1.0Introduction: the Impetus for Employee Engagement

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.

TABLE OF CONTENTS

1.0Introduction: The impetus for employee engagement

1.1The State of Engagement

1.2Implications of Health Care Reform

1.3Organizational Benefits of Employee Engagement

1.4The Drivers of Employee Engagement

1.4.1Ability and Desire to Contribute

1.4.2Quality of Work Environment

1.4.3Feeling Valued

1.4.4Growth Opportunities

1.4.5Perception of Leadership and Supervisor

1.4.6Pride in Service and Mission

1.5Measuring Employee Engagement

2.0Case Study at Magee-Womens Hospital of UPMC

2.1Introduction to Magee-Womens Hospital

2.2Measuring employee engagement at Magee-womens hospital

2.3Analysis of Engagement

2.3.1Highest Scoring Unit: Unit A

2.3.2Lowest Scoring Unit: Unit B

2.4Discussion

2.5recommendations

2.6Public Health Relevance

2.7Conclusion

Appendix A : EMPLOYEE ENGAGEMENT INITIATIVES AT MAGEE-WOMENS

Appendix B : UPMC ENGAGEMENT SPECTRUM CATEGORIES

Appendix C : 2015 NDNQI RN PRACTICE ENVIRONMENT SCALE

bibliography

List of tables

Table 1. Example Statements of Ability and Desire to Contribute

Table 2. Example Statements of Quality of Work Environment

Table 3. Example Statements of Feeling Value

Table 4. Example Statements of Growth Opportunities

Table 5. Example Statements of Perception of Leadership and Supervisor

Table 6. Example Statements of Pride in Service and Mission

Table 7. Magee-Womens Overall MyVoice Engagement

Table 8. Unit A’s MyVoice Engagement

Table 9. Unit B’s MyVoice Engagement

Table 10. Organizational Outcome Trends from 2013 to 2015

List of figures

Figure 1. The Effect of Employee Engagement on Patient Experience Measures

Figure 2. The Impact of Employee Engagement on Value Based Purchasing Points

Figure 3. Unit A NDNQI Survey Data

Figure 4. Unit B NDNQI Survey Data

Figure 5. Change in HCAHPS Scores: 2013-2015

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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 beunder 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 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 literaturefocused 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.

1.1The 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 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 less engaged and more likely to leave an organization compared to other employees (Press Ganey, 2016). Nurses in particular have the lowest engagementand, 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.

1.2Implications 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 reinforce the links between employee actions, patient outcomes, and financial results (Press Ganey, 2015a; Sherwood, 2013).

1.3Organizational 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).

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 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). 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).

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 workforce do notnecessarily know how to drive this change (Press Ganey, 2015a). The next section will review the main drivers of employee engagement.

1.4The 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.

1.4.1Ability 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 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).