motivation to learn - Capacity to learn - Freedom to 'challenge the system' Staff acquisition & development Rigorous recruiting Selective hiring Extensive Training Leadership alignment & development Management training linked to organizational needs Performance contingent compensation Succession planning Employee Outcomes Lower turnover Higher satisfaction / engagement Lower burnout Higher general well-being Organizational performance Fewer "never events" Lower malpractice costs Innovation adoption Lower agency costs Lower turnover costs Career develop- ment Exogenous Factors Factors influencing HPWP adoption: Senior leadership support HR involvement with strategic planning Capabilities of the people charged with implementation Lower union density Higher number of network affiliations Financial condition / slack resources Factors influencing HPWP impact & sustainability Higher quality of the local labor market Continued leadership support Staffing Care system Outcomes Frontline control & freedom to challenge Employment security Reduced status distinctions Teams / decentralized decision-making Organizational engagement Information sharing (organizational) Performance- contingent Incentives Employee involvement in decision-making Conveying mission & vision 3. The ‘direct effect’ bundle: Frontline empowerment  Employment security  Reduced status distinctions  Teams / decentralized decision-making

17. Part 2: “Work Practices in Sharp Healthcare” Presenter: Nancy Pratt, RN, MS Senior Vice President Clinical Effectiveness Sharp HealthCare

18. ' Quality of candidate Pools - Pool size - Applicant quality Quality of hires (capabilities) -Experience -Capacity to learn -Motivation -Loyalty System reliability / resilience Staff resources - Staffing adequacy - Staffing stability Staff effectiveness - Quality focus - Communication - Problem-solving Capacity for continuous system improvement - Motivation to learn - Capacity to learn - Freedom to 'challenge the system' Staff acquisition & development Rigorous recruiting Selective hiring Extensive Training Leadership alignment & development Management training linked to organizational needs Performance contingent compensation Succession planning Employee Outcomes Lower turnover Higher satisfaction / engagement Lower burnout Higher general well-being Organizational performance Fewer "never events" Lower malpractice costs Innovation adoption Lower agency costs Lower turnover costs Career develop- ment Exogenous Factors Factors influencing HPWP adoption: Senior leadership support HR involvement with strategic planning Capabilities of the people charged with implementation Lower union density Higher number of network affiliations Financial condition / slack resources Factors influencing HPWP impact & sustainability Higher quality of the local labor market Continued leadership support Staffing Care system Outcomes Frontline control & freedom to challenge Employment security Reduced status distinctions Teams / decentralized decision-making Organizational engagement Information sharing (organizational) Performance- contingent Incentives Employee involvement in decision-making Conveying mission & vision 4. The ‘leadership’ bundle: Leadership alignment and development  Management training linked to organizational needs & goals  Performance-contingent compensation for broader goals  Development / continuity planning

19. 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

20. Case Study Approach

21. 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; and,  Potential for cases to serve as best practices examples worthy of attention and possible emulation by other healthcare organizations 21

22. 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) 22

23. 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) 23

24. 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 24

25. Case Study Results

26. Overview of Case Study Sites Site Size/StructureRecognitionsMajor Workforce Initiatives 1Large urban, multi-site health system, Midwest ~15,000 FTEs Fortune “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 FTEs Baldridge, 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 FTEs None, 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 FTEs Davies award for EHR implementation “Patients First” culture Organizing framework= Studer Group “Pillars” Extensive information sharing, focus on leadership development 26

27. 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.” 27

28. 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.” 28

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

30. 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” *Note: Performance Contingent Compensation addressed in Bundle #4 “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.” 30

31. 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” 31

32. 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.” 32

33. HPWP Bundle #4: Leadership Alignment/ Development Common PracticesUnique Innovations Management training linked to organization needs Leadership development for promising mid-level managers Management training curriculum Emerging leader program to develop management skills among promising non- management employees Physician leadership coaching Succession Planning Leaders charged with identifying potential successors Use of formal “talent management” system to surface Performance- contingent compensation If used, tied to scorecard results 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.” 33

34. 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. 34

35. 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. 35

36. 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 36

37. 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 37

38. 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!! 38

39. Common Challenges of HPWP Implementation, Use  Physician involvement: level of engagement and buy-in varies  Unionized employees 39

40. Next Steps…

41. 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 41

42. 42 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

43. Any Questions? Andrew Garman Nancy Pratt Ann Scheck McAlearney

44. 44 Supplemental Information

45. 45 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.