Many hospitals have taken steps to cultivate a highly engaged workforce, expecting that higher engagement translates into better patient care. While there is an abundance of evidence from other industries that engaged employees perform their jobs better, there is far less attention to this engagement – performance link in healthcare. 

Researchers in England have used the NHS Staff Survey to show how high levels of staff engagement are related to a range of positive patient outcomes, including their overall satisfaction with the care received. In Canada, while individual hospitals may be able to showcase high-performing units where dedicated staff provide outstanding care according to patients themselves, there is no systematic evidence that connects these big data points – a major gap in our understanding of health system performance. 

As a first step in filling this gap, in cooperation with NRC Health, I compared results from 34 Ontario hospitals that conducted NRC Health’s proprietary Inpatient Experience Survey (IES) and Employee Experience Survey (EES) during 2014 and 2015. 

I focused on two IES questions: 

  • Overall, how would you rate the care you received at the hospital? (Poor, Fair, Good, Very good, Excellent) 
  • Would you recommend this hospital to your friends and family? (Yes definitely, Yes probably, No) 

Responses to both questions are positively skewed, with only 7.1% of patient respondents rating the care they received as poor or fair and 5.2% stating they would not recommend the hospital to family or friends. These numbers may attest to the overall decent care quality delivered in these Ontario hospitals. However, the fact that patient satisfaction is not normally distributed limits the variation in these scores across hospitals. 

Hospital mean scores for the two patient satisfaction items were added to the EES data file, which included 21,283 hospital employees who indicated that they provide direct patient care in the 34 hospitals. I then assessed to what extent five employee experience measures at each hospital were related to the two IES item scores. Specifically, I focused on the following work experience measures: 

  • A 6-item engagement scale. 
  • Rate hospital as place to work. 
  • Can trust the organization. 
  • Work unit provides top-quality patient care. 
  • Patient-centred work environment scale. 

I found statistically significant positive relationships between all five EES measures and both IES measures. That is, the more engaged employees are, the more positively they rate their hospital as a place to work; the more they trust their organization, the higher the perceived quality of patient care delivered by their unit; and the more they consider their work environment to be ‘patient centred’, the more likely it is that inpatients would recommend the hospital to family or friends and highly rate the quality of care they received. 

These results are strikingly consistent. However, they reflect very small differences in IES mean scores. For example, employees in the lowest engagement score quartile work in hospitals that have a mean score of 2.631 on the ‘recommend the hospital’ IES measure, compared with 2.655 for employees in the highest engagement score quartile. In other words, a several-percentage point increase in a hospital’s employee engagement score won’t result in an equivalent improvement in patients’ experiences. 

I also looked for variations in the two inpatient experience measures by Ontario Hospital Association-defined peer group. Focusing on employee engagement scores (a composite of six EES engagement items), these vary significantly across small, community and teaching hospitals. Employees in community hospitals have the lowest engagement scores and teaching hospitals have the highest. Employees in small hospitals have slightly lower engagement levels than those in teaching hospitals, still well above community hospitals. The two IES measures follow this pattern, with community hospitals having the lowest levels of patient satisfaction based on these two measures, teaching hospitals the highest, with small hospitals close behind. 

We cannot infer that positive employee work experiences are a direct cause of high patient satisfaction. The best we can say at this point is that there is a consistent, positive yet weak relationship between how healthcare providers experience their work environment and how patients perceive the quality of that care. 

As intriguing as these findings may be, clearly more research must be done to better understand the dynamics of these relationships. Two things would help in this regard. One would be to coordinate the timing of the two surveys, so that the IES directly follows the EES. Also helpful would be using a more sensitive measure of inpatient satisfaction that captures a wider range of negative and positive responses – which Ontario recently started doing, with the adoption of the Canadian Patient Experience Survey – Inpatient Care (CPES-IC) survey. 

Addressing these measurement issues may be what is needed to provide solid confirmation of the intuitive logic that the quality of hospital employees’ work experiences directly influence the quality of the patient care they provide.

About the Author

Graham Lowe is a workplace consultant ( and the author of Creating Healthy Organizations and (with Frank Graves) Redesigning Work. He has advised many healthcare organizations on how to create engaging and patient-centred work environments.


The author would like to acknowledge the support of Sonia Jacobs and Ada Hui at NRC Health for providing the IES and EES data and offering advice throughout this project.

To learn more about NRC Health’s patient experience and workforce (employee, physician, volunteer) experience solutions, please contact NRC Health at or 1-866-771-8231.