Creating, evaluating, reporting and enhancing healthy work environments (HWEs) for healthcare staff is essential in order to improve performance outcomes. This is not a new idea. We have known for a long time, for instance, that healthcare employees enjoy their jobs more and do them more efficiently and effectively when they believe their work environments are, among other things, safe and respectful. While there is widespread agreement on these and other fundamentals, the challenge that has dogged at least two generations of healthcare decision-makers, practitioners and scholars is how to measure the quality of work environments in ways that support organizational performance.
In their lead essay in this issue of Healthcare Papers, Graham Lowe and Ben Chan step into this complex and well-trodden arena. HWEs, they say, "contribute to higher-quality health services and positive work experiences for employees and physicians." They point to strong evidence showing that even the future sustainability, cost-effectiveness and overall performance of Canada's healthcare system depend on HWEs. In this respect, and adding urgency to Lowe and Chan's work, many readers might find it startling to read that no jurisdiction in Canada currently includes HWE metrics in performance reporting. (Note: In his commentary, E. Michael Higgins contends that, while literally true, Lowe and Chan's reading of the Canadian situation neglects recent provincial-level "efforts to establish performance expectations related to the people dimension of health organizations.")
Lowe and Chan argue that ad hoc and organization-specific initiatives are inadequate for effecting continuous quality improvement in healthcare work environments. A common measurement tool that is capable of guiding, coordinating and spurring on system-wide change is, they reason, "critical" to success (a lesson the authors learned, in part, from the National Health Service's highly successful Staff Survey in England). The main feature of Lowe and Chan's article is, therefore, a "comprehensive framework for assessing and publicly reporting the quality of [healthcare] work environments." This tool is based on a model of relationships among organizational factors as well as employee and organizational outcomes. Lowe and Chan maintain that implementing their framework at the organizational, provincial/territorial and national levels will counter the "slow and uneven" rate of HWE progress seen to date.
"An idea whose time has come": that's the verdict of Heather Laschinger on Lowe and Chan's "compelling" proposal. Laschinger, however, urges the authors to refine and clarify various components of their framework; for example, deciding among the "plethora of available scales for measuring the same concept" and the indicators to be used in a hierarchical set of measurements. Most important of all, Laschinger holds, is developing greater clarity around the multi-faceted – even amorphous – concept of employee engagement.
A focus on employees is similarly found in Bonnie Adamson's commentary. Taking a largely ground-level view, Adamson draws on her practical experience as the chief executive officer (CEO) of Toronto's North York General Hospital (NYGH). Beginning from the premise that "our most valuable asset is our people," Adamson says that "the health of their work environment is a key accountability of all leaders and should be top of mind at all times." In order to illustrate her point, she recounts recent steps taken at NYGH as it has strived to become a "learning organization":
- Designing and testing a front-line improvement system
- Engaging staff in designing and initiating improvements
- Focusing on employees' emotional intelligence
- Building skills for dialogue, reflection, team learning and strategic thinking
- Implementing leadership models
- Investing in managers to acquire facilitation skills
Examining the issue on a more theoretical level, Louise Lemieux-Charles argues that relationships among care providers, workplaces and organizational outcomes are at the heart of the quest for a comprehensive, system-wide HWE framework. In her commentary, Lemieux-Charles considers why, despite our solid understanding of the factors that contribute to HWEs, progress in measuring them has been so slow. One of the key reasons for this paradox, she says, is that discussion and analysis have, to date, "emphasized professional groups rather than organizational performance." When she ponders Lowe and Chan's recommendation to track concepts and indicators by specific human resources functions or by quality improvement teams, Lemieux-Charles is concerned that, as her own research has demonstrated, "teams are often constrained in their ability to develop and use indicators, as well as by their capacity to capture, retrieve and transform data into useful information."
In his commentary, Higgins argues that Lowe and Chan's contention that workplace quality is the determining factor in the "future sustainability, cost-effectiveness and performance of Canada's healthcare system" needs to be modified. There are just too many other variables, he says, that affect these performance dimensions. Two other success factors that stand out for Higgins are the impact of leadership and physicians on workplace health and quality (the latter point aligns with one of Adamson's observations). Further, while he is in general agreement with Lowe and Chan on the importance of common work environment metrics and accompanying performance incentives, Higgins stresses that we must distinguish between "legitimate opportunities for improvement and acceptable variation … derived from the human dimension of the workforce." Performance targets, he argues, must be similarly nuanced; and, if staff surveys are to be used to gather data, their design and the methods by which they will be analyzed, interpreted and used must be carefully considered – a point with which, I suspect, Lemieux-Charles would agree.
Mary-Lou MacDonald and Jason Slaunwhite add a further wrinkle to the discussion: the need to regard safety-related data. Commenting from the perspective of their senior positions in the Nova Scotia Health and Community Service Safety Association, MacDonald and Slaunwhite concur with Lowe and Chan on the importance of having a standardized and consistent HWE framework. Where they diverge, however, is in the relative stress placed on employees' occupational health and safety. Acknowledging that Lowe and Chan's framework refers to some employee-safety aspects, MacDonald and Slaunwhite urge that employees' occupational health and safety should play a much larger role. And, while they similarly applaud the NHS's Staff Survey, they take issue with the intertwining of patient safety and staff safety in both it and the framework Lowe and Chan propose. Instead, they recommend "separating the two constructs in future attempts to create a comprehensive framework" for HWEs.
Drawing on their research in Australia in the field of human resource management (HRM), in their commentary Pauline Stanton and Sandra Leggat conclude that Lowe and Chan's proposal "may be exactly what is required to enhance people management in health services." This positive statement is followed, though, by an important however, which prefaces three major concerns. On the matter of the kinds of indicators Lowe and Chan propose, most are "lag measures" – they evaluate past performance and thus delay awareness of emerging problems.
Stanton and Leggat's other concerns speak directly to one of the challenges most of the commentators address in their responses to Lowe and Chan's paper: the difficulty facing implementation. For Stanton and Leggat, two considerations stand out in this context:
- Top-down approaches to performance measurement lead to employee resistance.
- Without senior leadership (crucially including CEOs), strategic HRM stands a high probability of failure.
A majority of this issue's commentators would likely agree with these points. In fact, Higgins argues that "optimizing leadership effectiveness … is the number one critical success factor for both implementing and committing to a universal accountability framework for HWEs … and for achieving the desired future state in healthcare workplaces." Adamson similarly says that individual organizations' leadership "has the most direct impact" on HWEs, and she cautions that a framework such as the one Lowe and Chan have developed must allow for organizations to tailor its design to suit their own circumstances and objectives.
Yet, if such implementation-friendly flexibility is made a part of a system-wide, standardized HWE framework, it will no doubt prove challenging (though not impossible) to accommodate Laschinger's calls to "embed the practice into accountability agreements of healthcare organizations" and to tie "key levers" such as accreditation and funding to workplace quality management. Perhaps an important step toward overcoming the implementation hurdle would entail, as Lemieux-Charles ponders, investing substantial management authority in a single national body (she raises the possibility of the Canadian Institute of Health Information assuming that role).
HWE measurement and reporting that is policy driven, system wide, nationwide and entirely standardized: these are tall orders for a country and a healthcare system that are so locally and regionally diverse. Nevertheless, I am taken by Lowe and Chan's combination of idealism (a national reporting system that's up and running in five years) and pragmatism. On the latter, our lead authors persuasively contend that success will depend on the hard work of bringing together a wide range of stakeholders and on the active participation of "strong champions who can communicate the urgency and benefits of common metrics, tools and reporting systems." Likewise, they advise, HWE metrics and improvement goals must be woven into existing quality frameworks, and not merely tacked on as another dimension.
None of this will be easy, Lowe, Chan and their commentators in this issue agree. All our authors believe, however, that it is urgent that we try.
About the Author(s)
Peggy Leatt, PhD, Editor-in-Chief
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