The importance of a high-performance work environment in hospitals.

Work environment, sometimes also called “work climate” or “culture,” has become an important factor in health services research, shown in numerous studies to be associated with positive outcomes for workers, patients, and organizations. However, what do we mean when we say an organization has a good work environment or culture or climate? Does an organization have multiple cultures or work environments, for example, on different units or among different professions? If so, whose work environment matters for understanding what an organization does or how it performs? These questions motivated the current study, which examines the diversity of work environments in hospitals as well as the implications for processes and outcomes for organizations, employees, and patients. Drawing on the literature on high-performance work systems, we define work environment as being comprised of a bundle of practices designed to promote broader worker engagement and organizational commitment. This bundle includes but extends beyond sufficient material resources and support for the work itself. It also encompasses managerial practices, such as an emphasis on worker discretion and participation in decision making; facilitation of communication and information sharing; and human resource management practices focused on developing workers’ skills and recruiting and retaining qualified workers (Baron and Kreps 1999; Appelbaum, Bailey et al. 2000; Guthrie 2001; Doeringer, Evans-Klock et al. 2002; Bartel 2004; Evans and Davis 2005). Together, this bundle of management practices comprises what we term a high-performance work environment (HPWE). The HPWE measures we use resemble those identified by Aiken and colleagues in a series of studies describing a supportive work environment for nurses. That research suggests that organizational arrangements that promote nurses’ professional status and discretion yield greater job satisfaction for nurses and better patient outcomes, including greater satisfaction and lower mortality rates (see, e.g., Aiken, Smith et al. 1994; Aiken, Sloane et al. 1997a, b; Aiken and Patrician 2000; Clarke, Sloane et al. 2002; Vahey, Aiken et al. 2004). The strength and consistency of these findings begs the question of whether the benefits of a supportive work environment extend to the experience and performance of other care providers as well. The Institute of Medicine (IOM) recommends that health care be analyzed and understood as a system (Kohn, Corrigan et al. 1999) in which patient safety and quality of care require collaborative, interdisciplinary teamwork focused on patient-centered care (Corrigan, Donaldson et al. 2001). This framework suggests the fruitfulness of expanding the scope of investigation—beyond nurses or any single occupational group for that matter—to include all providers involved in delivering patient care. Such an approach is consistent with the work on high-performance work system in other industries, which emphasizes the importance of engaging and empowering the entire workforce regardless of education, job title, or experience, such that, for example, even the assembly-line worker in a manufacturing plant becomes a crucial partner in organizational performance (Macduffie 1995; Appelbaum, Bailey et al. 2000). In this study, we adopt this same democratic approach and test its applicability in the hospital setting. We hypothesize that a high-performance work environment, as characterized by the perceptions of a broad range of occupations engaged in care, will relate positively to desirable work processes, such as collaboration and empowerment; retention as measured by intent to quit, job satisfaction, and actual turnover; and care quality as measured by patient ratings and adverse events.