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

On September 19, 2011, Ann Scheck McAlearney made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (2.2 MB).

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

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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

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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.

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Research Overview

An image of 4 doctors is shown.

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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.

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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.

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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?

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Methods: Case Study Approach

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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).

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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 materials).

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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.

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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.

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Preliminary Findings

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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.

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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).

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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).

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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.

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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, E-mails). 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).

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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, performance initiatives.

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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.

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Next Steps...

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What's Next?

• Complete site visits (by June, 2012).
• Analyze results (on-going).
• Disseminate and publish findings (2012).

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Any Questions?

Ann Scheck McAlearney
mcalearney.1@osu.edu

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Supplemental Information

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Organizational Factors

Factors influencing HPWP adoption:

1. Senior leadership support.
2. HR involvement with strategic planning.
3. Capabilities of the implementers.
4. Higher number of network affiliations.
5. Financial condition / slack resources.
6. Lower union density.

Factors influencing HPWP impact & sustainability

1. Quality of the local labor market.
2. Financial condition.
3. Continued leadership support.

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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.