Introduction: The impetus for employee...
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THE INFLUENCE OF EMPLOYEE ENGAGEMENT ON ORGANIZATIONAL OUTCOMES: A CASE STUDY AT MAGEE-WOMENS HOSPITAL OF UPMC by Evangeline A. Harpst BA, Hendrix College, 2014 Submitted to the Graduate Faculty of Department of Health Policy and Management Graduate School of Public Health in partial fulfillment of the requirements for the degree of Master of Health Administration
Transcript of Introduction: The impetus for employee...
THE INFLUENCE OF EMPLOYEE ENGAGEMENT ON ORGANIZATIONAL OUTCOMES: A CASE STUDY AT MAGEE-WOMENS HOSPITAL OF UPMC
by
Evangeline A. Harpst
BA, Hendrix College, 2014
Submitted to the Graduate Faculty of
Department of Health Policy and Management
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Health Administration
University of Pittsburgh
2016
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Evangeline A. Harpst
on
March 21, 2016
and approved by
Essay Advisor:
Wesley M. Rohrer, PhD, MBA ______________________________________Vice Chair of Education and Director of the MHA Program Department of Health Policy and Management Graduate School of Public Health University of Pittsburgh
Essay Readers:
Carrie Leana, PhD, BA ______________________________________George H. Love Professor of Organizations and ManagementProfessor of Business Administration, of Medicine, and of Public and International AffairsUniversity of Pittsburgh
Patty Genday, MSN, MBA, RN ______________________________________Executive Director, Women’s ServicesMagee-Womens Hospital of UPMC
Copyright © by Evangeline A. Harpst
2016
ABSTRACT
Under the Affordable Care Act, hospitals are now reimbursed based on the patient experience
and clinical outcomes. Recognizing the critical role of employees in shaping key elements of the
patient experience, many organizations are turning to employee engagement as a way to
maximize value-based reimbursement and thrive in a value and consumer driven environment.
This paper provides an overview of the organizational benefits of employee engagement,
including patient satisfaction, higher quality of care, and better financial results, and focuses on
the key drivers of engagement in health care. A case study on employee engagement at Magee-
Womens Hospital of UPMC studies the link between engagement and organizational outcomes
on two inpatient units. The case study found certain organizational outcomes such as patient
satisfaction and perceived quality of care to be correlated with engagement, and also highlighted
the role of the direct manager in driving changes in unit level engagement. The public health
relevance of this paper is through understanding the benefits and drivers of engagement,
organizations can improve patient outcomes and the health of the community, while positioning
the organization for a viable future.
Wesley M. Rohrer, PhD, MBA
THE INFLUENCE OF EMPLOYEE ENGAGEMENT ON ORGANIZATIONAL
OUTCOMES: A CASE STUDY AT MAGEE-WOMENS HOSPITAL OF UPMC
Evangeline A. Harpst, MHA
University of Pittsburgh, 2016
TABLE OF CONTENTS
1.0 INTRODUCTION: THE IMPETUS FOR EMPLOYEE ENGAGEMENT...........1
1.1 THE STATE OF ENGAGEMENT.....................................................................2
1.2 IMPLICATIONS OF HEALTH CARE REFORM..........................................4
1.3 ORGANIZATIONAL BENEFITS OF EMPLOYEE ENGAGEMENT.........5
1.4 THE DRIVERS OF EMPLOYEE ENGAGEMENT......................................10
1.4.1 Ability and Desire to Contribute...................................................................10
1.4.2 Quality of Work Environment......................................................................11
1.4.3 Feeling Valued................................................................................................12
1.4.4 Growth Opportunities....................................................................................13
1.4.5 Perception of Leadership and Supervisor....................................................14
1.4.6 Pride in Service and Mission.........................................................................16
1.5 MEASURING EMPLOYEE ENGAGEMENT...............................................16
2.0 CASE STUDY AT MAGEE-WOMENS HOSPITAL OF UPMC.........................19
2.1 INTRODUCTION TO MAGEE-WOMENS HOSPITAL..............................20
2.2 MEASURING EMPLOYEE ENGAGEMENT AT MAGEE-WOMENS
HOSPITAL..........................................................................................................................20
2.3 ANALYSIS OF ENGAGEMENT.....................................................................23
2.3.1 Highest Scoring Unit: Unit A........................................................................23
2.3.2 Lowest Scoring Unit: Unit B..........................................................................26
2.4 DISCUSSION......................................................................................................29
2.5 RECOMMENDATIONS...................................................................................33
2.6 PUBLIC HEALTH RELEVANCE...................................................................36
2.7 CONCLUSION...................................................................................................36
APPENDIX A : EMPLOYEE ENGAGEMENT INITIATIVES AT MAGEE-WOMENS. 38
APPENDIX B : UPMC ENGAGEMENT SPECTRUM CATEGORIES..............................41
APPENDIX C : 2015 NDNQI RN PRACTICE ENVIRONMENT SCALE.......................42
BIBLIOGRAPHY........................................................................................................................44
LIST OF TABLES
Table 1. Example Statements of Ability and Desire to Contribute...............................................11
Table 2. Example Statements of Quality of Work Environment...................................................12
Table 3. Example Statements of Feeling Value.............................................................................13
Table 4. Example Statements of Growth Opportunities................................................................14
Table 5. Example Statements of Perception of Leadership and Supervisor..................................15
Table 6. Example Statements of Pride in Service and Mission.....................................................16
Table 7. Magee-Womens Overall MyVoice Engagement.............................................................21
Table 8. Unit A’s MyVoice Engagement......................................................................................26
Table 9. Unit B’s MyVoice Engagement......................................................................................29
Table 10. Organizational Outcome Trends from 2013 to 2015.....................................................32
LIST OF FIGURES
Figure 1. The Effect of Employee Engagement on Patient Experience Measures..........................6
Figure 2. The Impact of Employee Engagement on Value Based Purchasing Points.....................9
Figure 3. Unit A NDNQI Survey Data..........................................................................................24
Figure 4. Unit B NDNQI Survey Data..........................................................................................27
Figure 5. Change in HCAHPS Scores: 2013-2015........................................................................31
1.0 INTRODUCTION: THE IMPETUS FOR EMPLOYEE ENGAGEMENT
There are many ways to promote employee engagement in health care organizations, ranging
from employee recognition and career development, to the quality of leadership and the work
environment they experience. Many of these drivers of engagement can be under the
organization’s control, yet can be difficult to achieve in a field as complex and demanding as
health care. Employee engagement is just one of the challenges facing health care executives and
managers, along with increasing competition, a changing regulatory environment, inadequate
reimbursement, and shifting community needs.
Organizations will always face difficulties retaining health care providers and support
staff because of the relative ease with which they can obtain another job. However, retaining top
talent will be critical for health care organizations as they enter a new era post-health care
reform. The Affordable Care Act (ACA) shifts health care to a value-based purchasing context,
where providers of care are now accountable to payors for patient outcomes. Health care
providers will no longer receive the same level of reimbursement if the care they provide does
not meet defined standards of quality and patient satisfaction. Pay-for-performance
reimbursement and a concurrent rise in consumerism brings patient outcomes into sharper focus.
Health care is a high-touch industry – meaning that employees have frequent contact with
patients. To make a true difference in the patient’s experience and outcomes health care
organizations will have to focus on the people driving this experience: all their employees who
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affect patient care directly or indirectly. This paper will make the case that health care leaders
must put the time, energy, and resources needed into employee engagement to make a significant
and lasting impact with their end user – the patients.
Employee engagement has been shown in the literature to lead to more satisfying patient
experiences and improved patient outcomes. It is also correlated with important organizational
goals such as reduced turnover, improved patient safety, higher quality, and increased
profitability (Harter, Schmidt, Agrawal, & Plowman, 2014; Lowe, 2012; Press Ganey, 2015a).
For organizations looking to thrive in a value-based purchasing environment, where employees
and health care leaders must achieve more with less, employee engagement is a crucial part of
the solution.
This essay will provide an overview of the literature focused on the organizational
benefits of employee engagement, the drivers of engagement, and measurement best practices.
Then, the author will present a case study of employee engagement at Magee-Womens Hospital
of UPMC, with an analysis of engagement, and make recommendations.
1.1 THE STATE OF ENGAGEMENT
Patients can easily discern whether an employee is engaged or not. Engaged employees are
energetic and enthusiastic about their work (Lowe, 2012; Press Ganey, 2015a). These employees
are invested in the success of the organization, proactive in sharing ideas and, as many studies
have found, willing to expend discretionary effort (Caldwell & Watson, 2011; Engagement
Strategies Media, 2016; Krause, 2015; Lowe, 2012). It is common for engaged employees to
experience values congruence with the organization and to want to play a role in fulfilling the
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mission (Blizzard, 2003; Lowe, 2012). Engaged employees also have “strong emotional, rational,
and behavioral attachments to their job and their organization,” often displayed through pride
and loyalty to the organization (Lowe, 2012). Not surprisingly, engaged employees are more
likely to recommend the organization as a place to work and to receive care (Lowe, 2012; Press
Ganey, 2016; Press Ganey, 2015a; The Advisory Board Company, 2014). Engaged employees
go above and beyond job expectations, and have been described as the ideal employee (Lowe,
2012).
Individuals who enter health care are often highly motivated to provide compassionate
care (Press Ganey, 2016). If the culture of an organization does not allow them to do so, they can
become disengaged, affecting everything from retention, to productivity, to patient outcomes
(Press Ganey, 2016; Scotti, Harmon, & Behson, n.d.). Two separate surveys on employee
engagement in health care indicate significant room for improvement. The Global Workforce
Study done by Towers Watson in 2011 found that only 44% of health care employees are
actively engaged in their work (Caldwell & Watson, 2011). Based on these results, over half of
health care employees are somewhat or actively disengaged with their work experience.
Compared to 2007, the number of respondents who said they were willing to put in a great deal
of effort to help the organization succeed decreased from 72% in 2007 to 66% in 2010 (Caldwell
& Watson, 2011; Healthcare Source Blog, 2014). A more recent survey administered by The
Advisory Board Company found that overall engagement in the health care industry leveled off
in 2014 after gains since 2010. In 2014, 40.5% of the workforce was engaged, while 5.8% were
disengaged. This plateauing effect was expected, because continual gains become more difficult
to achieve the more an organization improves (The Advisory Board Company, 2014).
Additionally, the 2015 Employee Engagement National Database found that direct caregivers are
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less engaged and more likely to leave an organization compared to other employees (Press
Ganey, 2016). Nurses in particular have the lowest engagement and, given the critical role of
nursing staff in providing direct patient care, this is especially troubling (The Advisory Board
Company, 2014).
These statistics are alarming health care leaders who understand the impact their
employees have on patient outcomes. Post health care reform, negative patient outcomes are now
tied to real financial consequences.
1.2 IMPLICATIONS OF HEALTH CARE REFORM
To encourage improved performance and slow the rising cost of health care, the ACA created
several hospital payment reform programs. Under these pay-for-performance programs, the
Centers for Medicare and Medicaid Services (CMS) rewards hospitals for providing higher
quality and higher value services to patients (Press Ganey, 2015b). One of the most influential of
these programs is the Hospital Value-Based Purchasing (VBP) program, where a portion of
payment is set aside to fund an incentive pool for hospitals based on the quality of services they
provide (Press Ganey, 2015a). Value-based incentive payments are based on Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) scores (commonly known as
patient satisfaction scores) and certain clinical process measures (Krause, 2015; Press Ganey,
2015a). Hospitals face a two percent potential loss under the VBP program, in the range of tens
of thousands of dollars up to millions of dollars at risk for hospitals that receive over half of their
reimbursement from the federal government (Sherwood, 2013). The VBP program and others
will shift the health care industry from a volume-based to a value-based orientation, and
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reinforce the links between employee actions, patient outcomes, and financial results (Press
Ganey, 2015a; Sherwood, 2013).
1.3 ORGANIZATIONAL BENEFITS OF EMPLOYEE ENGAGEMENT
The literature demonstrates a strong correlation between employee engagement and patient
satisfaction – a link that has caught the attention of health care executives looking for evidence-
based strategies to increase their HCAHPS scores (Blizzard, 2003; Harter et al., 2014; Press
Ganey, 2016; Press Ganey, 2015a). Gallup created a health care consulting model which
proposes that engaged employees are key to improving patient satisfaction and loyalty. To create
this model, Gallup analyzed three years of inpatient satisfaction data and found a significant
correlation between overall employee engagement and overall patient satisfaction (Blizzard,
2003). Other studies have demonstrated the positive relationship between employee engagement
and HCAHPS performance (Press Ganey, 2016; Press Ganey, 2015a). For example, a study of
over 2,200 health care facilities found that hospitals ranking in the top 20% of employee
engagement score better in every HCAHPS dimension: communication with nurses,
responsiveness of staff, physician care, pain management, medication explanations, discharge
instructions, and overall hospital rating (see figure 1) (Press Ganey, 2016).
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Nurse Responsiveness Physician Pain Medication Discharge Rate0
10
20
30
40
50
60
70
80
90
100
Top 20% of Employee Engagement Bottom 20% of Employee Engagement
Ave
rage
Nat
iona
l Per
cent
age
Ran
k
Adapted from Press Ganey, 2016
Figure 1. The Effect of Employee Engagement on Patient Experience Measures
Another study found that 85% of engaged employees displayed a genuinely caring
attitude towards patients, compared to only 38% of disengaged employees (Healthcare Source
Blog, 2014). Intuitively, a caring attitude translates into a better experience for patients.
Engagement allows employees to be at their best with patients, and do what they entered health
care to do – provide high-quality and compassionate care. Clearly, patients take notice and
respond accordingly.
Employee engagement goes beyond patient satisfaction, however. It is positively
correlated to better outcomes for patients in the form of higher quality of care and patient safety
(Harter et al., 2014; Press Ganey, 2015a; Sherwood, 2013). A Gallup study of 200 hospitals
found that the engagement level of nurses showed the highest correlation to mortality, even
above the number of nurses per patient day (Krause, 2015). Another review of engagement and
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clinical outcomes at the NHS in England shows that for every 10% increase in engagement there
was a reduction in MRSA by .057 cases per 10,000 bed days (Krause, 2015).
Another quality metric affected by engagement is avoidable readmission rates. Under the
Hospital Readmission Program established by the ACA, health care facilities with higher than
expected readmission rates for conditions such as heart attack, heart failure, and pneumonia will
face reduced payments. Hospitals with high employee engagement have fewer readmissions and
consequently experience considerably lower readmission penalties than hospitals with
disengaged employees (Press Ganey, 2015a).
Levels of engagement also affect how employees perceive the quality of care they
deliver, which is closely related to the patients’ perception of quality of care (Press Ganey,
2015b; Scotti et al., n.d.). One study found that highly engaged employees were two-thirds more
likely to report that their work unit “always” provided top quality service. Only one in five in the
low engagement group believed excellent quality service was always provided (Lowe, 2012).
Major human resource goals, from recruitment to improved retention to reduced
absenteeism also seem to be positively influenced by engagement (Caldwell & Watson, 2011;
Engagement Strategies Media, 2016; Lowe, 2012; Sherwood, 2013). Retaining top talent will be
critical for organizations as they enter a value and consumer-driven environment. Now, not only
do providers need to be excellent clinically, but they must also have strong interpersonal skills.
This challenge of retaining top talent, compounded by an increasing shortage of providers, can
be mitigated with employee engagement (Caldwell & Watson, 2011; Press Ganey, 2016). The
Towers Watson study mentioned earlier found that engagement and likelihood of staying with
the employer are closely correlated (Sherwood, 2013). Another study found that 90% of highly
engaged employees plan to stay with their organization, at least for the near future (Lowe, 2012).
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Conversely, studies show that close to half of disengaged employees will be job hunting in the
next 12 months (Lowe, 2012). Organizations know that turnover is costly. Jones, in the Journal
of Nursing Administration (as cited in Press Ganey, 2015b, p. 19), found that the cost of
replacing a nurse is $82,000 and as much as $125,000 for a specialty nurse. By improving
engagement, organizations can reduce this cost and retain their best employees.
Finally, financial performance is greatly impacted by employee engagement. Research
has shown that revenue, operational budget and even stock performance are positively correlated
with engagement (Berrett & Spiegelman, 2013; Engagement Strategies Media, 2016; Fuller,
2014; Harter et al., 2014). One study found that facilities “with engaged workers had eight
percent higher net revenue per patient than facilities with lower engagement” (Healthcare Source
Blog, 2014). Gallup polls also show a boost in productivity and profitability by 20% or more in
companies with high engagement (Fuller, 2014).
Hospitals with engaged employees recover value-based incentive payments in higher
amounts than hospitals with a less engaged workforce. In 2013, hospitals with high employee
engagement received $1.17 for every dollar at risk in VBP payments, whereas hospitals with low
employee engagement received $0.91 for every dollar at risk (Press Ganey, 2015a). When
looking at VBP program points, top performers in employee engagement score “on average 38
VBP points higher on HCAHPS, 12 points higher on core measures, and 16 points higher in total
performance” (see figure 2) (Press Ganey, 2015a).
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HCAHPS Core Measures Total Performance0
10
20
30
40
50
60
70
Low Performers High Performers
VB
P Po
ints
Adapted from Press Ganey, 2015a
Figure 2. The Impact of Employee Engagement on Value Based Purchasing Points
Clearly, these results validate the considerable impact employees have on the patient
experience and resulting financial outcomes. Organizations that fail to engage employees will
lose revenue under current payment reforms (Press Ganey, 2016; Press Ganey, 2015a). Not only
will failing to engage employees negatively influence financial performance, but these
organizations will also be less likely to be selected as an Accountable Care Organization (ACO)
and to be included in narrow networks and preferred provider delivery models (Press Ganey,
2016). The investment in employee engagement is well worth the cost in a value-based
purchasing environment.
Despite these indisputable benefits, engaging employees in the shifting health care
environment remains a challenge. Many organizations try multiple efforts to improve
engagement, with little to no success. Disengaged employees often do not have the tools or
supervisory support to improve. Further, leaders who want to improve the engagement of their
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workforce do not necessarily know how to drive this change (Press Ganey, 2015a). The next
section will review the main drivers of employee engagement.
1.4 THE DRIVERS OF EMPLOYEE ENGAGEMENT
An in-depth understanding of the drivers of engagement is critical for health care organizations
and leaders striving to improve engagement. After reviewing the literature, the author has
established six categories which cover the major drivers of engagement: ability and desire to
contribute, quality of the work environment, feeling valued, growth opportunities, perception of
leadership and supervisor, and pride in service and mission. These categories are by no means
mutually exclusive, but rather are overlapping and interdependent. Some categories, such as
“feeling valued,” can be dependent on the direct supervisor and leadership of the organization.
The essential elements of employee engagement in health care follow.
1.4.1 Ability and Desire to Contribute
This fundamental driver has to do with the ability as well as the volition to perform daily job
functions and tasks. To be able to fully contribute, employees must have clear goals and
objectives and understand what is expected of them at work (Sherwood, 2013). Defining and
clarifying outcomes to be achieved is a basic employee need and manager responsibility, and is a
first step to employees feeling able and confident in their roles (Harter et al., 2014). Ability to
contribute can also depend on whether employees feel their job utilizes their skills and abilities
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and is a good match for their talents (Harter et al., 2014; Press Ganey, 2016; The Advisory Board
Company, 2014).
Willingness to contribute depends in part on whether employees like the work they do
and at least enjoy some aspects of their job. It is also important for employees to understand how
their actions contribute to the organization’s mission and connect to the bigger picture
(Engagement Strategies Media, 2016; The Advisory Board Company, 2014).
Engagement survey questions reflective of “ability and desire to contribute” driver:
Table 1. Example Statements of Ability and Desire to Contribute
I know what is expected of me at work (Harter et al., 2014)I have clear job goals and objectives (Lowe, 2012)My job makes good use of my abilities/skills (Press Ganey, 2016)My current job is a good match for my skills (The Advisory Board Company, 2014)I like the work I do (Press Ganey, 2016)
I understand how my daily work contributes to the organization’s mission (The Advisory Board Company, 2014)
1.4.2 Quality of Work Environment
The quality of the work environment is essential for not only employee satisfaction, but also for
performance (Harter et al., 2013; Lowe, 2012). It is the responsibility of management to create
environments that allow employees to consistently perform at their peak (Caldwell & Watson,
2011; Scotti et al., n.d.). To facilitate high-performing environments, adequate staff and
resources to get the job done are required (Lowe, 2012). It also means removing process barriers
and ensuring optimal work conditions, such as proper safety, lighting, equipment, scheduling,
and clear direction from the supervisor when needed (Lowe, 2012). Optimal work conditions are
also referred to as performance support, which enables employees to do their best work and
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achieve results for patients and customers (Scotti, Harmon, & Behson, n.d.). Having the needed
supplies and resources is critical for employees to feel that their organization supports them and
values what they and their department do (Harter et al., 2014).
In addition to having the basic resources to perform their job well, there are also two
other important variables critical for employee engagement: 1) the tools and support to deal with
stress and burnout, and 2) a supportive team and good relationships with coworkers (Lowe,
2012; Sherwood, 2013; The Advisory Board Company, 2014).
Engagement survey questions reflective of “quality of work environment” driver:
Table 2. Example Statements of Quality of Work Environment
I have the tools and resources I need to provide the best care/service for our clients/patients (Press Ganey, 2016)
I have the materials and equipment I need to do my work right (Harter et al., 2014)I have adequate resources to do my job (Lowe, 2012)My organization helps me deal with stress and burnout (The Advisory Board Company, 2014)I feel I belong to a team (Lowe, 2012)
1.4.3 Feeling Valued
At the heart of feeling valued is recognition for good work and employees feeling like their
opinions count (Harter et al., 2014; Krause, 2015; The Advisory Board Company, 2014).
Employee recognition most often comes from managers; however, it can also come from fellow
employees, patients and their families. Recognition is increasingly important as the
demographics of the workforce change. Numerous studies have shown that millennials like to be
recognized frequently, even up to multiple times per day (Engagement Strategies Media, 2016).
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While this may seem excessive to older managers, organizational culture and management styles
must change with the expectations of the workforce.
Employees also want to feel like the organization listens to them and values their
suggestions (Engagement Strategies Media, 2004; Harter et al., 2014; Krause, 2015). In a work
setting that does not consider employee feedback, employees will stop offering suggestions and
disengage with the organization, resulting in higher turnover and lower work quality (Healthcare
Source Blog, 2014).
Engagement survey questions reflective of “feeling valued” driver:
Table 3. Example Statements of Feeling Value
My organization recognizes employees for excellent work (The Advisory Board Company, 2014)In the last 7 days, I have received recognition or praise for doing good work (Harter et al., 2014)Organization treats employees with respect (Press Ganey, 2015a)The organization values my work (Lowe, 2012)My ideas and suggestions are valued by the organization (The Advisory Board Company, 2014)At work, my opinions seem to count (Harter et al., 2014)
1.4.4 Growth Opportunities
Providing growth opportunities, which include career development, is proven to be a vital part of
engaging a workforce (Blizzard, 2003; Caldwell & Watson, 2011; Harter et al., 2014; Krause,
2015; Sherwood, 2013; The Advisory Board Company, 2014). If a person’s desire to advance in
his or her career is not fulfilled, he or she will search for work elsewhere (Engagement Strategies
Media, 2004; Krause, 2015). Employees, now more so than ever, look for opportunities for
personal development and advancement in their job. Towers Watson explored the factors that
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attract individuals to seek employment in organizations, and found that advancement
opportunities rose in its ability to attract from the 6 th place in 2007 to the 3rd place in 2010 (just
below competitive pay, and vacation and other paid time off) (Caldwell & Watson, 2011).
Consequently, providing career planning tools, resources, and opportunities is a potent form of
attracting employees, in addition to engaging the current workforce (Caldwell & Watson, 2011;
Sherwood, 2013).
Career development goes beyond promotion within the traditional hierarchy, however. It
also entails providing opportunities for employees to expand their skills and knowledge sets, to
keep current on the latest technology and techniques, and to benefit from a diversity of
experiences (Blizzard, 2003; Caldwell & Watson, 2011). It is critical for employees to have a
mentor or trusted peer to discuss their goals and development options. As indicated from the
example statements below, this is not necessarily the direct manager’s responsibility, although
he/she may play this role (Harter et al., 2014; Sherwood, 2013).
Engagement survey questions reflective of “growth opportunities” driver:
Table 4. Example Statements of Growth Opportunities
This organization provides career development opportunities (Press Ganey, 2016)
I am interested in promotion opportunities in my unit/department (The Advisory Board Company, 2014)
This last year, I have had opportunities at work to learn and grow (Harter et al., 2014)In the last six months, someone at work has talked to me about my progress (Harter et al., 2014)There is someone at work who encourages my development (Harter et al., 2014)
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1.4.5 Perception of Leadership and Supervisor
Employee perceptions of both senior leadership and their frontline managers are perhaps the
most influential drivers of engagement. The Towers Watson Global Workforce Study found the
quality of an organization’s senior leadership to be the number one driver of engagement in
health care (Sherwood, 2013). One of the most critical aspects of leadership that drives
engagement is whether decision-making is perceived to be in line with the organization’s values
and mission (Sherwood, 2013; The Advisory Board Company, 2014). Other ways senior
leadership can influence engagement is through a clear commitment to high-quality care and
encouraging employees to give their best efforts at work (Caldwell & Watson, 2011; Lowe,
2012).
The importance of the frontline manager also cannot be overstated. These supervisors and
managers translate “strategy into action, enable individuals and teams to work productively, and
coach people on their job performance and development” (Caldwell & Watson, 2011). The role
of the manager is critical because often the other drivers of engagement are dependent on the
actions and support of the manager (Engagement Strategies Media, 2016; Sherwood, 2013).
Accordingly, studies completed by Gallup found that 70% of the variance in engagement is tied
to the employee’s direct manager, highlighting the impact of their role (Krause, 2015). It is
important for employees to be confident in their manager’s abilities, feel supported and
respected, and to be treated fairly by their manager (Sherwood, 2013).
Engagement survey questions reflective of “perception of leadership and supervisor”
driver:
Table 5. Example Statements of Perception of Leadership and Supervisor
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The actions of executives in my organization reflect our mission and values (The Advisory Board Company, 2014)
Senior management is committed to high quality care (Lowe, 2012)Employees have confidence in senior management’s leadership (Press Ganey, 2015a)I respect the abilities of the person I report to (Press Ganey, 2016)My supervisor can be counted on to help with difficult tasks (Lowe, 2012)
1.4.6 Pride in Service and Mission
The final driver is pride in the services produced by the organization. In health care, this is high-
quality care and services. Employees want to feel that their organization provides high-quality
care and service to patients and are invested in the organization’s mission (Press Ganey, 2015a;
The Advisory Board Company, 2014). If this is not the case, it is difficult for them to be proud of
the organization and engaged in their work. A measure of this driver is whether employees see
upper level management and their work team as committed to high-quality care (Caldwell &
Watson, 2011; Harter et al., 2014; The Advisory Board Company, 2014).
Engagement survey questions reflective of “pride in service and mission” driver:
Table 6. Example Statements of Pride in Service and Mission
My organization provides excellent care to patients (The Advisory Board Company, 2014)I believe in my organization’s mission (The Advisory Board Company, 2014)Organization provides high quality care and service (Press Ganey, 2015a)
My associates or fellow employees are committed to doing quality work (Blizzard, 2003; Harter et al., 2014)Senior management is committed to high quality care (Lowe, 2012)
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1.5 MEASURING EMPLOYEE ENGAGEMENT
Once health care organizations are convinced of the benefits of employee engagement and
understand the drivers, the next logical step is measurement. Measuring employee engagement
leads to many benefits: leaders can hear the employee voice, identify opportunities for
improvement and areas of strength, retain high performers, and benchmark results with other
organizations (Engagement Strategies Media, 2016; Fuller, 2014).
The typical approach to measuring employee engagement is an annual engagement
survey where employees rate their own level of engagement (Fuller, 2014; Krause, 2015). With
literally thousands of questions available to measure employee engagement, the challenge is
creating a succinct survey that still captures reliable and meaningful data leaders can use to
confidently make decisions (Engagement Strategies Media, 2016). Some articles suggest using a
third party vendor, so that results are unbiased and can be compared to national benchmarks
(Engagement Strategies Media, 2016).
Press Ganey stresses the importance of gathering detailed data on a work unit level
(2016). This allows organizations to tailor work improvement plans to the unit’s engagement
level and unique drivers. To create a highly engaged workforce, measurement alone is not
sufficient; it must be complemented with accurate results and improvement efforts (Press Ganey,
2016).
Human resource experts prefer a multidimensional approach to measuring employee
engagement, and typically look at job satisfaction, organizational commitment, and other
performance related indicators (Lowe, 2012). Below are a few examples of how various
organizations measure engagement via surveys:
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Gallup uses the Q12, which is their standard employee satisfaction survey based on 30
years of accumulated qualitative and quantitative research. This survey consists of 13
questions in total, and includes statements that measure factors found to be highly
indicative of employee engagement (Harter et al., 2014).
In their Global Workforce Study, Towers Watson used “nine separate items that measure
the strength of [employees] connections to the organization using three dimensions:
rational (how well they understand their roles), emotional (how much passion and energy
they bring to their work), and motivational (how well they perform)” (Caldwell &
Watson, 2011).
Ontario Health used a 95 item questionnaire assessing drivers of engagement, individual
outcomes, and organizational outcomes. Employees were asked to assess 36 features of
their job, including “training and development opportunities, their team, their supervisor,
senior management, and how the organization supports its employees” (Lowe, 2012).
A main challenge of measuring employee engagement lies in valid and reliable
measurement, especially since the measures used in the base year will be the foundation for
employee engagement measures in the future (Engagement Strategies Media, 2016). The
downside of the survey approach is that it becomes dated quickly and there is the potential for
employees responding how they think their employers want them to respond (Fuller, 2014).
Additionally, the survey method looks at self-perceived engagement, which is important but
might not actually reflect the employee’s actual engagement level. To combat the subjective
nature of this kind of survey, it is important to balance these perceptions with more objective
measures such as amount of work that occurs outside of normal working hours and level of
18
participation in ad-hoc meetings (Fuller, 2014). Complementing attitudinal data with objective
measures should provide a more accurate picture of engagement (Blizzard, 2004; Fuller, 2014).
19
2.0 CASE STUDY AT MAGEE-WOMENS HOSPITAL OF UPMC
The purpose of this case study is to apply the concepts learned in the literature review in a real
world scenario at Magee-Womens Hospital of UPMC. The author analyzed data from the two
inpatient units scoring highest and lowest in nursing engagement to determine if organizational
outcomes such as patient satisfaction and nursing turnover are correlated with engagement. The
comparison of high and low scoring units will address why different units may score higher in
engagement than others, what drives changes in engagement, and will identify areas for
improvement.
In this case study, employee engagement is addressed using two different surveys: the
National Database of Nursing Quality Indicators (NDNQI) nursing satisfaction survey and the
UPMC MyVoice employee engagement survey. These surveys are comprehensive as each
captures the drivers of engagement previously identified in this paper by the questions used to
measure engagement. Patient satisfaction was measured using Press Ganey HCAHPS scores and
turnover metrics were gathered from Magee-Womens Human Resource department. In the
NDNQI survey, quality of care was estimated through the “perceived quality of care” question.
Additionally, job enjoyment, while not strictly an organizational outcome, was also compared
across units to reveal differences in this measure.
20
2.1 INTRODUCTION TO MAGEE-WOMENS HOSPITAL
Magee-Womens Hospital of UPMC is a large, nationally-ranked teaching and research hospital
which offers care to both men and women in all major specialties. It is ranked ninth in the nation
in gynecological services by U.S. News and World report in 2015, and nationally recognized in
cancer and orthopedics. Its historical focus on women's and gender-specific care continues in its
quality women’s care, and has allowed it to expand to offering a full spectrum of clinical and
surgical services. Magee-Womens’ stated goal is to give individually-tailored health care to each
patient and to quickly bring research advances to the bedside. It functions as a trauma center, has
360 beds, a large well-trained staff and four floors of ambulatory facilities. Magee-Womens has
been a major resource and health care provider in the Pittsburgh community since its inception in
1911 (UPMC, 2016a; U.S. News & World Report, 2016).
Numerous employee engagement efforts are underway at Magee-Womens, ranging from
leadership visibility and communication to human resource initiatives such as values-based
hiring, recognition programs, and engagement initiatives unique to each unit and position
category. Some of these initiatives were created in response to the MyVoice survey results in
2011 and 2014. For a partial list of hospital-wide engagement efforts, see Appendix A.
2.2 MEASURING EMPLOYEE ENGAGEMENT AT MAGEE-WOMENS
HOSPITAL
Magee-Womens measures employee engagement in several ways to determine if these efforts are
successful. The first is the MyVoice survey, which is an engagement survey and also described
21
as a “commitment from leadership to give UPMC staff a channel to voice feedback and make
sure it becomes action” (UPMC, 2016b). The MyVoice survey is a system-wide initiative, and
was first administered in 2011 and most recently administered in 2014. UPMC uses the third-
party vendor Decision Wise to administer the survey and analyze the results.
The MyVoice survey has six domains: My Work, My Coworkers, My Department, My
Supervisor, My Business Unit, and UPMC. There are 42 questions that compose these
overarching domains, and the results are categorized into favorable, neutral, and unfavorable
responses.
Based on the survey results, employees were categorized by engagement level based on
their responses to six engagement anchor questions. The four different categories are Fully
Engaged, Key Contributor, Opportunity Group, and Fully Disengaged. Refer to Appendix B for a
description of how employees in each category are characterized. At Magee-Womens in 2014,
26% of employees were Fully Engaged, 51% were Key Contributors, 18% were in the
Opportunity Group, and 5% were Fully Disengaged.
Table 7. Magee-Womens Overall MyVoice Engagement
Fully Engaged 26%
Key Contributors 51%
Opportunity Group 18%
Fully Disengaged 5%
Each hospital unit also has a breakdown of how their employees responded to gauge
overall engagement on the unit. These unit level responses are only available for 2014, which
prevents trending of this data.
22
Due to the inability to trend engagement results on the unit level with the MyVoice
survey, the NDNQI nursing satisfaction data was used to correlate engagement with business
outcomes. Nursing engagement specifically has been linked with higher quality of care and
overall performance (Press Ganey, 2015b). The NDNQI survey is completed by nurses only. To
be eligible for the survey, nurses must spend at least 50% of their time at the bedside with
patients and be employed on the unit for a minimum of three months. The survey is composed of
the Practice Environment Scale (PES) and other survey questions that measure job enjoyment,
nurse-nurse interactions, intent to stay, and nurse characteristics. The full length PES survey can
be found in Appendix C.
The PES was described by Lake as the “organizational characteristics of a work setting
that facilitate or constrain professional nursing practice” (2002). The PES looks at the following
five categories: 1) Nurse Participation in Hospital Affairs 2) Nursing Foundations for Quality of
Care 3) Nurse Manager Ability, Leadership, and Support of Nurses 4) Staffing and Adequate
Resources, and 5) Collegial Nurse-Physician Relationships. These categories are measured by
specific questions which nurses respond to using a 4-point Likert scale and the following
response options: strongly agree, agree, disagree, strongly disagree.
The NDNQI survey was administered in October of 2013 and 2015, and responses were
measured on a unit level and compared to the mean of similar units at other teaching hospitals
across the country. The author selected the NDNQI mean PES score as the measure of nurse
engagement, because almost all of the questions asked in the NDNQI survey fall within the
engagement drivers enumerated above. Although the domains may be categorized differently,
the survey captures the elements of engagement and thus serves as a useful indicator of nursing
engagement.
23
Based on the results from the PES survey, the lowest negatively scoring and highest
positively scoring inpatient units (that also receive HCAHPS scores) were selected to further
analyze and identify trends in organizational outcomes and areas for improvement. The specific
units have been de-identified for this analysis. The unit scoring highest in the PES will be
referred to as Unit A, while the lowest scoring will be referred to as Unit B.
2.3 ANALYSIS OF ENGAGEMENT
2.3.1 Highest Scoring Unit: Unit A
NDNQI: From 2013 to 2015, the overall mean PES score (the metric of engagement used) on
Unit A improved. Increases were seen in every domain over the two-year period, with the
highest increase seen in “Nurse Manager Ability, Leadership, and Support of Nurses.” Unit A
did have a change in their unit director over the two-year time frame. Interestingly, the new unit
director previously worked in Unit B until October of 2014, left Magee-Womens Hospital, and
came back to be the unit director of Unit A in August of 2015, two months prior to the NDNQI
survey.
24
Nursing P
articip
ation in
Hospital A
ffairs
Nursing F
oundations f
or Qualit
y of C
are
Nurse M
anage
r Abiliit
y, Lead
ership, a
nd Support o
f Nurse
s
Staffing a
nd Resource
Adequacy
Collegial
Nurse-Physi
cian Rela
tionships
Mean Prac
tice En
vironmen
t Scal
e Score
2.00
2.20
2.40
2.60
2.80
3.00
3.20
3.40
3.60
Score
Figure 3. Unit A NDNQI Survey Data
Unit A performed above the mean in every domain with the exception of Collegial-Nurse
Physician Relationships (although below the mean by only .01 percentage point). To find
opportunities for improvement, the author examined the survey answers comprising the lowest
scoring domain, Collegial-Nurse Physician Relationships. Out of the three questions, the two
which scored farthest below the mean were “A lot of team work between nurses and physicians,”
and “Collaboration (joint practice) between nurses and physicians.” Thus, a leadership driven
focus on teamwork between nurses and physicians should result in improvement in these scores.
Based on responses from the NDNQI “Unit Perceived Quality of Care” section, nurses’
perception of quality of care increased from 2013 to 2015. In 2015, Unit A’s Job Enjoyment
25
scale was well above the mean (4.37 compared to 3.79), placing them in the 85 th percentile
compared to similar units at other teaching hospitals.
Press Ganey HCAHPS: The nurse communication HCAHPS domain increased by three
percentage points over the two-year time frame, which is below the overall hospital’s 4.5 percent
increase in this domain. The largest increase was seen in “Nurses explain in a way you
understand,” which increased by almost five percentage points. Unit A’s other HCAHPS
domains (including care transitions, responsiveness of hospital staff, communication with
doctors, hospital environment, communication about medicines, and discharge information),
increased from 2013 to 2015, with the exception of pain management, which slightly decreased.
Unit A’s HCAHPS trend paralleled the hospital’s scores, which increased over the two-year
period; however, compared to the hospital overall, Unit A’s gains were typically greater.
MyVoice: Based on the MyVoice 2014 survey responses, the highest scoring domain for
Unit A was My Coworkers, which obtained a 91% favorable response rate. The lowest scoring
domain was My Business Unit, with only a 57% favorable response. The majority of lowest
scoring questions fell into the My Business Unit category, and revolved around hospital
leadership trust, visibility, and communication, for example, “The leaders of my hospital are
visible on a daily basis.” Highest scoring questions focused on the work relationships in Unit A,
including questions such as “My coworkers treat me with respect” and “My coworkers care
about me as a person.” The highest scoring question in this unit was “I clearly understand what
my supervisor expects of me,” indicating clear manager communication and expectations.
In 2014, the overall staff engagement in the Unit A was as follows: 29% were Fully
Engaged with their job, 50% were Key Contributors, 14% were in the Opportunity Group, and
7% were Fully Disengaged.
26
Table 8. Unit A’s MyVoice Engagement
Fully Engaged 29%
Key Contributors 50%
Opportunity Group 14%
Fully Disengaged 7%
The engagement index, composed of employees in the Fully Engaged and Key
Contributor categories, was 79%. This was two percentage points higher than Magee-Womens
engagement index overall.
HR Metrics: Nursing turnover rate in this unit decreased from 18.3% in fiscal year 2013
to 16.0% in fiscal year 2015. Turnover was at a low point in fiscal year 2014 at 15.2%. Overall
this shows a downward trend in turnover over the two years, and an expected inverse relationship
with engagement scores.
2.3.2 Lowest Scoring Unit: Unit B
NDNQI: From 2013 to 2015, Unit B’s overall engagement score decreased. Scores dropped in
all five NDNQI domains except for Collegial Nurse-Physician Relationships. The domain that
had the largest decrease was Staffing and Resource Adequacy; however, this is also the only
domain where this unit outperformed the NDNQI mean of similar units in other teaching
hospitals.
27
Nursing P
articip
ation in
Hospital A
ffairs
Nursing F
oundations f
or Qualit
y of C
are
Nurse M
anage
r Abiliit
y, Lead
ership, a
nd Support o
f Nurse
s
Staffing a
nd Resource
Adequacy
Collegial
Nurse-Physi
cian Rela
tionships
Mean Prac
tice En
vironmen
t Scal
e Score
2.00
2.20
2.40
2.60
2.80
3.00
3.20
3.40
3.60
Score
Figure 4. Unit B NDNQI Survey Data
To identify areas for improvement in Unit B, the author explored the domain where this
unit scored farthest below the mean in 2015: Nurse Manager Ability, Leadership, and Support of
Nurses. The individual questions in this category where the unit scored farthest below the mean
are “Supervisors use mistakes as learning opportunities, not criticism,” and “A supervisory staff
that is supportive of the nurses.” Nurses in this unit do not necessarily perceive their nursing
manager as supportive when they make mistakes. This domain saw a fairly large drop from 2013
to 2015. As mentioned above, Unit B had a change in leadership over this period; the unit
director left in October of 2014. The NDNQI scores suggest that nurses view their new manager
as less supportive.
28
Outside of the PES questions, from 2013 to 2015 the perceived quality of care decreased
slightly. Unit B scored well below the mean in the Job Enjoyment scale, scoring around the 36 th
percentile.
Press Ganey HCAHPS: In contrast with a decrease in nurse engagement, the HCAHPS
nurse communication scores increased over the two years. The question with the greatest gains
was “Nurses treat with courtesy and respect,” which increased by one percentage point.
Although scoring below the mean in all NDNQI domains, Unit B has higher overall HCAHPS
scores in the “Communication with Nurses” domain than Unit A.
Although the nurse communication scores increased, Unit B decreased in five out of the
eight HCAHPS domains from 2013 to 2015, contrasted with the pattern of increases in overall
hospital scores. Additionally, the overall experience metrics (“likelihood to recommend” and
“overall rating”) decreased over the two-year time frame; again, in contrast with the hospital and
with Unit A. This noticeable difference suggests a relationship between decreased engagement
and lower patient satisfaction scores.
MyVoice: In 2014, Unit B’s highest scoring domain was My Coworkers, which received
a 93% favorable score. The lowest scoring domain was My Business Unit, which had a 57%
favorable score. Compared to Unit A, the percentage of favorable responses in all domains was
not substantially different and in some cases higher, and fell within five percentage points of the
other unit.
Unit B’s lowest scoring questions were similar to Unit A’s, with a focus on questions in
the My Business Unit category. The same trend of leadership visibility, trust, and communication
was seen in the lowest scoring questions, but in a slightly different order. The highest scoring
questions focused on enjoying the work team and a unit commitment to high-quality, patient
29
centered care. “I know what my supervisor expects of me” also made the top five highest scoring
questions.
Looking at the distribution of engagement on Unit B, 21% of all employees were
categorized as Fully Engaged in 2014, which is five percentage points lower than Magee-
Womens overall and eight points lower than Unit A. However, the Key Contributor group was
larger than Magee-Womens overall, and Unit B also had fewer employees rank in the lowest
scoring groups (Opportunity Group and Fully Disengaged) compared to the overall hospital and
Unit A.
Table 9. Unit B’s MyVoice Engagement
Fully Engaged 21%
Key Contributor 64%
Opportunity Group 11%
Fully Disengaged 4%
Unit B’s engagement index was 85%, which was higher than both the hospital overall
and Unit A.
HR Metrics: The turnover rate trended steadily downward from 19.4% in fiscal year
2013 to 14.6% in fiscal year 2015, which did not support the trend between engagement and
turnover found in the literature. Here, turnover decreased despite a dip in engagement.
30
2.4 DISCUSSION
Major themes in the data emerged after the author completed her analysis. First, the impact of the
direct manager seems to be a significant contributing factor to changes in engagement on each of
the units. Second, though their impact on engagement, frontline managers can also affect metrics
tied to engagement, such as patient satisfaction. Third, in this case study, engagement appears to
have a relationship with certain organizational outcomes, such as patient satisfaction, perceived
quality of care, and job enjoyment, while not with others, such as turnover. Each of these will be
explored further in the discussion.
Over the two-year time frame, engagement declined on Unit B, while the opposite
occurred in Unit A. At the same time, each unit experienced a change in the unit director,
involving the same leader (unbeknownst to the author upon initial review and trending of the
data). It appears that in this case the direct manager is a major contributing factor to changes in
engagement on each of the units, and this pattern was noticed prior to knowledge of the
leadership change.
Prior to the leadership change, in 2013 Unit B’s highest scoring NDNQI domain was
nurse manager ability, indicating strong leadership on the unit. Their scores in 2015, however,
reflected the loss of this leader—nurse-manager ability was now their lowest scoring domain,
falling below the NDNQI mean. Over this period, the unit director transferred to Unit A, and as a
result Unit A saw the greatest increase in scores in the nurse-manager ability domain. During the
same period, Unit A went from scoring below the mean to well above in this domain.
This case study presented the unique opportunity to observe the direct effect of a
particular unit director’s leadership style. From this data we can infer a positive relationship
between leadership style and engagement scores, while recognizing the limits of a sample size of
31
one. As previously discussed, many of the other drivers such as growth opportunities, feeling
valued, and the work environment are dependent upon or at the very minimum influenced by the
frontline manager. Although unable to prove strength of association, the data suggests a link
between the frontline manager and engagement, one that was also found to be true in the
literature.
In addition to driving improvement or decline in engagement, a frontline manager’s
influence can ultimately be seen in the metrics tied to engagement, such as patient satisfaction.
Again, during the same measurement period (2013 to 2015), the hospital saw increases in all
patient satisfaction HCAHPS domains including the global experience ratings of “likelihood to
recommend” and “overall rating.” Unit A followed this pattern and experienced even greater
gains than the hospital overall. In contrast, Unit B experienced decreases in five out of eight
domains in addition to declines in their overall experience ratings (see figure 5). This suggests a
relationship between engagement and patient satisfaction, and that a frontline manager can
influence organizational outcomes through his/her impact on engagement.
32
Hospital Rating Recommend Hospital
Nurse Com-munication
Staff Re-sponsiveness
Doctor Com-munication
Hospital Envi-ronment
Pain Man-agement
Medication Communication
Discharge Communication
Care Transitions-8
-6
-4
-2
0
2
4
6
Hospital Overall Unit A Unit B
Figure 5. Change in HCAHPS Scores: 2013-2015
In this case study, engagement appears to be related to perceived quality of care. As
engagement declined in Unit B, so did nurses perceptions of care quality on the unit. Unit A,
however, experienced positive gains in both measures. Perceived quality of care should not be
overlooked, as studies have found that nurse and patient perception of quality of care typically
follow similar patterns (Press Ganey, 2015b; Scotti et al., n.d.). For this reason, any decreases in
the perception of care quality should be taken seriously (Press Ganey, 2015b).
Turnover, the last organizational outcome, decreased in both units over the studied time
frame. In this particular measure, we would have expected to see turnover increase on Unit B to
reflect a decrease in engagement, so in this case study engagement and turnover did not follow
the pattern found in the literature.
33
The Job Enjoyment Scale, while not strictly an organizational outcome but reflective of
the work setting, highlighted one of the most substantial differences between the two units. Unit
B ranked around the 36th percentile in job enjoyment, while Unit A ranked around the 85 th
percentile. Press Ganey found that job enjoyment differs based on unit type, with pediatric units
scoring highest and adult units scoring lowest (Ganey, 2015b). However, by looking at percentile
scores we can compare the standing of the two units in job enjoyment. Staffing is an influential
factor contributing to both job enjoyment and intent to stay (Press Ganey, 2015b). The unit
directors can look at the effectiveness of staffing in order to improve the job enjoyment of nurses
on their respective units.
Table 10. Organizational Outcome Trends from 2013 to 2015
Organizational Outcome Unit A Unit BEngagement (PES) ↑ ↓Perceived Quality of Care ↑ ↓Job Enjoyment ↑ ↓HCAHPS Overall Experience ↑ ↓Turnover ↓ ↓
With regards to the MyVoice survey, the two units scored highest in the same domain,
My Coworkers, and lowest in the same domain, My Business Unit, and had similar high and low
scoring questions. The need to improve hospital leadership visibility and communication and the
strength in coworker relationships were trends highlighted in two otherwise diverse units. The
MyVoice survey data that were available did not indicate a substantial difference in domain
scores between the units. However, these data includes all staff and not just nurses, and was
administered in 2014. Since this was prior to the change in unit director on the units, there is
reason to believe it cannot reliably be compared to engagement of nurses in the 2015 NDNQI
survey.
34
Although interesting patterns were found in this case study, it is important to note the
limitations of the data. First, the PES is not specifically a measure of nursing engagement,
although its questions are reflective of the drivers of engagement. Second, only two years of the
NDNQI data were available, which made it difficult to draw any definitive conclusions. The
limited number of data points could explain why in some circumstances the organizational
outcomes did not relate with engagement as expected. The author also compared two diverse
units, whose different patient populations have dissimilar acuity of illness and average lengths of
stay. Additionally, the engagement data used to describe trends was focused on nurses, where in
reality the engagement of all employees (physicians, housekeepers, PCTs, etc.) influences patient
outcomes and experience.
2.5 RECOMMENDATIONS
To provide context for the author’s recommendations it should be noted that Magee-Womens has
taken actions to enhance employee engagement. Magee-Womens measures engagement using
comprehensive engagement surveys (MyVoice and NDNQI), demonstrating a commitment by
hospital leadership to measure and improve the engagement of staff. Engagement was measured
on a work unit level, which allows each unit to tailor their engagement plan to local
circumstances (Press Ganey, 2016). Hospital leadership also responded quickly to the MyVoice
survey results and created many new engagement initiatives to target low scoring areas, hospital-
wide, many of which focused on leadership visibility, communication, and trust. Magee-
Womens and the Human Resources department were also notably transparent with hospital
35
MyVoice survey results, posted them online, and indicated how the hospital would address low
scoring areas.
Similar actions were done with the NDNQI nursing satisfaction survey. Nursing
leadership followed up with the nurse manager of every unit to discuss results, and each manager
was expected to create a work improvement plan.
A further strength of Magee-Womens is hiring motivated and team-oriented individuals,
indicated through high scores in the “My Coworkers” section of the MyVoice survey. Magee-
Womens also recently began using a values-based hiring technique, which is another way to
intentionally select employees that will positively contribute to the culture.
Recommendations based on the author’s findings for both units and Magee-Womens
Hospital are as follows:
1. Recognize the role of the manager in engagement and provide manager training in this
area. This case study demonstrated the impact that managers can have on engagement,
both positively and negatively. A good manager can improve engagement and
consequently other metrics tied to engagement, like quality of care and patient
satisfaction. Managers at Magee-Womens need to understand their important role in
driving engagement and have adequate training, knowledge, and tools to succeed. In
order to keep managers accountable, engagement metrics should be tied to their goals and
tracked and measured to show progress (The Advisory Board Company, 2014).
2. Each unit must determine the most critical drivers of engagement and target lowest
scoring areas for improvement. The lowest scores in Unit A were Collegial Nurse-
Physician Relationships, and in Unit B it was Nurse Manger Ability, Leadership, and
36
Support of Nurses. These indicate problem areas which can help focus action for
improvement.
3. More frequent measurement of engagement is desirable. The results from the NDNQI
survey prove much can change over a two-year period. Taking a pulse on engagement
more frequently would be beneficial so that corrective action can be taken.
4. Gather input from employees. Not only does this make employees feel valued, one of the
key drivers of engagement, but employees also are reliable sources of insight into the
needs and expectations of the customer. Managers “must acknowledge this truth and
survey the opinions of frontline providers” (Scotti et al., n.d.).
5. Engage employees in developing their own engagement. Engagement cannot be solely
the responsibility of management; it is a two-way street. Employees must be encouraged
to take an active role in their engagement.
6. Stay focused on the drivers of engagement. Managers must balance many competing
priorities, which makes this recommendation easier said than done. However, by focusing
on actions that are proven to engage employees, it will ultimately lead to better
organizational outcomes on the unit and health outcomes for the patient—and it can be
argued that nothing should have higher priority.
2.6 PUBLIC HEALTH RELEVANCE
It is important to look at the public health significance of employee engagement. By creating
highly engaged employees, we know from the literature and from this case study that there will
be a positive impact on the patient experience. Even more significant than that, it should lead to
37
better clinical outcomes for patients in the form of reduced mortality, fewer adverse safety
events, and higher quality of care. Thus, not only is employee engagement a strategically sound
choice for organizations, it is in the best interest of the community as well. Employee
engagement and its effects on patient care will help health care organizations achieve their goal
to improve health while striving towards the national triple aim: improve the patients experience
of care, reduce costs of care, and improve the health of populations.
2.7 CONCLUSION
This paper has reviewed the major benefits of employee engagement, which range from
improved financial performance to the improved health of the community served. Some of the
more direct organizational outcomes are seen more clearly when analyzed in the case study at
Magee-Womens Hospital of UPMC. In particular, this case study highlighted the role of the
frontline manager, which cannot be underestimated when organizations make employee
engagement a strategic goal. Frontline managers must be held accountable for the engagement of
their direct reports and also be supported in their endeavors to improve engagement. Although
engagement is not something that can or will change overnight, it is well worth the effort.
Engaged employees will put forth the discretionary effort that helps an organization achieve its
most vital goals. Finally, as health care reform brings value to the forefront, organizations will
turn their focus on their employees, the people who must create that value for patients.
Engagement will lead to an energetic and passionate workforce, healthy patients, and an
organization well positioned for a viable future.
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Appendix A: EMPLOYEE ENGAGEMENT INITIATIVES AT MAGEE-WOMENS
A.1.1 Leadership Visibility & Communication
Leadership Rounding and the eRound app: UPMC’s Leadership Rounding program
promotes staff engagement and the sharing of ideas. The introduction of UPMC’s eRound app
provides a web-based, real-time tool to help guide leaders on patient and staff rounding.
Executive Leadership Q&A Sessions: Held annually at every business unit, these
question-and-answer sessions with executive leadership give staff the opportunity to hear about
essential issues facing UPMC and ask questions about current topics.
Chats: Many leaders are now offering online chat sessions with staff in their business
units or divisions. The online chats offer an opportunity for staff to ask questions on any topic of
importance to them.
You Asked We Answered: Many business unit leadership teams now have an online
forum to ask questions. Staff can email a questions, the team researches the answer, and then it is
posted on Infonet for all staff to read.
52 for You: The online tool consists of 52 weeks of effective leadership tips that help
managers foster a culture based upon the UPMC core values.
39
Breakfast with Magee Leadership: During the one-year employment anniversary
month, employees are invited to join Magee Leadership for breakfast to discuss community,
system-wide and Magee updates, ask questions, offer feedback, and meet other employees.
Daily Extra: To help eliminate email overload and information coming from multiple
sources, local and system wide news and information is now consolidated into one daily news
email for staff.
A.1.2 Employee Recognition
Above and Beyond: Above and beyond recipients can be nominated by patients and their
families, staff members, physicians, and visitors. Nominees should reflect UPMC’s core values.
ACES: Award for Commitment and Excellence in Service (ACES) honors staff who
exemplify UPMC’s five core values and exceed a high level of service. Each year, fewer than 1
percent of UPMC staff from across the health system receive this honor.
Daisy award: The DAISY award is a nationwide program that rewards and celebrates
the extraordinary clinical skills and compassionate care given by nurses. Patients, visitors,
nurses, physicians, employees may nominate a nurse by filling out a Daisy nomination form and
submitting it to the Professional Practice Counsel.
Good Catch Award Program: A good catch occurs anytime a potential safety-related
incident or event is avoided. Unit managers, individual employees, or A Just Culture committee
representatives notify our patient safety officer, and the managers then presents the employee
with a handwritten card of gratitude and a Garden View Café money gift card. The employees
name is also listed and shared publicly on hospital screensavers, as well as the Nursing Caring
Times publication and the “Safety at Magee” website.
40
A.1.3 Employee Participation and Training
Culture of Service Excellence education: The Culture of Service Excellence is a
system-wide service standards initiative. Education sessions focus on skills and resources for
living out the UPMC values, including the CARE+ standards of service and service recovery
model.
Employee Engagement Committee: The employee engagement committee was formed
to be the main focus group for conveying the ideas, thoughts and suggestions of employees at
Magee-Womens Hospital. Each department is allowed to have a representative attend each
session to be the voice for that specific department. Human Resource representatives and
selective leaders of the committee also attend.
A.1.4 Human Resource Initiatives
Hiring for Values: During the application process, all candidates now complete an
assessment specific to UPMC’s values.
Values Added to Performance Reviews: Values are now 50 percent of every
employee’s evaluation.
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Appendix B: UPMC ENGAGEMENT SPECTRUM CATEGORIES
42
Appendix C: 2015 NDNQI RN PRACTICE ENVIRONMENT SCALE
Practice Environment Scale
For each item, please indicate the extent to which you agree that the item is PRESENT IN YOUR CURRENT JOB. Response options: strongly agree, agree, disagree, strongly disagree.
Nurse Participation in Hospital Affairs
1. Career development/clinical ladder opportunity.
2. Opportunity for staff nurses to participate in policy decisions.
3. A chief nursing officer which is highly visible and accessible to staff.
4. A chief nursing officer equal in power and authority to other top-level hospital executives.
5. Opportunities for advancement.
6. Administration that listens and responds to employee concerns.
7. Staff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees).
8. Staff nurses have the opportunity to serve on hospital and nursing committees.
9. Nursing administrators consult with staff on daily problems and procedures.
Nursing Foundations for Quality of Care
1. Active staff development or continuing education programs for nurses.
2. High standards of nursing care are expected by the administration.
3. A clear philosophy of nursing that pervades the patient care environment.
4. Working with nurses who are clinically competent.
5. An active quality assurance program.
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6. A preceptor program for newly hired RNs.
7. Nursing care is based on a nursing, rather than a medical, model.
8. Written, up-to-date nursing care plans for all patients.
9. Patient care assignments that foster continuity of care, i.e., the same nurse cares for the patient from one day to the next.
10. Use of nursing diagnoses.
Nurse Manager Ability, Leadership, and Support of Nurses
1. A supervisory staff that is supportive of the nurses.
2. Supervisors use mistakes as learning opportunities, not criticism.
3. A nurse manager who is a good manager and leader.
4. Praise and recognition for a job well done.
5. A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a physician.
Staffing and Resource Adequacy
1. Adequate support services allow me to spend time with my patients.
2. Enough time and opportunity to discuss patient care problems with other nurses.
3. Enough registered nurses to provide quality patient care.
4. Enough staff to get the work done.
Collegial Nurse-Physician Relations
1. Physicians and nurses have good working relationships.
2. A lot of team work between nurses and physicians.
3. Collaboration (joint practice) between nurses and physicians.
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