Topic: Benchmarking and Standard Setting

Topic: Benchmarking and Standard Setting
In today’s health care environment, benchmarking is an important and common
mechanism to track quality and safety, develop standards, and compare
organizations. For this assignment, choose a health care setting of interest to
you, such as hospitals, sub-acute rehab facilities, skilled nursing facilities, home
health or others, and research two organizations that rank, set standards, or
benchmark organizations in this setting based off patient quality and safety.
Develop a 3–5 page, APA-formatted paper detailing the benchmarking and
standard-setting process in your chosen setting. Your assignment should
describe the benchmarking organizations and make recommendations for
leaders in this setting to ensure they meet the specific benchmarking standards.
Be sure to include the following in your assignment:

Examination of the different benchmarking and standard-setting agencies,
and their procedures for conducting surveys and determining compliance for
a specific health care setting.
Analysis of national safety goals available through benchmarking and
standard-setting organizations.
Evaluation of the benefits and outcomes of continuous readiness.
Assessment of identified risks related to a specific health care setting that
could adversely impact benchmarking, ranking, and compliance with external
Evaluation of current policy and procedure to determine if risks are
controllable or uncontrollable factors.
Evaluation of how to link health care safety goals to those of the
organizational strategic plan to create and sustain an organization-wide
safety culture in a specific health care setting.
Submission Requirements
Your assignment should meet the following requirements:

Length: 3–5 double-spaced pages, excluding the cover page and references
list. Include page numbers, headings, and running headers.
References: 3–5 current peer-reviewed references.
Format: Use current APA style and formatting, paying particular attention to
citations and references.
• Font and font size: Times New Roman, 12 point.
Review the scoring guide to ensure you understand the grading criteria for this
assignment. Submit your Word document as an attachment to the assignment

Note: Your instructor may also use the Writing Feedback Tool to provide
feedback on your writing. In the tool, click the linked resources for helpful writing
Below is the chapter reading with the reference below:

Rozovsky, F. A., & Woods, J. R., Jr. (Ed.). (2011). The handbook of patient safety
compliance: A practical guide for health care organizations. San Francisco, CA:
Jossey-Bass. ISBN: 9781118086995.
• Read Chapter 6, “Benchmarking: Evidence-Based Outcome Information
and Standards of Care,” pages 96–103.

BENCHMARKING: Evidence-Based Outcome Information and Standards of Care
Peter J. Pronovost
Fay A. Rozovsky
Health care is striving to become more evidence based. Patients, providers, insurers,
regulators, accreditors, and purchasers are all demanding evidence to support
improved quality of care. This is warranted. The evidence suggests that much of the
morbidity, mortality, and cost of care can be reduced. Although the use of evidence
to guide health policy is relatively new, it is likely to increase. Indeed, several
groups, including the Centers for Medicare & Medicaid Services (CMS), the National
Quality Forum (NQF), and the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), are collaborating to develop measures of quality of care.
How the use of outcome data will inform policy and purchasing decisions is
unknown. In this chapter we present an overview of the use of benchmark data for
patient safety and then explore how payors, providers, and consumers are using
benchmark data. In addition, we discuss whether benchmarking creates a standard
of care, and the risks and potential benefits of using benchmark data to create a
standard of care.
Benchmarking for Patient Safety: The Use of Evidence-Based Outcome Data
Benchmarking is simply a method of comparing your performance to someone
else’s. In internal benchmarking you compare your performance against prior
performance. In external benchmarking you compare your performance to that of
an outside organization or to some other external standard. Benchmarks generally
take the form of measures of quality and are based on the premise that to improve,
we need feedback regarding our performance. These measures may be empiric
measures of quality, such as the JCAHO performance measures (for example, giving
beta-blockers to a patient with a myocardial infarction), or standards such as the
JCAHO (2004) safety standards.
More than thirty years ago, Donabedian (1966) proposed that we can measure the
quality of health care by observing its structure, its processes, and its outcomes. The
Institute of Medicine (IOM) has defined health care quality as “the degree to which
health services for individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge” (Lohr and
Schroeder, 1990). The IOM’s definition and framework thus incorporate two of
Donabedian’s three elements in a broad approach to measuring health care quality:
(1) determining effects of health care on desired outcomes, including a relative
improvement in health and in consumer evaluations or experiences of health care,
and (2) assessing the degree to which health care adheres to processes that have
been proven by scientific evidence or agreed by professional consensus to affect
health or that concur with patient preference.
Measures of quality provide insights into many aspects of quality. For example, one
of the authors (PSP) saw something like this occurring when his five-year-old son,
Ethan, was asked to make a collage of himself. We pasted into the collage pictures of
Ethan with his sister and parents, at the beach, at camp, and at school. Although no
single picture allowed the viewer to know Ethan completely, by viewing all the
pictures, one could begin to know him. Some of the pictures were clear; others were
granular; some were important to Ethan; others were important to his parents, his
grandparents, and teachers. Quality measures, like the pictures in a collage, give us
many views of the quality of whatever we are trying to learn about.
The IOM has further suggested that health care should have the six aims of being
effective, safe, patient-centered, timely, efficient, and equitable (Institute of
Medicine, 2001). Whereas the aims of effectiveness and safety in health care are
nearly universal, societies and cultures around the world differ in how much
emphasis they give to each of the additional aims of patient-centeredness,
timeliness, efficiency, and equity. Process of care measures of quality assess
whether providers perform health care processes that have been demonstrated to
achieve the desired aims and avoid those processes that predispose toward harm.
Varied audiences need health care quality measures in order to receive feedback on
the quality of care provided. Organizations may use this feedback as they go about
health care purchasing, utilization, regulatory accreditation and monitoring, or
performance improvement (Pronovost and others, 2004; Rubin, Pronovost, and
Diette, 2001). For all these purposes it is imperative that the results of quality
measures be meaningful, scientifically sound, generalizable, and interpretable
(McGlynn, 1998). To achieve these goals, quality measures must be designed and
implemented with scientific rigor and informed by the best available evidence.
Many groups are using quality measure data to benchmark their performance
against that of others. Despite this significant interest in benchmarking, we have
relatively few valid and reliable measures of quality that are routinely measured
and can be used to compare providers. Moreover, there is often uncertainty
regarding the validity and reliability for a quality measure. Until the measures
become robust, we must be cautious not to interpret them narrowly. We must allow
the science to evolve. Another concern with the broad use of benchmarking is that
although hospitals have limited resources for measuring quality, each stakeholder
(purchasers such as the Leapfrog Group, regulators such as CMS, and accreditors
such as JCAHO) has its own measures and its own definitions, increasing the
compliance burden on hospitals and limiting providers’ ability to use common
measures. Recent collaborative efforts by these stakeholders and by the NQF to
develop a common measure sheet should facilitate the development of common
In addition to developing rigorous measures we need to learn how to report the
results of these measures so they are most meaningful to consumers. Researchers
should continue to explore how best to present quality data to consumers.
Despite these concerns the potential benefits are great. The performance feedback
resulting from benchmarking can improve quality of care, and benchmarking will
likely continue.
How Payors Use Benchmark Data
Given the magnitude of the quality and safety problem in health care, it is not
surprising that many organizations, including health care purchasers, insurers,
accreditors, and providers nationwide, are attempting to address this issue. One
organization in particular, the Leapfrog Group, a consortium of over 150 Fortune
500 companies and large public employers, has focused on improving patient safety
for its members’ employees. For example, Leapfrog has created three hospital
purchasing specifications for use by consumers and insurers that pay for employees’
health care and also adopted the NQF safe practices (see Chapter Three) (Milstein
and others, 2000).
The Leapfrog Group is growing daily and now addresses the needs of over thirtyfive million employees from private and public employers such as Ford, Verizon, 3M,
and the state of Massachusetts. Similar consortia, such as the Buyers Health Care
Action Group and the Pacific Business Group on Health, are also Leapfrog Group
members. Collectively, group members and their employees exercise significant
purchasing power. In some market areas, employees of Leapfrog companies occupy
a significant percentage of hospital beds. The consortium seeks to create a business
case for quality by encouraging employees to use providers who have adopted
transformational methods of performance improvement, a step providers are
unlikely to take without a focused market reward.
The Leapfrog Group’s three initial standards call for the following: (1) volume-based
rules for specific neonatal care, (2) computerized physician order entry (CPOE)
systems, and (3) higher levels of ICU physician staffing by intensive care physicians
(intensivists). Implementing these standards in nonrural U.S. hospitals is expected
to prevent 56,000 deaths a year, and most of this improvement is expected to result
from improved ICU physician staffing (Provonost and others, 2002; Provonost and
others, in press). To increase the number of hospitals meeting these standards, the
Leapfrog Group implemented six regional rollouts in the past four years in which it
partnered with regulators, insurers, and providers to support the implementation
The Leapfrog Group is using several methods to encourage members’ employees to
use hospitals that meet these standards. The group is working to increase public
awareness of hospitals that meet the standards and is offering financial incentives
and disincentives, such as an increased co-pay if an employee chooses a nonLeapfrog provider. Despite the magnitude of this endeavor, little is known about its
impact on health care. Research is underway to measure the impact in the regions
targeted for rollouts.
Even though the implementation and evaluation effort is ongoing, the Leapfrog
standards have indeed become a benchmark, and failure to comply with these
standards may increase an organization’s liability exposure. Trial lawyers will likely
interpret the Leapfrog standards as standards of care, further encouraging hospitals
to implement these standards.
How Benchmark Data Become the Standard of Care
Benchmark data generally reflect a standard, a policy relating to a structural
element of a hospital, or an empirical measure of quality. Performance on either an
outside standard (such as a Leapfrog Group standard) or a quality outcome (that all
patients with a myocardial infarction should receive beta-blockers, for example) can
become a standard of care. When a standard is the benchmark, it generally
represents the minimum performance that all hospitals should meet (for example,
all hospitals should have an ethics committee). When an evidence-based process
measure of quality of care is the benchmark, the standard of care is that all patients
receive that process (such as receiving beta-blockers for myocardial infarction).
Indeed, the standard of care is defined when the process measure is created. When
an outcome measure (mortality, for example) is the benchmark, the outcomes of the
top-performing organization often set that benchmark. Therefore the use of a
quality measure rather than a standard as a benchmark may enhance quality by
creating a maximum rather than minimum standard of care. Let’s consider an
example. One policy regarding infection control is that hospitals need an infection
control program. The presence of an infection control program becomes the
standard of care. Because most hospitals meet this, they would exceed the standard
of care. However, if we use infection rates (such as rates of bloodstream infection)
as the benchmark, the hospitals with the lowest infection rates create the standard
of care; all those with higher rates may be perceived as failing to meet the standard.
One challenge in the use of benchmark data is to use them for learning rather than
judging. Although using benchmark data for learning sounds like a straightforward
concept, putting it into practice may require a shift in the culture of many health
care organizations. Health care organizations have been judgmental of providers on
a variety of issues, including resource utilization, performance, and economic
credentialing. At the same time, health care providers have fought the idea of
following one clinical approach or guideline, labeling such behavior cookbook
Benchmarking is supposed to go beyond judgmental appraisal. It does not set rigid
parameters for measurement. Rather, when done appropriately, benchmarking
supports a clinical framework that fosters quality care. Run charts, control charts,
and statistical process controls (SPCs) are tools that can be used for this purpose.
Measuring outcomes or performance over a period of time, providers can ascertain
whether they have been within the benchmark criteria.
Providers have been hesitant to embrace benchmark concepts for a number of
reasons. Distrust of the benchmark data and concern about flawed algorithms are
key issues. If data are not risk adjusted or weighted correctly, a benchmark or
algorithm may be set that is inaccurate and can lead to patient injury or to an
incorrect decision to initiate a peer review process for some care providers. Payors
relying on such information might terminate agreements or decide not to renew
provider contracts. Provider concerns about benchmarking data must be addressed
before there can be widespread acceptance of such information in revising
guidelines for care. Gaining such support will require fulfilling a number of
considerations, including the following:
Agreement on a consistent methodology for setting benchmarks
Agreement that clinical benchmarks be premised on a common set of factors,
including quality, safety, and likelihood of successful outcome
Development of benchmarks that are evidence based
Definitions of what constitutes evidence based
Consistent use of risk adjusting and weighting of data
Recognition that a benchmark is a range of expected outcomes, leaving room for
individual exceptions
Provision for documenting the reason for an exception to the benchmark
Use of exceptional cases and innovations to refresh the benchmark
Education for those who use benchmark data, including demonstrated competency
in using the information
Establishment of a process for periodic evaluation and updating of evidence-based
Health care facility executives and board members should understand that
benchmarks can help them in meeting their obligations under federal and state law
for the provision of quality assessment and performance improvement (QAPI) (68
Fed. Reg. 16, 3435–3455, Jan. 24, 2003). The results of benchmark data can guide
future planning, budgeting, staffing, and operations. Good evidence-based outcomes
can also be useful when contracting with payors. With public policy experts and
lawmakers exploring revamping payment to reflect pay for performance,
benchmark data take on added importance. Aligning economic incentives with
patient safety will drive the change to evidence-based outcomes in the delivery of
How Consumers Use Benchmark Data
Quality data and benchmark information are important to many consumers. They
want to know which hospital or provider has the best rating for performing certain
types of surgeries or other specialized care. In selecting a nursing facility for a
parent, they want to know which skilled facility has a positive rating. They look to
the Centers for Medicare & Medicaid Services (2004) (which offer a service called
Nursing Home Compare), several states (such as Virginia, 2004, and New York,
2004), and a number of national associations for such information. New privatepublic sector tools are also anticipated, including a national quality initiative
(Centers for Medicare & Medicaid Services, 2004).
Just as providers need training for the interpretation of evidence-based data, the
same is true of consumers. Information presented in a technical manner will do little
to educate consumers. However a benchmark report card with a user-friendly
format may encourage them to ask care providers for further information. Data
about complications, length of stay, infection rates, and morbidity and mortality
might lead to patients’ rejecting one hospital or doctor and favoring another. Indeed,
the communication of such information may become part of the consent process, to
the extent that evidence-based clinical information shapes the discussion of the
potential benefits and risks of a proposed treatment.
The possibility that benchmark data may provoke a shift in market share by
changing the ways consumers make their choices may create a new incentive for
improving patient safety. It is important for health care organizations and providers
to make certain that benchmark data are understandable to all concerned. For
example, they may wish to field-test the benchmark report card to evaluate the
ability of consumers to interpret and use the data. This might be done in various
sample population groups. Care providers then need to go one step further, learning
from the data generated through examining evidence-based outcomes.
Conclusion: Using Benchmark Data to Achieve Patient Safety Compliance
The potential for using benchmark data to improve the quality of care is significant.
Nevertheless, several prerequisites must be met before the improvements can be
realized. First, each quality measure must be valid, reliable, and linked to
meaningful improvements in safety. Second, a system must exist for sharing best
practices among the sites participating in a benchmarking process. Third, providers
must implement interventions and improve performance on each measure. They
must avoid the common trap of allowing the collection of benchmark data to
become an end in itself, with no link to improvement.
Centers for Medicare & Medicaid Services. “Nursing Home Compare.”
[]. 2004.
Centers for Medicare & Medicaid Services. “The ‘National Voluntary Hospital
Reporting Initiative (NVHRI)’ Will Now Be Known as ‘Hospital Quality Alliance
(HQA): Improving Care Through Information.’”
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Donabedian, A. “Evaluating Quality of Medical Care.” Milbank Quarterly, 1966, 44,
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, D.C.: National Academy Press, 2001.
Joint Commission on Accreditation of Healthcare Organizations.
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Leapfrog Group. “Purchasing Principles.”
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Lohr, K. N., and Schroeder, S. A. “A Strategy for Quality Assurance in Medicare.” New
England Journal of Medicine, 1990, 322, 1161–1171.
McGlynn, E. A. “Choosing and Evaluating Clinical Performance Measures.” Joint
Commission Journal of Quality Improvement, 1998, 24, 470–479.
Milstein, A., and others. “Improving the Safety of Health Care: The Leapfrog
Initiative.” Effective Clinical Practice, 2000, 2(6), 489–496.
New York State Department of Health. “New York State Physician Profile.”
[]. 2004.
Provonost, P. J., and others. “Physician Staffing Patterns and Clinical Outcomes in
Critically Ill Patients: A Systematic Review,” The Journal of the American Medical
Association, 2002, 288(17), 2151–2162.
Provonost, P. J., and others. “How Can Clinicians Measure Safety and Quality in Acute
Care?” Lancet, 2004, 363(9414), 1061–1067.
Provonost, P. J., and others. “Interventions to Reduce Mortality Among Patients
Treated in Intensive Care Units.” Journal of Critical Care, in press.
Rubin, H., Pronovost, P., and Diette, G. “From a Process of Care to a Measure: The
Development and Testing of a Quality Indicator.” International Journal of Quality in
Health Care, 2001, 13(6), 489–496.
Virginia Department of Health Professions. “Physician Information Project.”
[]. 2004.
Implementing High-Performance
Work Practices in Healthcare
Organizations: Qualitative and
Conceptual Evidence
Ann Scheck McAlearney, ScD, professor and vice chair, Department of Family Medicine,
The Ohio State University, Columbus; Julie Robbins, PhD, post-doctoral researcher,
Department of Family Medicine, The Ohio State University; Andrew N. Garman, PsyD,
professor, Department of Health Systems Management, Rush University, and CEO,
National Center for Healthcare Leadership, Chicago, Illinois; and Paula H. Song, PhD,
associate professor, Health Services Management and Policy, College of Public Health,
The Ohio State University
Studies across industries suggest that the systematic use of high-performance work
practices (HPWPs) may be an effective but underused strategy to improve quality of
care in healthcare organizations. Optimal use of HPWPs depends on how they are
implemented, yet we know little about their implementation in healthcare.
We conducted 67 key informant interviews in five healthcare organizations, each
considered to have exemplary work practices in place and to deliver high-quality care,
as part of an extensive study of HPWP use in healthcare. We analyzed interview transcripts inductively and deductively to examine why and how organizations implement HPWPs. We used an evidence-based model of complex innovation adoption to
guide our exploration of factors that facilitate HPWP implementation.
We found considerable variability in interviewees’ reasons for implementing
HPWPs, including macro-organizational (strategic level) and micro-organizational
(individual level) reasons. This variability highlighted the complex context for
HPWP implementation in many organizations. We also found that our application
of an innovation implementation model helped clarify and categorize facilitators of
HPWP implementation, thus providing insight on how these factors can contribute
to implementation effectiveness. Focusing efforts on clarifying definitions, building
commitment, and ensuring consistency in the application of work practices may be
particularly important elements of successful implementation.
For more information about the concepts in this article, please contact
Dr. McAlearney at
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Increasing evidence suggests that a link
exists between a capable workforce
and the delivery of high-quality patient
care across healthcare settings (Aiken,
Clarke, Cheung, Sloane, & Silber, 2003;
Aiken, Clarke, Sloane, Sochalski, &
Silber, 2002; McCue, Mark, & Harless, 2003; Tang, 2003). In healthcare
organizations challenged to address
issues associated with suboptimal care
quality and patient safety (e.g., IOM,
2001; Kohn, Corrigan, & Donaldson,
1999; McGlynn et al., 2003), the use of
innovative management practices—or
high-performance work practices—may
be an important strategic opportunity to
consider (Garman, McAlearney, Harrison, Song, & McHugh, 2011).
High-performance work practices
(HPWPs) include a set of human
resource (HR) practices—for example,
performance appraisal, training, and
teamwork—that, when implemented
together, show a positive relationship
with organizational outcomes (e.g.,
Becker & Huselid, 1998, 2006; Combs,
Ketchen, Hall, & Liu, 2006; Huselid,
1995). Drawing on evidence from
healthcare and other industries, Garman
et al. developed a theoretical model
to conceptualize the use of HPWPs in
healthcare. This model defines HPWPs
as “a set of practices within organizations that enhance organizational
outcomes by improving the quality
and effectiveness of employee performance” (Garman et al., 2011, p. 202);
these practices are organized into four
“subsystems” that focus on (1) engaging
staff, (2) aligning leaders, (3) acquiring
and developing talent, and (4) empowering the front line. McAlearney et al.
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JHM58(6).indd 447
(2011) provided preliminary support
for this model in a study that found (1)
these HPWPs were present in healthcare organizations known for their use
of innovative management and HR
approaches, and (2) HPWP implementation was linked to care quality outcomes, although this linkage was not
quantitatively confirmed. These findings
are consistent with previous research on
HPWPs that linked different sets of HR
practices, for example, training, performance appraisal, and teamwork, to
lower patient mortality rates in hospitals
(West et al., 2002; West, Guthrie, Dawson, Borrill, & Carter, 2006).
Despite accumulating evidence
from multiple settings and sectors
that a positive relationship may exist
between HPWPs and organizational
outcomes (Becker & Huselid, 2006;
Combs et al., 2006; Huselid, 1995),
little is known about how organizations can successfully implement these
practices (Lengnick-Hall, LengnickHall, Andrade, & Drake, 2009). In this
article, we seek to extend the work of
Garman et al. (2011) and McAlearney et
al. (2011) to improve our understanding of how healthcare organizations can
successfully implement HPWPs. First,
we consider the organizational context
for implementation among five healthcare organizations that have successfully
implemented HPWPs (i.e., the rationale
for HPWP adoption). Second, we use
an evidence-based model of innovation
effectiveness as a framework to identify
facilitators of successful HPWP implementation. Our objective is to improve
our understanding of how healthcare
organizations can appropriately facilitate the implementation of HPWPs.
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The aim of this article is to guide future
research on how HPWPs can be implemented to improve care quality and
patient safety. More practically, findings
from our study of health systems that
have successfully implemented HPWPs
can be used as a guide by other healthcare organizations.
JHM58(6).indd 448
professional or organizational values,
competencies, and mission—as key
factors. Subsequent research on the
implementation of worksite wellness
programs provides additional support
for the validity and applicability of this
model in healthcare settings (Weiner
et al., 2009); therefore, we use this
model as our framework for analyzing
facilitators of HPWP implementation, as
shown in Figure 1. The enhanced model
in Figure 1 presents all of the constructs
and relationships described by Helfrich
et al. (2007) and includes a summary
of the evidence presented in this article
that supports the relevance of each construct to HPWP implementation.
We conceptualized the use of HPWPs
within healthcare organizations as
implementation of a complex innovation that requires “active and coordinated use by multiple organizational
members to benefit the organization”
(Klein & Sorra, 1996, p. 1057). By
definition, HPWPs require organizations to develop innovative practices
across multiple functions (e.g., clinical,
administrative) and to implement them
consistently across multiple levels of the
organization. We observed this complexity among our case study sites and
therefore turned to the theory and literature on innovation implementation
(Helfrich, Weiner, McKinney, & Minasian, 2007; Klein & Sorra, 1996; Rogers,
2003; Weiner, Lewis, & Linnan, 2009) to
guide our study of HPWP implementation and use.
Building on the innovation adoption literature (Klein, Conn, & Sorra,
2001; Klein & Sorra, 1996), Helfrich et
al. (2007, p. 282), we developed and
tested a model of innovation implementation in complex healthcare organizations that recognized the importance
of (1) an “innovation champion”—an
individual who promotes the innovation within the organization—and (2)
the “innovation–values fit”—the perceived fit between the innovation and
Case Studies of HPWP Organizations
This research on HPWP implementation was conducted as part of a larger
study designed to validate Garman et
al.’s (2011) model of HPWPs and to
explore the link between HPWPs and
quality outcomes (McAlearney et al.,
2011). The study is based on case studies
(Yin, 1994) conducted with five purposively selected healthcare organizations
to investigate whether and how HPWPs
were being used in U.S. healthcare
organizations. Our sample included
five organizations that had demonstrated success in HPWP implementation and reported links between these
practices and quality outcomes. While
we considered selecting organizations
on the basis of quality outcomes and
then exploring the role of HPWPs as a
factor in those outcomes, we ultimately
determined that a sample selected on
the basis of HPWPs would provide more
robust insight into the various facets of
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Source: Adapted from Helfrich et al. (2007).
Key:      Anticipated relationships;    Emergent relationships
HPWP Evidence
• Monetary resources
• Human resources
Resources are made available to support implementation policies and
practices associated with HPWPs
Financial Resource Availability:
HPWP Evidence
• Formal and systematic accountability
• Adequacy of leader/staff skills
• Systematic performance management
• Standardized best practices and tools
Formal organizational actions ensure user
skills, create incentives, and identify and
address barriers to use of HPWPs
HPWP Evidence
• Focus on mission and patient care
• Long-term focus
• Resistance to change
Use of HPWPs is perceived as an organizational priority by targeted organizational members
Implementation Climate:
HPWP Evidence
• Link to quality
and organizational
performance outcomes
Consistency and quality of
HPWP use in practice
HPWP Evidence
• Formal champions
• Informal change agents
HPWP Evidence
• Focus on organizational change
• Motivation to change
HPWP Evidence
• Leadership commitment and involvement
• Coordinated organizational communication
Implementation Policies and Practices:
Champion promotes the use of HPWPs with targeted
organization members and management
Presence of a Champion:
Management has communicated rationale, priority
for HPWPs
Management Support:
The perceived fit between the innovation
and professional or organizational values,
competencies, and mission
Innovation–Values Fit:
f i gu r e 1
Conceptualizing HPWP Implementation Using a Complex Innovation Implementation Framework
I m p l e ment i ng H i gh -P erfor mance W ork P ractices in H ealth care O rganization s
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these practices that were the focus of our
We used an iterative process to
identify and select organizations that
had demonstrated success in HPWP
implementation. First, we sought references to “best practice” sites through
review of the published academic and
trade literature. Then, we solicited referrals from identified experts and sought
suggestions from members of a project
advisory panel to identify organizations
known for their innovative HR practices.
We also strived to select organizations
such that our sample would vary on
the basis of factors such as size, location, and type of delivery system, both
to enhance the generalizability of our
conclusions across a wide range of
hospitals and to determine whether
any of these variables influence HPWP
The five hospital-based health systems we selected for study had collectively won various awards (e.g., Malcolm
Baldrige National Quality Award, Fortune’s Best Companies to Work For) for
their HR and/or organizational innovations and provided us with a group of
organizations that varied on the basis
of additional HR-related factors, such
as the degree to which HR management
was centralized and integrated into strategic business operations. No organization we contacted refused to participate
in our study; Table 1 provides more
information about these organizations.
Data Collection
This study of HPWP implementation
is based on data collected for a broader
study that explored the role of HPWPs
in healthcare and their link to quality
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JHM58(6).indd 450
and patient safety outcomes. Our main
source of data was the 67 key informant interviews we conducted within
the study organizations (7 to 16 per
site). Key informants included a mix of
executive-level and nonexecutive-level
administrative staff (n = 28), ranging
from chief executives to project managers; HR personnel (n = 23); and clinical
personnel (e.g., chief medical officer,
chief nursing officer, quality coordinator) (n = 16). To ensure consistency
in our complement of key informants
across sites, we selected key informants
using a standard list based on organizational title and role. In addition, we
worked with a main contact at each site
to identify other informants within the
organization who could provide insight
into our research.
The research team, composed of
three lead investigators and a research
assistant, conducted nearly all of the
interviews in person during two-day
site visits to each case study organization; a few interviews were conducted
by telephone when informants were
not available at the time of our visit.
Interviews lasted from 30 to 60 minutes and were recorded and transcribed
verbatim to permit rigorous data
analysis. We obtained human subjects
approvals from the institutional review
boards of The Ohio State University
and Rush University, and we assured all
study participants that their responses
would remain confidential and
We used a semistructured interview
guide to ensure consistency in data collection. This interview guide included
both open-ended questions and followup question probes (McCracken, 1998;
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TA B L E 1
Case Study Sites
Major HPWP Initiatives
Urban, multisite
academic health
(~8,000 FTEs)
• Organizational focus on
Urban, multisite
health system
(~15,000 FTEs)
• Focus on creating a just
Urban, multisite
health system
(~15,000 FTEs)
• Internally branded platform
• Malcolm Baldrige
to align goals and internal
• Extensive, formal process for
information sharing
• Focus on creating a just
culture for patient safety
• Planetree recognition
• Magnet designation
Urban, safety net
(~5,500 FTEs)
• Leadership committed to
• University
Rural, multisite
health system
(~3,500 FTEs)
• Focus on creating a patients-
• Pebble Project
first culture
• Extensive, formal process for
• HIMSS Davies Award
reinforcing values, soliciting
employee feedback, and
developing leaders
• Established a work culture
committee that includes the
COO, CFO, and VP of HR
• Magnet designation
• University
Consortium’s Quality
Leadership Award
• Fortune’s “Best
Companies to Work For”
culture that emphasizes
• Magnet designation
patient safety
• Comprehensive, internally
branded selection/
onboarding program
focused on culture and fit
• Extensive formal process for
information sharing
“right people” strategy and
talent management process
• Use of Lean as a platform for
organizational improvement
Consortium’s Quality
Leadership Award
information sharing
Note: FTE = full-time equivalent; HIMSS = Healthcare Information and Management Systems Society.
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Miles & Huberman, 1994) and was
pilot tested before its use in this study.
In addition, we gave all key informants
a two-page handout, which describes
the HPWPs included in Garman et al.’s
(2011) model, to use as a reference during the interview process. The interview
guide covered nine major domains;
however, for this study, we focused
primarily on data associated with the
three domains most relevant to HPWP
implementation: selection and adoption
of HPWPs, implementation of HPWPs,
and operations associated with the use
of HPWPs. The interview guide questions related to these three domains are
presented in Table 2.
We applied the constant comparative
method of qualitative data analysis
(Glaser & Strauss, 1967) to guide our
evaluation of the interview data. Our
data analysis team, composed of the
first two authors of this article and a
research assistant trained in qualitative methods, first used the interview
guide to develop a preliminary coding
dictionary and applied this list of a
priori codes to three common transcripts to ensure consistency among
coders regarding decisions about codes
and themes. The second author and a
research assistant then worked individually, meeting periodically with each
other and the lead author, to ensure
reliability in the application of codes
and in the development and application of new codes on the basis of
emergent themes in the data. Disagreements about codes or emergent themes
were discussed and resolved within the
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research team. Conversations with colleagues and ongoing review of the literature helped us with conceptualization,
validation, comparisons, and extension
of our findings whenever appropriate (Glaser & Strauss, 1967). We used
the qualitative data analysis software
package ATLAS.ti, Version 6 (Scientific
Software Development, 2009), to support our analysis.
Once all interview data were coded,
we conducted secondary analyses
of the subset of data most related to
HPWP implementation. We considered data associated with the three
implementation-­related domains of
our interview guide (i.e., selection and
adoption of HPWPs, implementation
of HPWPs, and operations associated
with the use of HPWPS) as well as other
implementation-related data identified through our initial coding process
(e.g., facilitators, barriers, effectiveness).
We explored the context for HPWP
implementation by identifying common themes among our case study sites
related to their reasons for implementing HPWPs. We used the Helfrich et al.
(2007) model of innovation adoption
as a conceptual framework to analyze
respondents’ perceptions and identify
common themes related to the determinants of implementation effectiveness
for HPWPs. To complete this analysis,
the research team developed additional
codes associated with each Helfrich et al.
(2007) model construct. As with the initial coding, the research team employed
an iterative process to code the data that
included checks for reliability, identification of themes, and resolution of
disputes about coding or themes.
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TA B L E 2
HPWP Interview Guide: Implementation-Specific Domains and Questions
Selection and Adoption of HPWPs
• For the purposes of our research, we are particularly interested in human resources
practices and workforce strategies we have labeled “high-performance work practices.”
Does this term bring to mind any practices that are currently used in your organization?
(How so?) What HPWPs would you describe as in use in this organization? [Probe
regarding specific practices in Garman et al. (2011) model.]
• Who was involved in decision making about the use of HPWPs in your organization?
What was the vision and/or involvement of senior administrative leadership? Of clinical
leadership? How were other operational leaders (e.g., administrators, clinical leaders,
finance, other leadership teams) involved?
• What was the rationale for the selection of the HPWPs that are used in this
Implementation of HPWPs
• Could you please describe how these HPWPs were implemented in this organization?
What went well? What could have been improved?
• How did the implementation of these high-performance work practices involve different
organizational and/or clinical representatives?
• How were the practices conveyed/communicated to managers? To staff?
• When you consider the implementation of these HPWPs, was the value of implementing
the practices as a group considered or was implementation of stand-alone practices
sufficient? Was the implementation staged?
• Did the introduction of these HPWPs involve major changes for the organization
(e.g., culture change initiative, new bonus compensation approach)? Could you please
describe these changes? Were these changes planned or did they involve surprises during
the implementation process?
• What changes have occurred with respect to HPWPs over time? How did these changes
• Do you have any stories about barriers to introducing and implementing HPWPs at this
organization? How were these barriers overcome?
• Were there things that occurred prior to implementation of these HPWPs that needed to
be addressed to facilitate implementation?
Operations Associated With Use of HPWPs
• After the initial implementation, have there been changes or modifications of
operations required over time?
• What types of organizational data are collected regarding HPWPs? How are these used?
• What recommendations do you have for the use of HPWPs in practice? How could
operations be improved?
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Implementation Context: Reasons for
Implementing High-Performance Work
When asked why HPWPs were implemented in their organizations, interviewees provided a broad range of
reasons, which we classified as either
micro-organizational or macro-­
organizational. Micro-organizational
reasons for HPWP implementation
shared a common focus on enhancing
the workforce or quality of work life
within the organization and included
the following: (1) improve employee
morale, (2) engage employees, and (3)
improve employee quality. In contrast,
macro-organizational reasons were
focused on improving organizational
outcomes: (4) transform organizational
culture, (5) improve quality and patient
satisfaction, and (6) enhance organizational reputation. Table 3 presents
representative verbatim comments from
interviewees that support our classification of the micro-organizational and
macro-organizational reasons for implementing HPWPs.
Applicability of an Innovation
Effectiveness Model to HPWP
When considering factors that might
facilitate HPWP implementation, we
found that the Helfrich et al. (2007)
model for innovation effectiveness
(hereinafter referred to as conceptual
model) in healthcare settings was both
appropriate and useful for analyzing
these facilitators. Specifically, we confirmed that each of the seven determinants of innovation effectiveness in the
conceptual model—(1) management
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JHM58(6).indd 454
support, (2) financial resource availability, (3) implementation policies and
practices, (4) innovation–values fit, (5)
presence of a champion, (6) implementation climate, and (7) implementation
effectiveness—was salient across our
study sites.
In this section, we briefly summarize each component of the model as
originally conceptualized by Helfrich
et al. (2007). We then present evidence
of these components’ applicability to
HPWPs, identifying specific factors
related to each model construct that
emerged as a common theme across
our case study sites. These findings are
depicted as “HPWP Evidence” in Figure
1 (see p. 449). Representative quotations from our key informants that support our characterizations are presented
in Table 4, and additional explanation
of these findings is presented next.
1. Management support. The conceptual model defines this construct as
the degree to which managers commit
to the “transformation of the organization” (Klein et al., 2001, p. 814) through
innovation and investment in policies
and practices to support its consistent
adoption (Helfrich et al., 2007, p. 283).
We found strong evidence that management support—and, specifically, the
factors of leadership commitment and
organizational communication—was,
in fact, a facilitator of HPWP implementation. Across all sites, committed leadership was recognized as a key
factor contributing to implementation
success. Many interviewees emphasized
the important role of the organizations’
top leaders in setting a vision and priorities and similarly noted the importance
of leadership among middle managers.
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TA B L E 3
Reasons for Implementing HPWPs in Healthcare Organizations
Representative Quotes
• Improve employee
• Engage employees
• Improve employee
• “We . . . had a situation where I was looking around me and
seeing lots of very talented people, very loyal, committed to the
organization and to what they were doing, but extremely frustrated
and not feeling good about the work they were doing. So it was a
real disconnect.”
• “We embarked on this initiative] starting with our employees and
engaging them and creating the kind of work experience they’re
looking for, and the work environment they’re looking for as
a platform that allows them to create that experience for their
• “We know that we have huge needs to have very skilled and
specialized staff, [especially] in a market that had been shrinking.”
• “As an organization we are focusing more on developing [clinical
leaders] earlier on in their careers, whether it be as a preceptor or
as a charge nurse, preparing them for that role that they’re going to
• “[We looked at] where service lines will be going and whether we
see differences in the professionals that may require us to recruit
differently or look at things in a different way.”
• Transform
• Improve quality
and patient
• Enhance
• “We’ve been committed for nine years to transform[ing] the
healthcare experience from the inside out. So we believe that
marketing begins at the bedside and it begins with our team
members, that it’s one thing to go out and tell people you’re the best
and actually do nothing differently in the experience you create.”
• “We’ve cultivated that culture [of fear and retribution], and now we
have to get rid of it . . . unless we change the culture we will never
perform at the levels we want to, which is the 99 to 100% rate.”
• “The goal of [our initiative] was to really transform the experience
here so that people would really want to drive across the bridge
and get their healthcare here.”
• “[Our Patient Safety Plan] really launched our whole initiative in
improving our patient safety culture. We wanted to really change
our culture and enhance our culture, not that we did not have one.”
• “[W]e really committed to becoming an employer of choice.”
• “People recognize top places to work, so from an employer
standpoint, people know that. They may not even visit our
hospitals, but there is an association between being a great place to
work and the feeling that they probably get good care there.”
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TA B L E 4
Factors Facilitating HPWP Implementation and Use, by Construct
Key Factors
Management Support
• Leadership
commitment and
• Coordinated
• “Leadership is key. If your top leaders feel it’s important . . .
then it’s going to affect the outcomes.”
• “Communications is huge . . . there’s a whole network of
people who have to know what’s going on in order for [the
HPWP initiative] to be successful.”
• “You’ve got to keep the message out there constantly . . . and
you have to come at it from different ways.”
Financial Resource
• Monetary
• HR commitment
• “[O]ne of the things that we struggle with is, can we identify
Policies and Practices
• Formal and
• Standardized best
practices and tools
• “When you can motivate an organization behind a common
goal, communicate the common goal, communicate where
you’re heading, and then start embedding it into your
performance management system and start making people
accountable, you move the organization.”
• “Our organization was not especially strong [before HPWP
implementation] in hardwiring and accountability. . . . You
really do have to be very good at it and really help your leaders
to develop skills in doing that. It’s one thing to commit to
something and it’s another to really make the effective change.
And it’s just too easy for people to slip back into what’s
• “If it’s a best practice for leaders or an HR practice that we think
will help the organization, that’s something we hardwire.”
• “Now [the organization holds] cross-campus meetings where
you can cross-pollinate the best practices and things like that.”
Innovation–Values Fit
• HPWPs as
organizational change
• Motivation to change
• “I think we’ve been very successful. . . . I sit back in board
meetings or in board committee meetings and [the physicians
who were skeptical earlier] now talk about [how] there’s been a
huge improvement in this or that and it’s just the way it’s done
here. So they are now telling the story of what we’re doing—
it’s been a really nice transformation for me to watch and be
part of.”
• “[HPWP is] an area that everybody looks to cut when you come
into tough times and budgets.”
• “[We were able to hire] additional staff.”
• “There was a commitment from the organization that these
folks [involved in implementing the HPWPs] would be able to
get away from their [regular] jobs for this period of time.”
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t a b l e 4 continued
• “I would say one of the strengths of this organization is [that]
the culture here was never bad. It was never awful. . . . But that’s
also a weakness because people thought we were good enough.
You know the biggest enemy to great is good.”
Presence of a Champion
• Formal champions
• Informal change
• “I have a couple of my chiefs of service who are as passionate
Implementation Climate
• Focus on mission and
patient care
• Long-term focus
• “The mission [of this organization is what] fuels us in different
about this—if not more so—than myself . . . very performance
data–driven, willing to say this is not acceptable performance.
How do we move the systems to make us move forward? . . .
You’ve got to have those people.”
• “There are very dedicated nurse champions, and equally
important is having a physician champion who is really
involved and reinforces it at QI [quality improvement] meetings
and [in other activities].”
• “We engaged our team members and action teams for change,
and they became the architects for change.”
• “We had pockets of real leaders at the staff level driving some
ways than other places I have worked. . . . You start saying it like
that [emphasizing the organization’s mission], and it feels real,
and you will get hearts instead of just backs involved in this.”
• “When you bring a project like [HPWP implementation] on,
it will require the time and attention of the management. I
think to say that I want to bring in this new big, hairy planning
process we will roll out, it’s too much. It’s too much in a short
period of time. So we recognized we needed to take a phased
Top-down, coordinated, organizational
communication about the goals of
the HPWP initiatives was identified as
another critical factor contributing to
successful implementation. Along these
lines, communications challenges—such
as unclear messages and variation in
manager communication skills—were
recognized as potential barriers to successful HPWP implementation.
2. Financial resource availability. This construct recognizes that
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JHM58(6).indd 457
organizations seeking to adopt innovations need slack resources available—both monetary and human
resources—to enable them to support
the necessary changes in policy or
practice associated with the innovation. Although our sample included
organizations that had already made a
commitment to HPWP implementation,
they recognized resource availability as
a critical factor contributing to implementation success. One interviewee
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JHM58(6).indd 458
commented, “To think that you can do
this on a shoestring budget [dooms the
initiative to] failure.” Other interviewees
recognized the importance of dedicating resources to support HPWP implementation and/or giving existing staff
time “away from the offices or floors” to
participate in HPWP-related efforts, such
as training and communication events.
3. Implementation policies and
practices. This construct suggests that
what is most important is not the specific content of the policies and practices
that affect the success of innovation
implementation but the consistency of
these practices and the degree to which
they reward the use of the innovation—
in this case, HPWPs. We found two
common approaches among our case
study sites for ensuring consistency of
use and rewarding use of HPWPs: (1)
formal and systematic accountability
and (2) standardizing best practices
and tools. Across organizations, we
found widespread evidence that creating
formal accountability (e.g., job descriptions, performance standards, performance management) was critical to
implementation success. Several of the
study organizations used performance
management systems to formalize their
accountability structures and focus individual efforts on supporting organizational goals. One interviewee described
that organization’s use of performance
management as a mechanism for ensuring consistency: “We incorporated the
values into our performance evaluation
process and actually created behavioral guidance for all of the values.”
Key informants also suggested that an
approach to hardwiring innovations in
practice was to identify, standardize, and
spread best practices within the organization to support consistent implementation. As one interviewee reflected,
“[When a practice is standardized] it
doesn’t depend on what strikes your
leader’s fancy because we want it consistent across the organization.”
4. Innovation–values fit. This
construct describes the extent to which
targeted users perceive that the application of an innovation is consistent
with their values (Helfrich et al., 2007;
Klein & Sorra, 1996). Notably, much of
the success in implementing and using
HPWPs in healthcare organizations
appeared to be related to this construct and the two related factors that
emerged: (1) focusing on organizational
culture change and (2) fostering motivation to change. We found evidence
that HPWP implementation was viewed
most positively when framed as an
organizational culture change effort that
was strongly linked to the accomplishment of an organization’s mission and
goals. One informant described HPWP
implementation as the “[focus of our
strategic plan] and all of the things we’re
trying to measure to [achieve our mission].” Interestingly, we also found that
previous organizational success created
a challenge for HPWP implementation:
Interviewees suggested that because
the organizations had previously been
successful, individuals did not necessarily see a compelling case, or “burning
platform,” for initiating change.
5. Presence of a champion. The
conceptual model suggests that the
presence of champions, or “charismatic
individuals” (Rogers, 2003, p. 414)
who “throw their weight behind the
innovation to overcome indifference
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or resistance” (Helfrich et al., 2007,
p. 295), was particularly important in
successful implementation of innovations in healthcare organizations. We
found that the role and importance of
champions—both formal champions
and informal change agents—at all
levels of the organization were identified
as critical factors for successful HPWP
6. Implementation climate. In the
conceptual model, this construct refers
to shared perceptions of the extent
to which the use of an innovation is
“promoted, supported and rewarded
by the organization” (Helfrich et al.,
2007, p. 281; Klein et al., 2001, p. 813).
Several overarching factors contributed
to a positive HPWP implementation
climate. First, organizations’ efforts to
characterize their HPWP implementations as focusing on mission and patient
care were important for creating a clear,
inarguable direction for change. Second,
many individuals in the organizations
we studied were inclined to trust the
organization’s intent to make changes
associated with HPWP implementation
because these changes were introduced
and phased in as part of a deliberate
long-term culture change. This longterm focus appeared to reinforce the
organizations’ commitment to the
change (i.e., not just pursuing a “quick
fix”); however, organizations also incorporated interim milestones/rewards
that, in turn, motivated further change.
7. Implementation effectiveness.
In the conceptual model, this construct
is defined in terms of both the benefits that the organization receives as a
result of an innovation and the “consistency and quality” derived by using
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JHM58(6).indd 459
it (Helfrich et al., 2007; Klein & Sorra,
1996). We found in related work by
McAlearney et al. (2011) that, despite
a lack of definitive quantitative support, there was a strong collective belief
within the case study organizations that
successful HPWP implementation was
linked to quality and organizational
performance outcomes, which suggests
implementation effectiveness.
Using an evidence-based model of complex innovation implementation, we
were able to effectively characterize the
factors that facilitate HPWP implementation in healthcare organizations. The
notion of innovation–values fit emerged
as a particularly salient factor; all five of
our case study sites sought to motivate
broad organizational change by emphasizing the link between HPWP-related
innovations and the achievement of
broader organizational goals and values,
such as improved quality of care and
increased patient safety. This finding is consistent with the strategic HR
literature that suggests that alignment
between HPWPs and broader organizational strategy is an important factor
contributing to implementation success
(Lengnick-Hall et al., 2009). In addition,
our results are aligned with innovation
implementation literature findings that
individuals are more likely to adopt
innovations that they value (Helfrich
et al., 2007; Klein & Sorra, 1996).
Similarly, we found that both formal
champions and informal change agents
played an important role in facilitating
HPWP implementation. Combined,
these findings support the relevance
of the innovation–values fit and the
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JHM58(6).indd 460
innovation champion constructs—the
two healthcare-specific adaptations in
the Helfrich et al. (2007) model.
Also important is the notable parallel between the reasons informants
expressed for implementing HPWPs and
the innovation–values fit construct of
this model. Both micro-organizational
and macro-organizational reasons
for HPWP implementation could be
encompassed as elements of the innovation–values fit factor, thus helping
facilitate HPWP implementation due
to the consistency in understanding
implementation rationale and projected impact. In addition, informants’
comments about the reasons organizations pursue HPWPs indicate that these
individuals perceive a link between
HPWP implementation and strategic
organizational considerations and
outcomes such as patient safety and
care quality. These findings suggest that
HPWPs can indeed serve a strategic role
within healthcare organizations, similar to what has been proposed by the
resource-based view of organizations
(e.g., Becker & Huselid, 2006; Wright &
McMahan, 1992).
Yet, identifying these key factors
does not guarantee implementation success—on the basis of either consistency
and quality of use or organizational outcomes. Instead, the use of an evidencebased model to frame these analyses
allows us to better articulate our findings about implementation factors
and provides insight that can improve
our understanding about innovation
implementation, thus increasing the
likelihood of implementation success.
In turn, our findings offer support for
the utility of the Helfrich et al. (2007)
model for analyzing the implementation of complex innovations in healthcare organizations. Finally, our study
provides a framework and evidence to
guide future inquiry into the factors
that affect the relationship between
HPWP implementation and differential
organizational outcomes in healthcare
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Practice Implications
Several findings from this study are
particularly relevant to management
practitioners. Our study highlights the
challenges of implementing and using
HPWPs, including issues associated with
workforce change, personnel capabilities, and overall organizational culture.
Importantly, though, by considering
the insights offered in viewing HPWPs
through the theoretical lens of the
innovation implementation literature,
we were able to characterize implementation factors that may facilitate effective
implementation of HPWPs in healthcare
organizations, including clear articulation of how these practices support
mission accomplishment, strong leadership involvement and support, clear
and consistent organizational communication, and formalized accountability
and performance management. Ideally,
our discussion of the factors that both
inhibit and facilitate HPWP implementation will help healthcare practitioners
translate knowledge about evidencebased HPWPs (e.g., Etchegaray, St. John,
& Thomas, 2011; Garman et al., 2011) to
Limitations of This Study
An important limitation of this study is
associated with our study design. While
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we sought to study organizations that
had work practices considered exemplary in the field, the scope of our study
was insufficient to enable us to compare
respondents’ comments about practices
at these exemplary sites with comments
from respondents at sites considered
to have average work practices or at
sites that experienced greater barriers to
implementation. Such a contrast group
would have allowed us to directly examine which of these model elements were
critical, or most critical, to successful
Additionally, we did not directly ask
informants about implementation practices relative to our conceptual model;
as a result, we may not have identified
all of the factors important to HPWP
implementation effectiveness. However,
our finding that these emergent factors
were consistent with the conceptual
framework we applied strengthens our
conclusions about implementation
and the applicability of the model as
a framework for understanding HPWP
Future research can extend the
exploratory work we report in this article
by studying HPWP implementation
among a larger number and a greater
variety of organizations, including
some that may be more typical of the
field than the exemplars included in
our study. This broadened focus would
allow investigators to both compare and
contrast work practices and consider
metrics that might be available to permit
quantitative analysis.
Findings from this research help
improve our understanding of how
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JHM58(6).indd 461
healthcare organizations can facilitate
HPWP implementation and provide
insight into the factors that may affect
implementation of these HPWPs. From
an academic perspective, these findings
emphasize the importance of conceptual frameworks used in innovation
implementation to help guide HPWP
implementation activities. From a practitioner perspective, our results suggest
that implementation can be facilitated
by efforts to clarify definitions, build
commitment, and ensure consistency
in applying work practices. Consideration of these implementation factors
from both perspectives can enhance the
capabilities of healthcare organizations
to improve both care quality and work
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Implementing EBP Column
Implementing and Sustaining EBP in Real
World Healthcare Settings: Transformational
Evidence-Based Leadership: Redesigning
Traditional Roles to Promote and Sustain a
Culture of EBP
Lynn Gallagher-Ford, PhD, RN, DPFNAP, NE-BC
Column Editor for “Implementing and Sustaining EBP in Real World Healthcare
This column shares the best evidence-based strategies and innovative ideas on how to
promote and sustain evidence-based practices and cultures in clinical organizations.
Guidelines for submission are available at
10.1111/(ISSN)1741-6787 under “Special Features.”
Evidence-based practice (EBP) is an essential characteristic of
individual clinicians as well as the healthcare environments
in which they provide care. To deliver the highest quality
of evidence-based care across and throughout each patient
experience deep and lasting changes must be made in traditional organizations. Implementing meaningful organizational changes to promote and sustain EBP as the foundation
of all practice and decision making requires ample knowledge
of EBP, a system-wide vision and commitment to providing
evidence-based care, resources, and courage. This may seem
like a short and simple list, but actualizing these critical elements requires more than sending a few people to an EBP
conference, designating a computer on each patient care unit
for staff to access articles, changing the name of a committee
or council, or buying an electronic resource with “embedded”
evidence. High impact transformative changes must be implemented and sustained over time for EBP to become the DNA
of an organization. Because the realities of healthcare organizations are ever changing and complex, they provide rich
opportunities for dynamic leaders to be innovative in making
EBP a reality.
When a large, complex healthcare system set out to transform
to an evidence-based organization, a nurse administrator (NA),
responsible for nursing quality, research, EBP, and education
across the health system, began by conducting cultural and
structural assessments of the organization related to preparedness for EBP as well as a comprehensive review of the departments for which she had responsibility and authority. The
NA used an evidence-based approach for determining the best
course of action. The NA consulted with EBP experts and the
literature to determine the most effective and efficient changes
that could be made within the NA’s scope of authority, which
would render the greatest impact on the organization’s transformation to EBP.
In the NA’s evidence-based approach to making this leadership decision, it was found that the development of a cadre of
EBP mentors to drive EBP across the organization was a welltested and effective strategy (Levin, Fineout-Overholt, Melnyk,
Barnes, & Vetter, 2011; Melnyk, 2007; Melnyk et al., 2004;
Wallin, Ewald, Wikblad, Scott-Findlay, & Arnetz, 2006). EBP
mentors, as first described in the ARCC model, are typically
advanced practice nurses (APNs) who have outstanding knowledge and skills in EBP along with expertise in individual and organizational change (Melnyk & Fineout-Overholt, 2010). The
NA also found that APNs, particularly clinical nurse specialists
(CNSs), are well suited for the role of EBP mentor because
they have the attitude, skills, and competencies to enact the
role and responsibility of the EBP mentor. In the NA’s organization, the CNSs reported to managers and directors in
a variety of roles in the nursing department and had erratic
Worldviews on Evidence-Based Nursing, 2014; 11:2, 140–142.

C 2014 Sigma Theta Tau International
Implementing EBP Column
“dotted line” relationships with the centralized nursing quality
department. The evidence-based organizational changes to be
implemented, determined by applying the seven-step EBP process to decision making, were to (a) redefine the CNS role to
include EBP mentor responsibilities with deliverables of EBP
changes and outcomes, and (b) reorganize the CNSs to report
centrally to the quality department with “dotted lines” to their
clinical units.
The NA needed to make a plan for introducing and executing this evidence-based change in a complex nursing enterprise. The NA’s history in the organization as a respected
leader and her strong transformational leadership style were
the tools used to undertake this transformative action plan.
The characteristics of a transformational leadership style were
a particularly good fit for leading the organization in implementing meaningful changes to promote and sustain EBP
as the foundation of all practice and decision making because transformational leadership is defined as a process in
which leaders and followers “find meaning and purpose in
their work, and grow and develop as a result of their relationship” (Barker, Sullivan, & Emery, 2006, p. 16). The hallmarks
of transformational leaders and followers are that: the leaders provide a vision and are skilled at motivating and inspiring others; and the followers trust, admire, and respect the
leader. Based on their relationships, transformational leaders
and followers become partners in pursuit of a common goal;
in this case, realigning and redefining CNS roles to promote
and sustain EBP in the organization. The environment created
by transformational leaders is change oriented and well suited
to support new ideas and innovation (Klainberg & Dirschel,
Leveraging her role and innate leadership style to implement this evidence-based organizational change to improve
care, the NA (a) clearly articulated her vision for the departmental change, (b) respectfully engaged the multitude of
stakeholders to be affected, (c) openly invited ideas for structuring the change process ahead, (d) creatively redistributed
allocated resources, (e) earnestly role modeled evidence-based
decision making in her own practice, (f) skillfully led individuals and groups through the challenges of the change process,
(g) quickly and effectively managed minor episodes of subterfuge toward the change, and (h) enthusiastically recognized
and rewarded individual and group successes along the way,
whether they were large or small.
Many of the CNSs have become vigorous, enthusiastic EBP
champions in the organization, and have gained tremendous
buy-in for EBP from staff. The CNSs are mentoring and leading
teams through the EBP process steps to make informed recommendations for practice changes and are gaining new respect
from colleagues who appreciate the EBP knowledge and expertise they bring to shared communities of practice. Frontline
clinicians are engaging in clinical inquiry and participating in
the EBP process steps with enthusiasm and many have commented on how the EBP experience has “re-energized” their
More than 13 EBP projects, mentored by the CNSs, have
been initiated and are at various stages of completion across
the health system. EBP projects are addressing patient falls,
catheter associated urinary tract infections, hospital acquired
pressure ulcers, suctioning protocols, and alarm fatigue, which
is only a partial list of projects that are underway and rendering
meaningful outcomes for patients, families, clinicians, and the
health system.
CNS positions were reorganized centrally under the quality
department with “dotted lines” to clinical units. The Health
System Nursing Quality, Research, EBP, and education organizational chart was recreated to reflect these changes. CNS roles
were redefined with EBP mentor responsibilities imbedded
and EBP practice change deliverables (projects and outcomes)
clearly articulated as expectations. CNS job descriptions and
performance appraisals were rewritten to reflect EBP expectations and deliverables.
The work that the NA has led in her organization has been
presented at conferences nationally and internationally. The
ongoing results of the work will continue to be disseminated whenever possible. Particular focus will be paid to:
EBP mentor development stories, EBP projects implemented,
patient, clinician and organizational outcomes, effective rewards and recognition programs, and results of nursing leadership EBP initiatives including educational interventions
Worldviews on Evidence-Based Nursing, 2014; 11:2, 140–142.

C 2014 Sigma Theta Tau International
The next step for the department is to build EBP attributes and
capacity (knowledge, skills, and positive attitudes) in nursing
leadership. Based on recent findings from Melnyk, FineoutOverholt, Gallagher-Ford, & Kaplan (2012), nurses have identified leaders and managers as one of the top five barriers
to implementing EBP. This finding, combined with internal
evidence from within the organization, grounds the decision
to develop and extend EBP education to nursing leadership
across the health system. In collaboration with EBP experts,
EBP education for nurse leaders is underway. Further development and refinement of an EBP education program that
will resonate with contemporary nursing leaders and increase
their confidence to lead, role model, and support EBP will
focus on:
1. The unique dual responsibilities of nurse leaders related to EBP:
a. embracing and role modeling EBP in their own
practice, and
b. creating cultures and environments that support
and sustain EBP;
2. Leveraging leadership styles.
Implementing EBP Column
r Nurse leaders must leverage their role and authority in organizations to create environments that
promote and sustain EBP.
r Traditional organizational structures (roles and
deliverables) can be re-designed and re-aligned
to more effectively promote, support, and sustain
r The role of CNS can be readily adapted to include
EBP mentor responsibilities.
r Transformational leaders are well suited to lead organizations in creating cultures that support EBP.
Levin, R. F., Fineout-Overholt, E., Melnyk, B. M., Barnes, M., &
Vetter, M. J. (2011). Fostering evidence-based practice to improve
nurse and cost outcomes in a community health setting: A pilot
test of the advancing research and clinical practice through close
collaboration model. Nursing Administration Quarterly, 35(1),
Melnyk, B. M. (2007). The evidence-based practice mentor: A
promising strategy for implementing and sustaining EBP in
healthcare systems. Worldviews on Evidence-Based Nursing, 4(3),
Melnyk, B. M., & Fineout-Overholt, E. (2010). Evidence based practice in nursing and healthcare: A guide to best practice. (2nd ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.
Melnyk, B. M., Fineout-Overholt, E., Fischbeck Feinstein, N., Li,
H., Small, L., Wilcox, L., & Kraus, R. (2004). Nurses perceived
knowledge, beliefs, skills, and needs regarding evidence based
practice: Implications for accelerating the paradigm shift. Worldviews on Evidence Based Nursing, 1, 185–193.
Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan,
L. (2012). The state of evidence-based practice in U.S. nurses:
Critical implications for nurse leaders and educators. Journal of
Nursing Administration, 42(9), 410–417.
C 2014, Sigma Theta Tau International
Barker, A. M., Sullivan, D. T., & Emery, M. J. (2006). Leadership
competencies for clinical managers: The renaissance of transformational leadership. Sudbury, MA, Jones & Bartlett Learning.
Klainberg, M., & Dirschel, K. (Eds.). (2010). Today’s nursing leader:
Managing, succeeding, excelling. Jones & Bartlett Learning.
Wallin, L., Ewald, U., Wikblad, K., Scott-Findlay, S., & Arnetz, B. B.
(2006). Understanding work contextual factors: A short-cut to
evidence-based practice? Worldviews on Evidence-Based Nursing,
3(4), 153–164.
doi 10.1111/wvn.12033
WVN 2014;11:140–142
Worldviews on Evidence-Based Nursing, 2014; 11:2, 140–142.

C 2014 Sigma Theta Tau International
Copyright of Worldviews on Evidence-Based Nursing is the property of Wiley-Blackwell and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.
The current issue and full text archive of this journal is available on Emerald Insight at:
Leadership in evidence-based
practice: a systematic review
Department of Medical and Health Sciences, Linköping University,
Linköping, Sweden
Ursula Reichenpfader, Siw Carlfjord and Per Nilsen
Received 22 August 2014
Revised 17 February 2015
25 March 2015
Accepted 20 April 2015
Purpose – This study aims to systematically review published empirical research on leadership as a
determinant for the implementation of evidence-based practice (EBP) and to investigate leadership
conceptualization and operationalization in this field.
Design/methodology/approach – A systematic review with narrative synthesis was conducted.
Relevant electronic bibliographic databases and reference lists of pertinent review articles were
searched. To be included, a study had to involve empirical research and refer to both leadership and
EBP in health care. Study quality was assessed with a structured instrument based on study design.
Findings – A total of 17 studies were included. Leadership was mostly viewed as a modifier for
implementation success, acting through leadership support. Yet, there was definitional imprecision as
well as conceptual inconsistency, and studies seemed to inadequately address situational and
contextual factors. Although referring to an organizational factor, the concept was mostly analysed at
the individual or group level.
Research limitations/implications – The concept of leadership in implementation science seems
to be not fully developed. It is unclear whether attempts to tap the concept of leadership in available
instruments truly capture and measure the full range of the diverse leadership elements at various
levels. Research in implementation science would benefit from a better integration of research findings
from other disciplinary fields. Once a more mature concept has been established, researchers in
implementation science could proceed to further elaborate operationalization and measurement.
Originality/value – Although the relevance of leadership in implementation science has been
acknowledged, the conceptual base of leadership in this field has received only limited attention.
Keywords Evidence-based practice, Leadership, Measurement, Systematic review,
Conceptualization, Conceptual inconsistency
Paper type Literature review
Despite widespread acceptance of the importance of implementing evidence-based
practice (EBP) and the use of findings from scientific research in clinical practice, many
patients still do not receive treatments with proven effectiveness or may receive care
that is of little benefit or harmful (Dopson et al., 2002; Greenhalgh et al., 2004; Oxman
et al., 1995). Implementation science has emerged as a vital interdisciplinary research
field to address the challenges associated with the gap identified between the production
and use of evidence in various settings. Explanations for this gap have largely focused
on the characteristics of the individual provider, such as limited access to research, poor
Leadership in Health Services
Vol. 28 No. 4, 2015
confidence in identifying and critically appraising evidence and perceived time
pp. 298-316
© Emerald Group Publishing Limited restrictions to integrate research into clinical practice (Rycroft-Malone, 2008;
Estabrooks et al., 2003; Squires et al., 2011).
DOI 10.1108/LHS-08-2014-0061
However, within the field of implementation science, there has been increasing Leadership in
recognition of the role of the organizational context in the implementation of EBP evidence-based
(Durlak and DuPre, 2008; Greenhalgh et al., 2004; Fixsen et al., 2005). Leadership has
been identified as an important contextual dimension (Taylor et al., 2011; Stetler et al.,
2011; Newton et al., 2003); leadership commitment and active interest are behaviours
that can positively affect the effectiveness of implementation (Helfrich et al., 2007). In
addition, leaders’ influence on the subjective norms of potential adopters through
interpersonal networks and communication must be considered (Leeman et al., 2007).
Although there is no universally agreed definition of leadership, many
conceptualizations reflect the assumption that leadership involves a process of exerting
intentional influence by one person over another person or group to achieve a certain
outcome in a group or organization (Gill, 2012; Yukl, 2006). There is evidence from
outside the health care field of the influence of leadership on organizational culture,
organizational performance (Ogbonna, 2000), organizational change (Battilana et al.,
2010) and organizational innovation (Denti and Hemlin, 2012; Siegel and Kaemmerer,
Although the relevance of leadership in implementation science has been
acknowledged, there seems to have been little empirical research on this concept in this
field. Thus, the role of leadership in the implementation of EBP and the processes
through which leaders can affect implementation success are largely unknown (Long
et al., 2013; Rycroft-Malone et al., 2011; Wallin et al., 2006; Wong et al., 2013; Aarons et al.,
2014). Therefore, the aim of this study was to systematically review published empirical
research on leadership as a determinant for the implementation of EBP in health care
and to investigate the conceptualization and operationalization of leadership in the field
of implementation science.
Our approach is based on a conceptual scoping review (Levac et al., 2010), where we
attempt to examine the range of research and identify potential research gaps in the
existing literature. The research question was formulated as follows: based on an
exploratory systematic review of empirical health-care implementation studies on the
concept of leadership, how is the leadership concept applied and contextualized? How do
study authors define and specify the concept of leadership or its essential components
and how is the construct measured?
The electronic databases PubMed and The Cochrane Library including the Cochrane
Database of Systematic Reviews were searched, and a separate search was conducted
via the search function at the Implementation Science journal website (see Electronic
Supplementary Material, Table S1, for search history). Medical Subject Headings as
search terms when available were used or key words when appropriate. Search terms for
leadership and research utilization or EBP were combined. All electronic searches were
limited to “English language”, “German language” or “Swedish language” In addition,
reference lists of pertinent review articles, key publications and commentaries were
searched manually. All searches were conducted in October and November 2013. Owing
to limited resources, abstracts and full-text articles could not be screened independently.
Studies available in abstract form were only excluded. Eligibility criteria with respect to
study design, publication type, study aim, setting, participants and outcomes were
To be eligible for inclusion, a study had to explicitly refer to leadership as a construct
(or leaders or leaders’ characteristics or leadership skills) in relation to the outcome of
EBP or research use (research utilization, knowledge transfer, knowledge translation,
knowledge utilization) in health care. Thus, studies exploring only general barriers or
organizational factors affecting implementation outcomes were excluded. In addition,
studies on instrument development or validation related to leadership and studies
focusing only on conducting research (as opposed to research use or knowledge
translation) were excluded. Studies exploring the effect of knowledge brokers, local
opinion leaders, external facilitators, facilitation or change agents, as well as studies on
leadership interventions (e.g. leadership development interventions, leadership training
programmes) were also excluded. No limitations with respect to a specific study design
were applied.
One member of the research team (UR) was responsible for reading the abstracts of
all the articles identified in this first search and applying the inclusion/exclusion criteria
using an abstract screening tool. Inclusion/exclusion criteria were developed and
discussed by all members of the research team (UR, SC, PN) and UR piloted the
inclusion/exclusion criteria with a subset of abstracts retrieved from PubMed. Two
members of the research team (SC and PN) reviewed the search terms, the search
strategy, the abstract screening strategy and the data abstraction criteria.
Data were abstracted from each included study by one member of the research team
(UR) using predefined criteria (study aims, study design and methods; study
participants; type of outcomes; health-care setting and country where the study was
conducted; main findings with respect to leadership: underlying theory, concept or
framework; leadership construct; leadership operationalization and measurement;
outcomes; type of data analysis; level of analysis; and stage of change process, i.e.
pre-implementation, implementation, post-implementation).
Study quality or study reporting quality was assessed with a structured instrument
based on the design of the individual study: Critical Appraisal Skills Program for
qualitative studies (Critical Appraisal Skills, 2013), the Assessment of Multiple
Systematic Reviews tool for systematic reviews (Shea et al., 2007) and the Mixed
Methods Appraisal Tool for mixed methods studies (Pluye et al., 2011). As there is
currently no consensus guideline for survey research available, the data abstraction
form in Bennett et al. (Bennett et al., 2010) was utilized. The operationalization of the
concept was analysed based on all studies using a survey approach and on qualitative
studies providing published information on the respective interview guides.
Our searches identified 1,149 citations. We screened 144 full-text articles for eligibility,
of which 17 were included in the study (Figure 1) (Aarons, 2006; Bergstrom et al., 2012;
Boström et al., 2007; Brown and McCormack, 2011; Cummings et al., 2010; Damschroder
et al., 2011; Estabrooks et …

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