Supporting those who dare to care: Five case studies of high-performance work practices in healthcare

Central to the delivery of high-quality care is the presence of a capable workforce. Evidence from a breadth of sources suggests that innovative human resource (HR) practices (also known as high-performance work practices (HPWPs)), such as systematic personnel selection and incentive compensation, serve to attract and retain highly qualified health care staff, and that HPWPs may represent an important and underutilized strategy for improving health care system performance. We designed this study in order to improve our understanding about potential links between HPWPs and quality of care and patient safety in U.S. healthcare organizations. Following an extensive literature review and synthesis, we developed a preliminary model of key subsystems ('bundles') of HPWPs, relations among them, and their organizational effects. We then, performed five case studies of U.S. healthcare organizations purposively selected based on known success in implementing HPWPs. Site visits conducted in 2009 included 71 interviews with key organizational and clinical informants, as well as collection of organizational documents on HPWPs in use. Interviews were recorded and transcribed verbatim to permit rigorous qualitative analysis. We found emphasis on all four of the HPWP subsystems that we previously characterized as directly relevant to healthcare'organizational engagement, staff acquisition/development, frontline empowerment, and leadership alignment/development. Moreover, we found substantial variation in HPWPs and innovative applications of them. In addition, we found evidence of links between HPWPs and employee outcomes (e.g., turnover, higher satisfaction/ engagement). Our informants reported that HPWPs made important contributions to care system and organization-level outcomes (e.g., fewer 'never events', innovation adoption, lower agency costs, and lower turnover costs). These case studies provide preliminary evidence and examples of ways that HPWPs can improve operations in healthcare organizations and can impact quality and safety. HPWPs should be regarded as very promising forms of performance improvement in healthcare. Further research is likely to specify which HPWP practices and combinations are of greatest potential for healthcare management.