High-Performance Work
Practices as Drivers of
Quality and Efficiency:
An Evidence-Based
Management Review
Andrew N. Garman, PsyD, MS
Associate Professor, Health
Systems Management
Rush University
Acknowledgments
• Sponsored by the Agency for Healthcare Research
and Quality (AHRQ), through the ACTION Network
initiative
– Health Research and Educational Trust
• The Ohio State University
• Rush University
• Project team:
–
–
–
–
–
Ann Scheck McAlearney - The Ohio State University
Andrew N. Garman – Rush University
Megan McHugh – Health Research & Educational Trust
Paula H. Song - The Ohio State University
Michael I. Harrison – Agency for Healthcare Research
and Quality
– Dina Moss – Agency for Healthcare Research and
Quality
Introduction
• High-Performance Work Practices
(HPWPs)
– Personnel practices associated with
improved organizational performance
– Mutually reinforcing HR systems (or
‘bundles’) are likely to have greater impact
Introduction
• Considerable body of ‘more is better’
research from other industries
• Much less research available on which
practices work best, in which types of
organizations, and under what conditions
Our Study
• A systematic review, to identify the results with
the greatest relevance to healthcare organizations
• Research questions:
– What evidence is there that HPWPs can benefit
healthcare organizations?
– Which HPWPs / bundles appear to have the greatest
potential for benefit?
– What are the mechanisms through which HPWPs have
positive effects?
Method: Literature Scan
Sources
• Research journals
– U.S., Europe, Australia
– Other developed countries
• Industry/trade associations
– SHRM Foundation – research archives
– University Healthsystems Consortium
– Advisory Board
• Government publications
– VA system, NHS, Other (e.g., military leadership)
Approach to Scan
• Two-step process:
– Step one:
• Identify practices, and practice bundles
• Assess relative promise of practices/bundles
for influencing outcomes in healthcare settings
– Step two:
• ‘Vet’ practices and bundles with advisory panel
• Identify most promising practices or bundles for
further study
Results: Logic Model
Exogenous Factors
Frontline
control & freedom to challenge
Factors influencing HPWP adoption:
•Senior leadership support
' •Lower union density
•Higher number of network affiliations
Factors influencing HPWP impact & sustainability
• Higher quality of the local labor market
• Continued leadership support
Quality of
candidate Pools
- Pool size
- Applicant quality
Rigorous
recruiting
Selective
hiring
Career
development
Employment security
Management training
linked to organizational needs
Reduced status distinctions
Performance contingent
comp: Manager
Teams / decentralized
decision-making
Succession planning
System reliability /
resilience
Staff resources
- Staffing adequacy
- Staffing stability
Quality of hires
(capabilities)
-Experience
-Capacity to learn
-Motivation
-Loyalty
Staff effectiveness
- Quality focus
- Communication
- Problem-solving
Extensive
Training
Leadership
alignment & development
Information
sharing
(organizational)
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Performancecontingent
comp: Employee
Organizational engagement
Staff acquisition & development
Conveying
mission & vision
Employee
involvement in
decision-making
Labor
costs
Organizational
performance
• Fewer
"never events"
• Lower
malpractice costs
• Innovation
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
• Lower turnover
•Higher satisfaction
/ engagement
•Lower burnout
•Higher general
well-being
Exogenous Factors
Bundle #2: 'Frontline
control & freedom to challenge'
'
Employment Security
Management training
linked to organizational needs
Reduced status distinctions
Performance contingent
comp: manager
Teams / decentralized
decision-making
Succession planning
Factors influencing HPWP adoption:
System reliability /
Senior leadership support
capacity for selfcorrection
Quality of Hires
Staff resources
Lower
union
density
Quality of
(capabilities)
- staffing adequacy
Candidate Pools
- Experience
- staffing stability
- Pool size number -of
Capacity
to learn
Higher
network
affiliations
- Applicant quality
-Motivation
Staff effectiveness
- quality focus
- communication
- problem-solving
-Loyalty
Bundle #4: ‘Management
efficiency'
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Factors influencing HPWP impact & sustainability
Higher quality of the local labor market
Information
PerformanceCareer
sharing
contingent
Continued
leadership
support
Rigorous
Selective
Extensive
Develop(organizational)
comp: Employee
recruiting
hiring
ment
Training
Organizational engagement
Bundle #1: ‘Staff talent acquisition & development’
Conveying
mission & vision
Employee
involvement in
decision-making
Labor
costs
Organizational
Performance
• Decreased
"never events"
• Decreased
malpractice costs
• More efficient
Innovation adoption
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
-Lower voluntary &
involuntary turnover
-Higher satisfaction
/ engagement
- Lower burnout
-Higher general
well-being
Exogenous Factors Affecting HPWPs
The ‘enabling’ bundle: Organizational Engagement
Bundle #2: 'Frontline
control & freedom to challenge'
Factors influencing HPWP adoption:
•Senior leadership support
' •Lower union density




Bundle #4: ‘Management
efficiency'
Employment Security
Management training
linked to organizational needs
Reduced status distinctions
Performance contingent
comp: manager
Teams / decentralized
decision-making
Succession planning
Organizational information sharing
Conveying mission & vision
Employee involvement in decision-making
Performance-contingent compensation
Factors influencing HPWP functioning &
continued success:
• Higher quality of the local labor market
• Continued leadership support
Quality of Hires
(capabilities)
- Experience
- Capacity to learn
-Motivation
-Loyalty
Quality of
Candidate Pools
- Pool size
- Applicant quality
Rigorous
recruiting
System reliability /
capacity for selfcorrection
Staff resources
- staffing adequacy
- staffing stability
Selective
hiring
Career
Development
Staff effectiveness
- quality focus
- communication
- problem-solving
Extensive
Training
Bundle #1: ‘Staff talent acquisition & development’
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Labor
costs
Organizational
Performance
• Decreased
"never events"
• Decreased
malpractice costs
• More efficient
Innovation adoption
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
-Lower voluntary &
involuntary turnover
-Higher satisfaction
/ engagement
- Lower burnout
-Higher general
well-being
Exogenous Factors Affecting HPWPs
The ‘high leverage’ bundle: Staff Acquisition &
Development
Factors influencing HPWP adoption:
•Senior leadership support
' •Lower union density
Factors influencing HPWP functioning &
continued success:
• Higher quality of the local labor market
• Continued leadership support




Bundle #2: 'Frontline
control & freedom to challenge'
Bundle #4: ‘Management
efficiency'
Employment Security
Management training
linked to organizational needs
Reduced status distinctions
Performance contingent
comp: manager
Teams / decentralized
decision-making
Succession planning
Rigorous recruiting
Selective hiring
Extensive training
Career development / internal labor pools
Quality of
Candidate Pools
- Pool size
- Applicant quality
Quality of Hires
(capabilities)
- Experience
- Capacity to learn
-Motivation
-Loyalty
System reliability /
capacity for selfcorrection
Staff resources
- staffing adequacy
- staffing stability
Staff effectiveness
- quality focus
- communication
- problem-solving
Information
sharing
(organizational)
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Performancecontingent
comp: Employee
Bundle #3: ‘Organizational Engagement’
Communicating
Mission & Vision
Employee
Involvement in
Decision-making
Labor
costs
Organizational
Performance
• Decreased
"never events"
• Decreased
malpractice costs
• More efficient
Innovation adoption
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
-Lower voluntary &
involuntary turnover
-Higher satisfaction
/ engagement
- Lower burnout
-Higher general
well-being
Exogenous Factors Affecting HPWPs
The ‘direct effect’
bundle: Frontline
control & freedom to
challenge
Bundle #4: ‘Management
efficiency'
Factors influencing HPWP adoption:
•Senior leadership support
•Lower union density
' •Higher number of network affiliations
Management training
linked to organizational needs
Factors influencing HPWP functioning &
continued success:
• Higher quality of the local labor market
• Continued leadership support
Succession planning
 Employment security
 Reduced status distinctions
 Teams / decentralized decision-making
Quality of Hires
(capabilities)
- Experience
- Capacity to learn
-Motivation
-Loyalty
Quality of
Candidate Pools
- Pool size
- Applicant quality
Rigorous
recruiting
System reliability /
capacity for selfcorrection
Staff resources
- staffing adequacy
- staffing stability
Selective
hiring
Career
Development
Staff effectiveness
- quality focus
- communication
- problem-solving
Extensive
Training
Information
sharing
(organizational)
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Performancecontingent
comp: Employee
Bundle #3: ‘Organizational Engagement’
Bundle #1: ‘Staff talent acquisition & development’
Communicating
Mission & Vision
Employee
Involvement in
Decision-making
Labor
costs
Organizational
Performance
• Decreased
"never events"
• Decreased
malpractice costs
• More efficient
Innovation adoption
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
-Lower voluntary &
involuntary turnover
-Higher satisfaction
/ engagement
- Lower burnout
-Higher general
well-being
Exogenous Factors Affecting HPWPs
The ‘leadership’ bundle:
Leadership alignment and
development
Bundle #2: 'Frontline
control & freedom to challenge'
Factors influencing HPWP adoption:
•Senior leadership support
•Lower union density
' •Higher number of network affiliations
Employment Security
Factors influencing HPWP functioning &
continued success:
• Higher quality of the local labor market
• Continued leadership support
Reduced status distinctions
Teams / decentralized
decision-making
 Management training linked to organizational
needs & goals
 Performance-contingent compensation for
broader goals
 Succession planning
Quality of Hires
(capabilities)
- Experience
- Capacity to learn
-Motivation
-Loyalty
Quality of
Candidate Pools
- Pool size
- Applicant quality
Rigorous
recruiting
System reliability /
capacity for selfcorrection
Staff resources
- staffing adequacy
- staffing stability
Selective
hiring
Career
Development
Staff effectiveness
- quality focus
- communication
- problem-solving
Extensive
Training
Information
sharing
(organizational)
Capacity for
continuous system
improvement
- Motivation to learn
- Capacity to learn
- Freedom to
'challenge the system'
Performancecontingent
comp: Employee
Bundle #3: ‘Organizational Engagement’
Bundle #1: ‘Staff talent acquisition & development’
Communicating
Mission & Vision
Employee
Involvement in
Decision-making
Labor
costs
Organizational
Performance
• Decreased
"never events"
• Decreased
malpractice costs
• More efficient
Innovation adoption
• Lower agency
utilization costs
• Lower turnover
costs
Employee Outcomes
-Lower voluntary &
involuntary turnover
-Higher satisfaction
/ engagement
- Lower burnout
-Higher general
well-being
Significance / Relevance
• Identifies evidence-based strategies from
other industries
• Provides a holistic model for examining
personnel practices within healthcare
settings
• Identifies salient exogenous and
organizational factors affecting HPWP
outcomes