How Employee Engagement Matters for Hospital Performance

Abstract

Managers increasingly understand that employee engagement is a prerequisite for high performance. This article examines how job, work environment, management and organizational factors influence levels of engagement among healthcare employees. Original data come from the Ontario Hospital Association-NRC Picker Employee Experience Survey, involving over 10,000 employees in 16 Ontario hospitals. The article provides a clear definition and measure of engagement relevant to healthcare. In addition to identifying the main drivers of engagement, findings shows that a high level of employee engagement is related to retention, patient-centred care, patient safety culture and employees' positive assessments of the quality of care or services provided by their team. Implications of these findings for healthcare leaders are briefly considered.

Full text

Healthcare Quarterly Vol.15 No.2 2012 29
Abstract
Managers increasingly understand that employee engage-
ment is a prerequisite for high performance. This article
examines how job, work environment, management and
organizational factors influence levels of engagement among
healthcare employees. Original data come from the Ontario
Hospital Association–NRC Picker Employee Experience
Survey, involving over 10,000 employees in 16 Ontario hospi-
tals. The article provides a clear definition and measure of
engagement relevant to healthcare. In addition to identifying
the main drivers of engagement, findings shows that a high
level of employee engagement is related to retention, patient-
centred care, patient safety culture and employees’ positive
assessments of the quality of care or services provided by
their team. Implications of these findings for healthcare
leaders are briefly considered.
Engaged employees are essential to the success of any
organization. Increasingly, healthcare employers are
taking steps to strengthen this people-performance
link. While many studies have looked at the job satis-
faction of healthcare employees, we know far less about how the
broader concept of engagement applies to healthcare settings.
Furthermore, a lack of good data on employee engagement in
Canadian healthcare organizations has made it difficult to use
the concept as a workplace improvement tool, which has been
the case in other industries.
This article fills these gaps. Using results from the first wave
of the Ontario Hospital Association (OHA)–NRC Picker
Employee Experience Survey (EES), involving over 10,000
employees in 16 Ontario hospitals, this article does three things:
(1) provides a clear definition and measure of engagement;
(2) examines the main work environment drivers of engage-
ment; and (3) documents the relationship between levels of
employee engagement and critical organizational outcomes.
The Quality Healthcare Workplace
High-performing organizations have healthy and engaged
employees. Their work environments are designed to enable the
development and utilization of the “people capacity” required
for success. Critically important in this regard is a culture that
values employees, leadership commitment to the organization’s
people-development goals and support systems that enable
people to excel in their jobs (Lowe 2010).
These ideas have taken root in healthcare and are evolving.
A decade ago, the focus was on creating healthier workplaces.
For example, the US Joint Commission on the Accreditation
of Healthcare Organizations linked high-quality care and
healthy workplaces in this way: “A healthy workplace is one
where workers will be able to deliver higher-quality care and
one in which worker health and patients’ care quality are
mutually supportive. That is, the physical and emotional health
of workers fosters quality care, and vice versa, being able to
deliver high-quality care fosters worker health” (Eisenberg et
How Employee Engagement Matters
for Hospital Performance
Graham Lowe
HEALTH HUMAN RESOURCES

30 Healthcare Quarterly Vol.15 No.2 2012
al. 2001: 447). Now, experts and practitioners are calling for
a comprehensive, strategically focused approach to measuring
and reporting the quality of healthcare work environments. (See
Healthcare Papers 10[3], published in 2010; the issue focuses on
using common work environment metrics to improve perfor-
mance in healthcare organizations.) This is a big step beyond
workplace health promotion programs, integrating employee
well-being within a comprehensive framework for improving
the quality of healthcare.
We also are learning more about the positive relationship
between staff satisfaction and patient satisfaction, echoing private
sector research showing strong correlations between employee
engagement scores and customer experiences (Harmon and
Behson 2007; Heskett et al. 2008). Recent studies in health-
care indicate that managers can improve patient care experiences
by improving employee satisfaction and retention (Collins et
al. 2008; Michie and West 2004; Rondeau and Wagar 2006;
Sikorska-Simmons 2006). Research conducted in England’s
National Health Service documents how hospitals with higher
levels of staff engagement provide higher-quality services and
have better financial performance (West et al. 2011).
To support this new direction in evidence-based human
resource practices, OHA recently created the Quality Healthcare
Workplace Model (Figure 1). The model outlines how health
system performance depends on a capable workforce in healthy
and productive workplaces. The OHA’s model suggests that the
quality of the work environment for staff and physicians is a
key determinant of a high-performing healthcare organization.
By integrating healthy workplace, human resources, quality and
patient safety goals within a performance-focused framework,
the model offers a useful guide to research and practice. At the
centre of the model is employee engagement.
Study Background
The development of the EES was guided by the model in Figure
1. The 95-item questionnaire assesses the drivers, individual
outcomes and organizational outcomes specified in the model.
(For further information, see OHA’s OHA-NRC Picker Employee
and Physician Experience Surveys Backgrounder.) A companion
survey for physicians was also developed but is not our focus
in this article. NRC Picker Canada was
a partner in the development of both
surveys. Some of the work environment,
patient safety and patient care items were
adapted from earlier NRC Picker surveys.
I acted as the project consultant.
The first wave of OHA members to
use the EES did so in late 2010 and early
2011. The total sample analyzed here
consists of 10,702 employees from 16
facilities. Table 1 shows that response rates
vary across peer groups, ranging between
45 and 60%. The overall sample response
rate is 46%, which is acceptable for an
employee survey (Baruch and Holtom
2008). (In studies published in peer-
reviewed academic journals, the average
response rate for employee surveys within
organizations is 53%.) The sample
composition reflects a concentration of
employees in community hospitals (43%
of the total sample) and teaching hospi-
tals (30% of total). The nine facilities in
the two other peer groups account for
27% of all respondents.
Looking briefly at respondents’ charac-
teristics, most have been in their current
job and with their employer for six years or
longer. More than two thirds are full-time
employees; the same proportion are union
members. A small percentage (6%) is in
FIGURE 1.
Ontario Hospital Association Quality Healthcare Workplace Model
Enabling context: strong values - compelling vision - clear mission - committed leadership
DRIVERS INDIVIDUAL
OUTCOMES
ORGANIZATIONAL
OUTCOMES
Work
Environment
Engaged and
capable employees
and physicians
Quality and
patient safety
Job
Characteristics
Retention,
recruitment,
and employer
reputation
Organizational
Supports
Employee and
physician health,
safety and quality
of work-life
Employee
productivity
and costs
Source: Reproduced with permission from the Ontario Hospital Association.
How Employee Engagement Matters for Hospital Performance Graham Lowe

Healthcare Quarterly Vol.15 No.2 2012 31
Graham Lowe How Employee Engagement Matters for Hospital Performance
temporary, per-diem or standby arrangements. About one in five
have management responsibilities. And two thirds have frequent
patient contact. Most (86%) respondents are female, and there
is a good representation of older and younger employees (9% are
under the age of 30 years, 18% are between the ages of 30 and 39,
31% are 40–49, 34% are 50–59 and 8% are 60 years and older).
How Employees Experience Their Work
The EES asks employees to assess 36 features of their job,
training and development opportunities, their team, their super-
visor, senior management and how the organization supports its
employees. These factors are on the left side of the OHA model
(see Figure 1). Logically, they can be considered upstream influ-
ences on – or “drivers” of – employee engagement.
Presented in Table 2 are the percentage of positive answers
to each of the evaluative items (combining responses of four
and five on five-point response scales). Items receiving positive
ratings of 60% or higher are called “strengths,” and items with
positive scores of 40% or less are labelled “improvement priori-
ties” (each is colour coded in Table 2). These cut points are
based on results for the entire sample; individual organizations
are encouraged to use this approach to interpret their own
employee survey results and plan follow-up actions.
A quick look at Table 2 reveals that the responses are most
positive regarding aspects of respondents’ team or work unit. It
is notable that 70% or more of respondents positively rate their
team as working well together, welcoming people from diverse
backgrounds and being respectful and supportive of each other.
Supervisors also receive a positive rating for fair treatment of
employees. And senior managers are widely seen to be committed
to high-quality care and to improving workplace safety.
The items with the lowest positive ratings identify opportuni-
ties for improvement. Beginning with teams, this general area
of strength received low positive ratings on two measures of
workload: the percentage of respondents disagreeing or strongly
disagreeing with the statement, “We work in ‘crisis mode’ trying
to do too much, too quickly,” and the percentage agreeing or
strongly agreeing with the statement, “We have enough staff to
handle the workload.” None of the supervisory ratings fall at or
below 40% positive. However, one senior management behaviour
– acting on staff feedback – receives only a 31% positive rating.
The lowest ratings are on two dimensions: training and devel-
opment, and job characteristics. Career development opportu-
nities receives the lowest positive rating (17%) of any of the 36
items being considered here. Furthermore, only one in three
respondents positively rate the opportunities they have to make
improvements in how their work is done, or to receive education
and training. In terms of job characteristics, there is consider-
able room for improvement in three areas: recognition, work-life
balance and flexibility in hours and schedules. Lack of time and
other resources to do one’s work also receive low positive ratings.
Employee Engagement
A high level of engagement is a strategic goal for a growing
number of organizations in many industries, including health-
care. Engaged employees are committed to their employer, satis-
fied with their work and willing to give extra effort to achieve
the organization’s goals. Evidence suggests that engagement
influences other major human resources goals, such as reten-
tion, job performance, absenteeism and (indirectly through the
employer’s reputation) recruitment (Gibbons and Schutt 2010;
Macey and Schneider 2008).
Human resources experts prefer a multi-dimensional
approach to measuring engagement. This combines a number
of questionnaire items into a scale, yielding a single engagement
score. The resulting composite engagement metric can be useful
to employers for tracking progress on actions taken to improve
employee engagement. Employee engagement scales typically
combine job satisfaction, organizational commitment and other
performance-related indicators of a motivated employee.
TABLE 1.
Sample characteristics by peer group
Peer Group Number of
Respondents Response Rate (%)
Percentage of
Total Sample
Community hospitals (n = 5) 4,613 45 43
Teaching hospitals (n = 2) 3,260 45 30
Non-acute facilities: complex continuing care, rehabilitation and
mental health, community health centres (n = 5)
1,986 49 19
Small hospitals (n = 4) 843 54 8
Total (n = 16) 10,702 46 100

32 Healthcare Quarterly Vol.15 No.2 2012
TABLE 2.
Respondents’ positive ratings of work environment dimensions
Dimension Questionnaire Item
Positive
Responses*† (%)
Job characteristics Able to decide how to do work 55.3
Have clear job goals/objectives 51.2
Flexibility in schedule/work hours 38.4
Balance of family/personal life with work 35.2
Have adequate resources/equipment to do work 30.3
Have time to carry out all your work 22.8
Get recognition for good work 22.0
Training and development Opportunity to use skills 51.3
Opportunity to take initiative 45.4
Opportunity to make improvements in how your work is done 34.1
Opportunity to receive education/training 30.7
Opportunity to advance in career 17.0
Work team We work together and help each other out 76.1
People from diverse backgrounds feel welcome 74.6
We treat each other with respect 71.3
We support one another 70.1
Feel I belong to a team 69.0
Able to make suggestions to improve work of unit/team 63.7
We collaborate well with other teams/units 54.9
Communication is open/honest 49.2
Consulted about changes that effect unit/team 42.3
We have enough staff to handle workload 30.9
We work in crisis mode (disagree) 24.0
Immediate supervisor Supervisor treats you fairly 67.4
Supervisor can be counted on to help with difficult tasks 55.4
Supervisor helps access training/development 50.6
Supervisor provides feedback on job performance 46.6
How Employee Engagement Matters for Hospital Performance Graham Lowe

Healthcare Quarterly Vol.15 No.2 2012 33
Measuring Engagement
The use of a multi-item scale score can streamline survey follow-
up and support a more detailed statistical analysis of results,
especially testing predictive models that show the “net” impact
of specific drivers on engagement. Standard social science
practices were followed in constructing the EES engagement
scale. Scale items were selected based on frequency distribu-
tions, correlations, face and construct validity considerations
and factor analysis. (Factor loadings for the six items range
between .77 and .89 [i.e., these items measure the same under-
lying concept – engagement] and Cronbach’s reliability a is .92.
The engagement scale has a range of six to 29 [five items are
measured on five-point “disagree-agree” scales, and one item
is measured using a four-point scale], a mean of 20.4 and a
standard deviation of 5.2.) The resulting engagement scale has
high internal reliability (tested using Cronbach’s a, a statistic
with a range of zero to one, with closer to one being better).
The six items in the engagement scale measure the key
dimensions researchers have identified as being central to the
concept of employee engagement (Gibbons and Schutt 2010).
Specifically, the engagement scale developed for the EES
measures three dimensions of engagement:
• Emotional: I am proud to tell others I am part of the organi-
zation. I find that my values and the organization’s values
are similar.
• Rational: I am satisfied with (my) job overall. Overall rating
of the hospital as a place to work (from poor to excellent).
• Behavioural: I look forward to going to work. This organiza-
tion really inspires the best in me in the way of job perfor-
mance.
This scale provides a robust and comprehensive measure of
employee engagement, captured in a single metric.
Identifying High-, Medium- and Low-Engagement
Groups
To simplify further analysis and reporting, engagement scale
scores were grouped into low, medium and high categories, based
on the distribution of scale scores. The high-engagement group
consists of individuals who responded four or five on the five-
point items and three or four on the one four-point item (their
score was 23 or higher out of 29). The medium-engagement
group had scale scores between 19 and 22 (note that the overall
scale mean is 20.3 and the median is 21, both falling within this
group). The low-engagement group scored 18 or lower.
Consistent with the distribution of engagement scores,
which is skewed slightly toward the low end of the scale, 33%
(n = 3,323) of all respondents are in the low category, while 39%
(n = 3,958) are in the medium- and 29% (n = 2,925) are in the
high-engagement categories, respectively.
TABLE 2.
Continued
Dimension Questionnaire Item
Positive
Responses*† (%)
Senior management Senior management is committed to high-quality care 62.3
Senior management is committed to improving workplace safety 62.0
Senior management communicates clearly with staff regarding goals 48.9
Senior management acts on staff feedback 30.7
Organization I understand the goals of this organization 67.3
Organization provides a clean work environment 60.4
Organization promotes staff health/wellness 52.3
Organization values my work 46.1
I feel that I can trust this organization 37.3
*Combines responses of 4 and 5 on a 5-point scale, where 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree and 5 = strongly agree. Green shading indicates strengths
(60% positive or more); blue shading indicates improvement priorities (40% positive or less).
†Numbers of respondents for items vary between 10,177 and 10,596 due to missing data.
Graham Lowe How Employee Engagement Matters for Hospital Performance

34 Healthcare Quarterly Vol.15 No.2 2012
Basic Variations in Engagement
A higher percentage of high-engagement employees work in
non-acute facilities (i.e., community health centres, continuing
care, rehabilitation and mental health facilities) compared with
other peer groups. Furthermore, small hospitals have a slightly
higher percentage of fully engaged employees, compared with
teaching hospitals and community hospitals. These differences
underline the need to develop peer group benchmarks for
tracking employee engagement and other key workplace metrics.
Variations in peer group engagement levels may, however,
reflect differences in staff composition, the populations being
served, organizational contexts or other factors. Thus, it is
important to compare the organizations within peer groups to
gain a fuller understanding of the range of factors influencing
engagement. For example, additional analysis revealed more
variation among the five organizations within the community
hospital peer group than among the peer groups as a whole.
The same is true for the four small hospitals in that peer group.
Furthermore, highly engaged employees are more likely to be
found in certain demographic or employee groups. While there
are no significant gender differences in engagement levels, there
are interesting differences among age groups. Survey respond-
ents under age 30 years and those 60 years and older are more
likely to be highly engaged than their coworkers between the
ages of 30 and 59 years.
There also is a “newness effect,” with new recruits to the
organization and continuing employees who recently moved
into another position experiencing an initially heightened
sense of engagement. However, this newness effect wears off by
the five-year mark. The biggest drop in engagement happens
between a new hire’s first and second year with the organization,
signalling a problem that orientation programs must address.
The same is true for ongoing employees settling into a new
position. Indeed, 42% of respondents who have been in their
job less than one year are in the high-engagement group. This
drops to 34% for those who have been in their job one to two
years and declines further, to 30%, in years three to five.
Also notable is that engagement levels are slightly higher
among part-time employees and those employed other than in
full-time positions. Temporary, per-diem and on-call workers
also report slightly higher engagement levels. Both these findings
raise some interesting questions about the role that employment
flexibility and length of work hours may play in engagement.
Finally, survey respondents who are not union members are
slightly more engaged than their unionized counterparts. And
employees with managerial responsibilities also are somewhat
more engaged, compared with non-managerial employees (these
are overlapping groups).
We cannot read too much into these findings. After all, we
are looking at the relationship between each demographic or
employment characteristic and engagement in isolation from
other possible influences. Many factors, particularly the work
experiences discussed in the previous section, may also be
important. To illustrate, new recruits (who also are likely to be
young) may initially receive adequate training and career devel-
opment and get regular recognition for their work – three work
environment features that generally receive low ratings. So these
initial job experiences, not seniority, would explain the higher
engagement levels of new recruits. The next section sheds light
on the factors that influence engagement.
Drivers of Engagement
The variations in engagement scores just discussed raise further
questions about what job, work environment, management and
other organizational factors influence engagement. The EES can
provide answers.
Top-10 Engagement Drivers
Regression analysis was used to identify “net impacts” on
engagement scale scores. (The multivariate statistical analysis
reported in this section uses linear regression models that do
not determine “causation” but, rather, can measure how much
of the variation in the engagement score is explained by each
factor [measured by a questionnaire item], after taking into
account all other factors included in the regression model. So
the term net impact is a non-technical way of describing the
explanatory power of a particular variable on an outcome, in
this case engagement, after having taken into account the influ-
ence of all other variables in the model on that outcome.) This
statistical modelling finds that most (over 70%) of the varia-
tion in engagement scores among all survey respondents can be
accounted for by 10 questionnaire items. Here are the top-10
work environment drivers of engagement, rank ordered by their
net influence on engagement scores:
1. I feel I can trust this organization.
2. I have an opportunity to make improvements in work.
3. The organization values my work.
4. Senior management is committed to high-quality care.
5. I have clear job goals/objectives.
6. I feel I belong to a team.
7. My organization promotes staff health/wellness.
8. I have a good balance of family/personal life with work.
9. My supervisor can be counted on to help with difficult tasks.
10. I have adequate resources/equipment to do my work.
Two points should be kept in mind when considering
the top-10 engagement drivers. First, the regression analysis
included 36 EES items assessing jobs, training and develop-
ment opportunities, work team, immediate supervisor, senior
management and organizational supports. Second, the analysis
also took into account the possible influences on engagement of
How Employee Engagement Matters for Hospital Performance Graham Lowe

Healthcare Quarterly Vol.15 No.2 2012 35
peer group, as well as
the demographic and
employment charac-
teristics shown, in
our earlier discus-
sion, to be related to
engagement.
One could
argue that trust
is an outcome of
these other work
experiences and, as
such, should not
be included in the
multivariate analysis
as a potential driver
of engagement. Trust
is a complex property
of organizational life,
being both a cause
and effect of work
experiences and
performance. After
removing trust from the regression model, the list of top-10
drivers of engagement remains largely the same, with only two
minor changes. First, the rank ordering shifts slightly: the top
three factors are (1) the organization values my work, (2) senior
management is committed to high-quality care and (3) I have
clear job goals/objectives. And, second, while the role of super-
visors remains important, “My supervisor can be counted on to
help with difficult tasks” is replaced by “My supervisor treats
me fairly.”
Other Influences on Engagement
Beyond the top-10 engagement drivers, other work environment
factors influence engagement scores. Employees’ assessments
of the following work environment factors had a statistically
significant influence on engagement scores, albeit less so than
the top-10 factors:
• Ihavetheopportunitytousemyskills.
• Iunderstandthegoalsofthisorganization.
• Iamabletodecidehowtodowork.
• Wehaveenoughstafftohandleworkload.
• Mysupervisortreatsmefairly.
• Ihaveanopportunitytoreceiveeducation/training.
• Myunitorteamdoesnotworkincrisismode.
• Myunitorteammemberstreateachotherwithrespect.
• Ihavetheopportunityforcareeradvancement.
• Seniormanagementcommunicateswithstaffaboutwhat
they are trying to achieve.
The newness effect on engagement, discussed earlier, disap-
pears when a broad range of work environment factors is taken
into account. Facility type (being employed in a teaching
hospital) and employment status (part-time or “other” employ-
ment status, being temporary/per diem or standby and not
being a union member) have very small positive effects on
engagement. Each of these factors explains less than 1% of the
variation in engagement scores.
Engagement and Key Outcomes
The OHA Quality Healthcare Workplace Model suggests that
more-engaged employees are better able than their less-engaged
colleagues to achieve organizational goals. This section provides
empirical confirmation that this indeed is the case, focusing
on four outcomes: retention, quality of patient care or services
provided by the respondent’s team/unit, patient safety culture
and patient-centred care.
Retention
One of the major human resource goals of any healthcare organi-
zation is to retain competent staff. Turnover is costly. It is widely
assumed that more-engaged employees stay and contribute. As
Figure 2 shows, this is the case among EES respondents. While
close to half of disengaged employees will be job hunting in the
next 12 months, only one in 10 of those who are highly engaged
will be looking for a new job with a different employer. In other
words, 90% of highly engaged employees plan to stay with the
organization, at least for the near future.
FIGURE 2.
Retention by level of engagement
52.1%
79.7%
89.7%
47.9%
20.3%
10.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Level of Engagement
Unlikely to look for a new job in next 12 months Likely to look for a new job in next 12 months
n = 10,053. Group differences are statistically significant (p < .001).
Graham Lowe How Employee Engagement Matters for Hospital Performance

36 Healthcare Quarterly Vol.15 No.2 2012
Work Unit Service Quality
Increasingly, healthcare organizations are using a variety of
tools to assess the quality of patient care and of the non-clinical
services provided. These tools range from wait times and hospital
readmissions to patient satisfaction surveys, awards for service
quality and informal client feedback. The EES provides another
equally useful metric for assessing quality: employees’ percep-
tions of the quality of patient care and other services provided
by their work unit.
Figures 3 and 4 document a clear pattern in patient care
and service quality. These results suggest that achieving higher
levels of employee engagement is part of the solution to quality
improvement. In both clinical and non-clinical units (based on
whether or not EES respondents have direct patient contact),
two thirds of highly engaged employees report that their work
units “always” provide top-quality service. This stands in
contrast to the low-engagement group, where only about one
in five believe that excellent quality service is always provided.
Patient-Centred Care
Creating and maintaining a patient-centred care environ-
ment has become a strategic goal for many hospitals. The EES
captures the main dimensions of a patient-centred care environ-
ment. Using the same statistical techniques described above to
create the EES, we constructed a multi-item Patient-Centred
Work Environment Scale (PCWE). (This six-item scale has a
range of six to 30, a mean of 21.2, a standard deviation of 4.8
and a Cronbach reliability a of .88, and factor loadings were
between .63 and .81.) The scale combines the following six
questionnaire items:
1. I support and involve family members when requested by the
patient.
2. I involve patients in decisions about their care.
3. I have the time I need to talk with my patients to make
sure they get the information they want about their medical
condition, treatment or tests.
4. I get timely information about my patients’ condition/treat-
ment/tests.
5. I have the time and information to prepare patients for
leaving the hospital/program.
6. I treat patients as individuals with unique needs and prefer-
ences.
The scores for the PCWE were divided into quartiles,
making it easier to examine the relationship to engagement.
Figure 5 shows the percentage of employees in the three engage-
ment groups who
are in each of the
PCWE quartiles.
Employees in the
highest quartile have
the most positive
assessment of the
six items measuring
patient-centred work
environment. We
find a strong and
consistent relation-
ship between engage-
ment and assessments
of such an environ-
ment. Specifically,
46% of highly
engaged employees
have PCWE scores
in the top quartile.
By contrast, only
21% of disengaged
employees are in the
top PCWE quartile. Equally important, while 6% of highly
engaged employees fall into the lowest PCWE quartile, this rises
to 38% among the least-engaged employees.
Safety Culture
The EES also measured patient safety culture. These measures
are designed to inform improvements in patient safety, which is
a priority for the Canadian healthcare system. Applying the same
methodology as above, a six-item Patient Safety Culture (PSC)
FIGURE 3.
Work unit provides top-quality patient care by level of engagement*
33.0%
8.1%
1.9%
46.5%
49.8%
30.5%
20.5%
42.2%
67.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Level of Engagement
Never/sometimes Usually Always
* Includes only respondents with frequent or occasional direct patient contact (n = 6,988). Group differences are statistically significant (p < .001).
How Employee Engagement Matters for Hospital Performance Graham Lowe

Healthcare Quarterly Vol.15 No.2 2012 37
scale was created.
(This six-item scale
has a range of six to
30, a mean of 20.6, a
standard deviation of
3.5 and a Cronbach
reliability a of .78,
and factor loadings
were between .53 and
.76.) The following
questionnaire items
make up this scale:
• Errors, near
misses and
incidents have
led to positive
changes here.
• After we make
changes to
improve patient
safety, we evaluate
their effectiveness.
• Weareinformed
about errors,
near misses and
incidents.
• Myorganization
encourages us
to report errors,
near misses and
incidents.
• Our procedures
and systems
are good at
preventing errors,
near misses and
incidents from
happening.
• Staffin myunit
are actively doing
things to improve
patient safety.
Figure 6 reports the results of the relationship between
engagement and PSC scores, using quartiles for the latter.
These results mirror what we saw in Figure 5 regarding a
patient-centred work environment. If anything, the relationship
between engagement and safety culture is even stronger, given
that 58% of highly engaged employees are in the top quartile of
PSC scores, while only 3% are in the lowest quartile.
Conclusion
This survey of hospital employees provides a unique opportu-
nity to explore the dynamics of employee engagement in health-
care. The results show a consistently strong relationship between
employee engagement and organizational performance, as
suggested in the OHA’s Quality Healthcare Workplace Model.
However, we should be careful not to infer causation. Further
analysis of EES and other employee survey data is required to
FIGURE 4.
Work unit provides top-quality services by level of engagement*
27.5%
6.9%
2.8%
49.2%
50.0%
31.7%
23.3%
43.1%
65.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Level of Engagement
Never/sometimes Usually Always
*Includes only respondents with no direct patient contact (n = 1,983). Group differences are statistically significant (p < .001).
FIGURE 5.
Patient-centred work environment scale scores (in quartiles) by level of engagement*
38.4%
16.3%
5.8%
26.2% 21.1%
29.4% 28.3%
20.2% 45.6%
14.4%
26.0%
28.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Level of Engagement
Lowest quartile 2nd quartile 3rd quartile Highest quartile
*Includes respondents with frequent or occasional patient contact (n = 6,949). Group differences are statistically significant (p < .001).
Graham Lowe How Employee Engagement Matters for Hospital Performance

38 Healthcare Quarterly Vol.15 No.2 2012
test the direction of causation in these relationships and how
they change over time. It is possible, for example, that being
part of a high-performing team is among the “causes” of high
engagement. Still, the results show that engagement levels are
positively and consistently related to a range of mission-critical
organizational outcomes in the 16 hospitals being studied.
While the study may not be fully representative of all Ontario
hospitals, it does provide insights that will be useful to Ontario
healthcare employers. The province’s Excellent Care for All Act
requires hospitals to measure, report and improve the work
environment as part of their overall quality improvement plan.
This study illustrates the types of employee survey measures
that can contribute to overall quality improvement initiatives.
And as more Ontario hospitals use the EES, its benchmarking
potential will grow. Also useful would be national benchmarks
of key outcome measures. This could include an engagement
scale score, such as the one used in this study, or a single-item
component of the engagement scale, such as job satisfaction
(Lowe and Chan 2010).
We now have an evidence-based definition of employee
engagement relevant to healthcare. Engaged employees have
strong emotional, rational and behavioural attachments to their
job and their organization. They experience pride, values congru-
ence, and job and organizational satisfaction, and they feel enthu-
siastic and inspired in their work. In short, the engaged employee
is the ideal employee. As the EES documents, engaged employees
benefit patients and reduce the workforce costs associated with
turnover. For healthcare leaders and policy makers, the overall
conclusion is that higher levels of employee engagement must
become a strategic
goal for all healthcare
organizations.
Closing the
engagement gap must
be a priority. Indeed,
the fact that one
third of employees
surveyed have low
levels of engage-
ment poses a signifi-
cant risk to patient
care, internal service
quality and staffing
budgets. Reducing
the engagement gap
must become part
of risk management
by hospital boards
and executive teams.
Results from surveys
such as the EES can
help managers and employees to identify actions that will close
the gap between the lowest- and highest-scoring groups by
raising the lowest scores. In this study, the gap is wide, with
a spread of between 45 and 73 percentage points in positive
response levels on key drivers between the low-engagement and
high-engagement groups. At the organizational level, focused
and persistent efforts will be required to narrow this gap.
The EES results also highlight the importance of trust.
Indeed, the key to unlocking higher levels of engagement
is for managers at all levels to build trust with employees.
Demonstrating basic respect, fairness and integrity in all
dealings with staff is the basis for trust (Burchell and Robin
2011). Trust building is an incremental and ongoing process
that happens in every interaction and becomes engrained in
an organization’s culture. A prerequisite in this regard is open
communication. As well, culture becomes the vital link between
positive staff experiences and performance. Other studies show
that high-performance hospitals have distinctive cultures that
empower middle managers, champion pro-performance values
and clearly communicate a corporate vision that guides their
actions (Mannion et al. 2005).
The profile of the engaged employee emerging from this
study reinforces the importance of effective people practices
(Michie and West 2004). Any manager can carry out a simple
self-assessment by reflecting on how closely the organization’s
employees fit this profile. Highly engaged employees not only
trust their employer, they also are able to improve how they
work, feel valued and have clear job goals and a sense of team
membership. They are able to perform effectively in their
FIGURE 6.
Patient safety culture scale scores (in quartiles) by level of engagement*
34.4%
10.8%
2.9%
38.6% 10.7%
33.8% 28.7%
17.5% 57.5%
16.3%
26.7%
22.1%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Level of Engagement
Lowest quartile 2nd quartile 3rd quartile Highest quartile
*Includes respondents with frequent or occasional patient contact (n = 6,862). Group differences are statistically significant (p < .001).
How Employee Engagement Matters for Hospital Performance Graham Lowe

Healthcare Quarterly Vol.15 No.2 2012 39
job because they have a supportive supervisor and adequate
resources and equipment. Their quality of work life is enhanced
because the organization takes steps to promote staff wellness
and work-life balance. And they understand that senior manage-
ment is committed to high-quality care. None of these engage-
ment drivers requires costly new programs. If anything, they call
for a back-to-basics approach to how healthcare organizations
manage and motivate their employees.
Acknowledgements
I would like to thank OHA and NRC Picker Canada for making
available the data analyzed in this article. Useful comments on
earlier drafts were provided by Kimberley Burrows and Dana
Ross at the Ontario Hospital Association, as well as Heather
Dawson and Melanie Jameson at NRC Picker Canada.
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About the Author
Graham Lowe, PhD, is president of the Graham Lowe
Group Inc. (www.grahamlowe.ca), a workplace consulting
firm based in Kelowna, British Columbia, and the author of
Creating Healthy Organizations (Rotman/UTP Publishing,
2010). He can be reached at glowe@grahamlowe.ca.
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