1. Extending the Search for High-Performance Work Practices (HPWPs) in Healthcare Organizations

2. Investigating the Role of HPWPs in Reducing and Preventing Healthcare- Associated Infections 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 Agency for Healthcare Research and Quality Annual Meeting, September 2011 2McAlearney 2011

3. Research Team Members and Collaborators Ohio State University  Ann Scheck McAlearney, ScD, Associate Professor, Health Services Management and Policy (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  Stephen Hines, PhD, Vice President for Research Agency for Healthcare Research and Quality  Michael Harrison, PhD, Sr. Social Scientist, Organizations & Systems 3McAlearney 2011

4. Research Overview 4McAlearney 2011

5. 5 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 McAlearney 2011

6. 6 Findings from First Study  Innovative HR practices, also known as high-performance work practices (HPWPs) may represent an important but underutilized strategy to improve health care systems (Garman, et. al. 2010)  Evidence-based model for HPWP in healthcare organizations confirmed through exploratory case studies (McAlearney, et al. 2010) - HPWP model evident in “exemplar organizations - Link to outcomes not direct, but widely accepted McAlearney 2011

7. New Research Questions Focused on HAI Interventions  Do HPWPs facilitate the adoption and consistent application of practices known to reduce or prevent HAIs? In what ways?  What distinguishes healthcare organizations that are more successful in adopting evidence-based practices in HAI reduction efforts from those organizations with less effective efforts?  What contributes to sustainability for successful HAI reduction efforts? How are HPWPs involved in efforts to sustain HAI reduction efforts? 7McAlearney 2011

8. Methods: Case Study Approach 8McAlearney 2011

9. Site Selection Criteria  Focus on CLABSI reduction efforts in hospital ICUs - To maximize variation, focus on “extreme” cases– i.e., sites with more vs. less successful efforts at reducing/sustaining reductions in CLABSI rates  Selection of four CUSP states from which to select case study “pairs” (from cohort 1)  Hospital “pairs” selected based on: - Participation in the same state collaborative - Differential outcomes in terms of CLABSI-reduction (during CUSP) (i.e., better vs. worse outcomes) - Similar organizational characteristics (i.e., size, teaching, urban/ rural) 9McAlearney 2011

10. Site Visit Process  Nine study site visits  Semi-structured interviews held with key informants  Rigorous analysis of interview data  Organizational documents collected and reviewed, as appropriate (e.g., CUSP information, CLABSI protocols, QI and infection control documents, educational material s) 10McAlearney 2011

11. Key Informants Interviewed  Hospital-Level Informants - Infection Control (e.g., Epidemiologist, nurses) - Organizational leaders (e.g., CEO, COO) - Clinical leaders (e.g., CMO, CNO) - Quality improvement professionals  Unit-Level Informants - ICU Nurses, Patient Care Coordinators, Physicians - ICU Nurse Managers, Directors, Physician Directors 11McAlearney 2011

12. Current Status of Project  4 site visits completed; 3 CUSP sites in 2 states - 2 “good,” 1 “less good”  114 key informant interviews completed - Executives (n=21): CEOs, CMOs, Nursing Leaders, Quality/ Safety - Managers (n=42): Nursing, Infection Control, IT, Quality/ Safety - Staff (n=51): Nurses, Physicians/ Residents, Infection Control, Project Management, Purchasing  5 additional site visits to be held 12McAlearney 2011

13. Preliminary Findings 13McAlearney 2011

14. Initial Observations  Consistency in focus on CLABSI reduction - Insertion bundles/ procedures, sterile procedures, central line insertion carts - Maintenance, e.g., “scrub the hub,” dressing changes - “Back to Basics,” e.g. hand hygiene, sterile technique - Identification of helpful products, e.g., end caps, Tru-D  Similar challenges - Reductions in ICU vs. hospital-wide - Data capture/ reliability - Information systems limitations 14McAlearney 2011

15. Emerging Themes: “Success Factors”  Benchmark is getting to zero, not just peers  Strong leadership involvement and support - Commitment to quality improvement and CLABSI reduction at Executive/ Board level - Leaders willing to “back up” efforts with changes in policy, action (e.g., MDs who won’t follow protocol) - Support staff for “doing the right thing”  Quality Improvement infrastructure - Dedicated staff/ resources to support/facilitate improvement efforts (e.g. data, root cause analyses) 15McAlearney 2011,

16. Emerging Themes: “Success Factors” (continued)  Accountability for results - CLABSI on scorecard, unit rates disseminated, variations explained, explored (e.g., root cause, PDSA) - Rewards/ recognition linked to improvement - Staff understand reason behind changes, success celebrated  Supportive organizational culture - Focus on systems, not individuals - Positive physician-nursing relationships  Multi-disciplinary focus, team effort (physicians, nurse, infection prevention, QI) 16McAlearney 201s1

17. Emerging Themes: Challenges to Overcome  Resource constraints: staff to support QI, additional nursing staff on units  Competing priorities: hard to maintain focus because so many things are “important”  Changes in personnel: new physicians/staff can introduce variation in practice  Voluntary physician staff: less “control” over MDs  Shifting healthcare culture: collaboration, teams, system vs. individual failure - 17McAlearney 2011

18. Emerging Themes: Role of HPWPs HPWP Subsystem Observed practices that support CLABSI-prevention Aligning Leaders Incentives for quality improvement/ CLABSI prevention clear, linked to results (e.g., performance evaluation, bonuses) Robust leadership education to support culture change, promote accountability, develop skills (e.g., coaching) Engaging Staff Clear, widespread, routine communication about CLABSI prevention goals, changes in protocol, changes in rates Policy/procedure changes linked to patient care goals Success recognized and celebrated Multi-channel communication with staff (e.g., bulletin boards, newsletters, emails) Communications campaign/ educational “blitz” to support major initiatives (e.g., hand hygiene, “scrub the hub,” “blue to the sky” Staff involved when deficit occurs (e.g., root cause analysis) 18McAlearney 2011

19. Emerging Themes: Role of HPWPs II HPWP Subsystem Observed practices that support CLABSI-prevention Acquiring and Developing Talent Emphasis on selecting the “right people” and giving them the tools they need to do the job Part of broader organizational “talent” initiatives Unit-based initiatives to ensure fit, quality of hires Quality and safety emphasis in on-boarding Empowering the Frontline Nurses empowered to stop procedures if sterile technique not being followed upon insertion; examples of other staff involvement (e.g., secretary empowered to enforce procedures) Staff involved in development of new protocols, selection of new products, perfomance initiatives 19McAlearney 2011

20. Emerging Themes: Role of Collaborative/ CUSP  Considerable variation in participation/ awareness across sites (n=3 CUSP sites)  Possible explanations: - Protocols for CLABSI are well-established; many hospitals efforts to prevent CLABSIs may have been underway at CUSP onset (thus affecting participation) - Smaller hospitals may be more likely to benefit because they have fewer resources to support quality improvement 20McAlearney 2011

21. Next Steps… 21McAlearney 2011

22. What’s Next?  Complete site visits (by June, 2012)  Analyze results (on-going)  Disseminate and publish findings (2012) 22McAlearney 2011

23. Any Questions? Ann Scheck McAlearney mcalearney.1@osu.edu 23McAlearney 2011

24. 24 Supplemental Information McAlearney 2011

25. ' Quality of candidate pools Quality of hires System reliability / resilience - Staff resources - Staff effectiveness Capacity for continuous system improvement HPWP Subsystem #3: Acquiring & Developing Talent HPWP Subsystem #3: Acquiring & Developing Talent Rigorous recruiting Rigorous recruiting Selective hiring Selective hiring Extensive Training Extensive Training HPWP Subsystem #1: Aligning Leaders HPWP Subsystem #1: Aligning Leaders 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 Financial condition / slack resources Lower union density Factors influencing HPWP impact & sustainability Quality of the local labor market Financial condition Continued leadership support StaffingCare processes Outcomes HPWP Subsystem #2: Engaging Staff HPWP Subsystem #2: Engaging Staff Communicating Mission & Vision Communicating Mission & Vision Information Sharing Employee Involvement in Decision-making Employee Involvement in Decision-making Performance-driven reward/recognition Performance-driven reward/recognition HPWP Subsystem #4: Empowering the frontline HPWP Subsystem #4: Empowering the frontline Employment security Reduced status distinctions Teams / decentralized decision-making Teams / decentralized decision-making 25 McAlearney 2011

26. 26 Related Publications  McAlearney, A.S., Garman, A., Song, P, McHugh, M., Robbins, J., Harrison, M. 2011. “High-Performance Work Systems in Healthcare Management, Part 2: Qualitative Evidence from Five Case Studies.” Health Care Management Review. 36(3): 214-226.  Garman, A., McAlearney, A.S., Song, P., Harrison, M., McHugh, M. 2011. “High-Performance Work Systems in Healthcare Management, Part 1: Development of an Evidence-Informed Model.” Health Care Management Review. 36(3): 201-213.  Song, P, Robbins, J., Garman, A., McAlearney, A.S. 2011. “High- Performance Work Systems in Healthcare Management, Part 3: The Role of the Business Case for HPWP Investment in Health Care.” Health Care Management Review. In press.  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. McAlearney 2011