Leadership for Quality and Safety

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here have been considerable worldwide concerns about hospital performance in patient safety and quality, with evidence that hospitals have not been successful in achieving acknowledged best practice in quality health care delivery. Our research suggests that inadequate human resource management practices may be contributing to unacceptable clinical outcomes.

High Performance Work Systems

Studies of high-performing organisations in a variety of industries consistently point to a positive relationship between high performance work systems (HPWS) (also referred to as high performance workplaces, high commitment workplaces, high-involvement work systems and high performance practice) and organisational performance.

There is mounting evidence of a relationship between HPWS and organisational performance, and in health care, which is a labour intensive industry effective human resource management practices have been shown to have a positive relationship with patient outcomes.

Our research has shown that health care organisations (in Australia anyway) do not have the necessary aspects of HPWS in place. We found that although the Chief Executive Officers (CEOs) of hospitals and community health services reported high levels of HPWS, the human resource and other mangers reported a distinct lack of HPWS from their perspectives. Despite those at the top believing their organisation had embraced the concepts, the messages had not reached the middle and front line managers. We have also found that Australian health care organisations have difficulty translating clinical performance expectations into the performance management systems and processes within their organisations.

Quality of care

The Victorian Patient Satisfaction Monitor (VPSM) is a voluntary patient satisfaction monitoring process that provides discharged hospital patients in the state of Victoria with an opportunity to complete a questionnaire on their views related to their hospital treatment. The VPSM reports Victorian public hospital patients’ assessment of their hospital stay in aggregated charts and tables to identify the areas patients are most satisfied with and those they expect to improve. This information is regularly used by hospitals to improve the quality of the services provided. In our research we wanted to be able to compare the employee perceptions of the quality of care with their patients’ perceptions (which will be addressed in future studies) and have used the 17 questions from the VPSM that patients use to rate their hospital stay. These questions address issues of courtesy, helpfulness, responsiveness and willingness to listen, the provision of information by staff, communication among staff members, and the perceptions of safety, privacy, and being respected of the patients.

Discussion

It is only relatively recently that the study of human resource management in the health care sector has been of interest. The recognition by many health jurisdictions that system improvements were unlikely to come from further system restructuring, and that a focus at a more micro level on changing work practices was has influenced increased activity in this area. Our research suggest that high performance work systems; specifically, selective hiring, extensive training, teams and decentralised decision making, information sharing, transformational leadership and job characteristics, such as appropriate workload, role clarity, and employee control are related to participation at the department or unit level and enhanced empowerment, which is then related to perceptions of higher quality care delivery.

The clear implication of these findings is that leaders in health care organisations should focus on ensuring human resource management systems, structures and processes that support HPWS. At the organisational level these practices comprise selective hiring, extensive training, fostering appropriate security and measurement of management practices. Staff training, in particular, is an area where health care organisations largely do not display the best practices found to be important in other high-risk industries. Despite consistent evidence of the need for sophisticated training to enhance clinical and organisational outcomes, health care professionals are largely expected to obtain their own continuing education on their own time, at their own expense. There is a strong need to re-orient organisational human resource management policies and procedures towards high performing work systems.

In addition, the organisational level practices need to be supported at the departmental level by middle managers who display transformational leadership, with skills in information sharing, and the ability to encourage teams and decentralised decision making. We know from the job characteristic model that skill variety, task identity, task significance, autonomy and feedback are important characteristics to consider in work design for those employees satisfied with their work context and with strong growth needs, and this seems to have been confirmed in health care by the research on magnet hospitals. This combination of organisational and unit level factors promote empowerment of staff, which is then related to perceptions regarding the quality of care delivered. This means that health care organisations need to take seriously the selection, training and ongoing support of managers who can, and wish, to empower their staff.

Considerations for health care managers

Managers in health care organizations need to be reflecting regularly on seven questions:

The answers to these questions will impact how well your unit or department provides high quality, safe patient care.

additional reading:

• Bartram, T., Stanton, P., Leggat, S. G., Casimir, G., and Fraser, B. (2007). Lost in translation: making the link between HRM and performance in healthcare. Human Resource Management Journal, 17(1), 21-41.
• Leggat, S. G., Bartram, T., and Stanton, P. (2005). Performance monitoring in the Victorian health care system: an exploratory study. Australian Health Review, 29(1), 17-24.
• Leggat, S. G., Bartram, T., and Stanton, P. (2008). Exploring the lack of progress in improving patient safety in Australian hospitals. Health Services Management Research, 21, 32-39.
• Leggat, S. G., and Dwyer, J. (2005). Improving hospital performance: culture change is not the answer. Healthcare Quarterly, 8(2), 60-66.
• Stanton, P., Young, S., Bartram, T., and Leggat, S. G. (2009). Singing the same song: translating HRM messages across managerial hierarchies. International Journal of Human Resource Management, In press.
• Young, S., Bartram, T., Stanton, P., and Leggat, S. (2009). High performance work systems and employee well-being: a two stage study of a rural Australian hospital. Journal of Health Organization and Management, In press.

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