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The link between management practices, health professional performance and patient outcomes



Introduction: Management practices in hospitals influence health professionals' performance, quality of health services and patient outcomes. However, scant attention was given to show the link between these practices and patient outcomes. The study aimed at examining the link between specific management practices, employee performance and patient outcomes in hospitals. Methodology: This study was conducted between June 2014 and July 2015. We reviewed Western literature to benchmark Western experiences and informing researchers and decision-makers in the healthcare industry. Results: The study identified hospitals as human capital intensive healthcare sector that needs effective management practice to enhance quality of health care outcomes. It also identified variations of management practices, particularly operations management and HR practices. It has shown that bundles of HR practices are pivotal in enhancing the attitudes, skills and behaviors of health professionals for better performance in rendering quality health services to meet expectations of patients. The study identified that patient outcomes are the results of employee performance which in turn is influenced by management practices. Conclusions: Modern management practices are crucial for maintaining and sustaining health professionals' performance and improving quality of patient outcomes in hospitals. Thus, hospital managers should design and implement operations and HR management practices to improve health professionals’ performance, resulting in improved quality of care that satisfies patients.
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“SS. Antonio e Biagio e Cesare Arrigo” Working Paper of Public Health
Title: The link between management practices, health professional performance and patient
Authors: Philipos Petros Gile; 12* Joris Van De Klundert;2 Judith Van De Broek;2
Type: Original Article
Keywords: management practice, HR practices, operations management, health professionals’
performance, patient outcomes, hospital.
1 Ethiopian Universities’ Partnership, CMC Road, POBOX 14051, Addis Ababa,Ethiopia.
2 Institute of Health Policy & Management, Erasmus University of Rotterdam, Postbus 1738, 3000 DR
Rotterdam,The Netherlands.
* Corresponding author
Azienda Ospedaliera Nazionale
“SS. Antonio e Biagio e Cesare Arrigo” Working Paper of Public Health
Introduction: Management practices in hospitals influence health professionals' performance,
quality of health services and patient outcomes. However, scant attention was
given to show the link between these practices and patient outcomes. The
study aimed at examining the link between specific management practices,
employee performance and patient outcomes in hospitals.
Methodology: This study was conducted between June 2014 and July 2015. We reviewed
Western literature to benchmark Western experiences and informing
researchers and decision-makers in the healthcare industry.
Results: The study identified hospitals as human capital intensive healthcare sector that needs
effective management practice to enhance quality of health care outcomes. It also
identified variations of management practices, particularly operations management
and HR practices. It has shown that bundles of HR practices are pivotal in
enhancing the attitudes, skills and behaviors of health professionals for better
performance in rendering quality health services to meet expectations of patients.
The study identified that patient outcomes are the results of employee performance
which in turn is influenced by management practices.
Conclusions: Modern management practices are crucial for maintaining and sustaining health
professionals' performance and improving quality of patient outcomes in
hospitals. Thus, hospital managers should design and implement operations and
HR management practices to improve health professionals’ performance,
resulting in improved quality of care that satisfies patients.
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“SS. Antonio e Biagio e Cesare Arrigo” Working Paper of Public Health
1. Introduction
Human Resources(HR), Operations Management(OM) and Health Service Research
literature show that healthcare systems have been facing with problems of ineffectiveness and
quality of patient care in Europe and America (Koppmans,2014; Aiken, Sermeus, Van den
Heede,2012;Radnor, Holweg &Waring,2011). HR is among the key dimensions of
management practices that deals with the process of managing work and people in
organizations. Whilst OM is mainly concerned with the management of processes and direct
resources as well as making decisions that are required to deliver values to customers (Van de
Klundert,2009) via the organization’s services.
Some scholars (e.g. Bloom et al.,2014) examined the link between 20 managerial practices in
healthcare that fall under three dimensions(operations, goal setting with targets and human
resources).Their study shows effects of these practices on healthcare outcomes in hospitals of
nine Western countries. In addition, Leggat et al. (2010) identified the positive effects of
management practices(e.g. high performance work systems) on quality of care in Australian
hospitals. McConnell et al.(2014) on the other hand researched 18 management practices with
four dimensions (operations management , target setting, performance monitoring and
employee incentives) in the US hospitals and shown that these practices affect performance
of employees and quality of patient care.
Other researchers (e.g. West, Guthrie,Dawson,Borrill, Carol & Carter, 2006; Van de
Klundert, 2009& Van den Broek, 2014) shown that healthcare organizations of Western
countries are under pressure to deliver high quality of care to the clients. Such organizations
are also confronted with challenges of rendering quality of care and achieving higher patient
satisfaction (West et al.,2006; Neumann& Jan, 2010 and Foropan& Prentice, 2008). Poor
operations and HR practices as well as poor performance of employees are among the major
causes for low quality of healthcare (Bloom, Sandun, & Van Reenen,2014;
McConnell,Chang, Maddox, Wholey & Lindrooth, 2014; Leggat,
Bartram,Casimir&Stanton,2010). Some studies have suggested the need for more investment
in improving OM and HR practices (Neumann & Jan, 2010) and health professionals’
performance for enhancing quality of care (Radnor et al., 2012; West,Borris, Dawson, Scully,
Carter, Anelay & Waring , 2002 & McConnell et al., 2014 ) . However, these studies didn’t
clearly show how HR and OM practices affect employee performance and patient outcomes.
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Prior empirical studies on operations management practices didn’t focus on healthcare sector
and non-western countries(Foropan& Prentice,2008;Zineldin, 2006;
Jacobsson,2012;Koopmans, 2014 & Bloom et al., 2014) . The same authors depicted that
poor OM and dysfunctional HR practices (e.g. poor training, poor teamwork, weak
incentives) can be the root causes of poor performance of employees and organizations.
Earlier studies lack clarity on how specific management practices like people management
and OM are linked to health professionals’ performance and patient outcomes. Even those
few studies(e.g. McConnel et al, 2014;Bloom et al,2014&West et al, 2002) that attempted to
examine the interaction between management practices in healthcare gave inadequate
attention on how these practices affect employee performance and how employee
performance in turn influence healthcare outcomes. The studies suggested future research to
consider integration of managerial practices aligned to the organizational goals of improving
employee performance and healthcare outcomes.
The overall aim of our research is to examine the link between specific management
practices, employee performance and patient outcomes in hospitals. Our focus is on the two
main dimensions of management practices, namely operations management and HR
practices. The major reasons for such a focus is that the previous studies were very
fragmented and lack clarity on the effects of these practices on employee outcomes with
some exceptions of HR practices in healthcare (e.g. Boselie 2010b;Veld,2012;West et al.,
2002). The general research question of this study is how and to what extent do management
practices (MPs) affect employee performance and patient outcomes in the western hospitals?
2. Methods
This study was conducted between June 2014 and July 2015. In order to achieve the aim of
the study and address the research questions, we developed a conceptual model (see figure 1)
and conducted a rigorous and comprehensive review of international literature benchmarking
developed countries’ experiences .
From scientific relevance point of view, the paper provides an overview of literature on the
link between specific management practices (OM and HRM), employee performance and
outcomes in hospital sector. It will act as a spring board to researchers in the field of
healthcare organizations and management practices, health services research and inform them
to delve into empirical examination of the link between the practices and patient outcomes
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(Veld,2012& Foropan& Prentice,2008) . Moreover, the study is supposed to contribute to the
literature in HRM, OM and health care management (Kaplan et al., 2010& McConnell et al.,
2014). It can also raise awareness of healthcare managers on OM and HR practices and their
influence on the outcomes of employees and patient care. It is supposed to enhance the
effectiveness of management body in paying more attention for evidence based interventions
to improve quality of management practices and patient outcomes (West et al., 2002&Bloom
et al., 2014). It will also enlighten decision makers on aspects of modern management
practices and employee performance to be focused to enhance their competitiveness in
ensuring quality of care and patient satisfaction (Leggat et al., 2010; Garman et al., 2011&
Graban, 2012).
3. Results
3.1 Linkage between management practices, employee performance and patient outcomes
Management in general is about “getting things done effectively through people and
operations” (Luke, 2011 and Young &Jordan, 2008). Extant literature (e.g. West, 2001; Luke,
2011; Michie &West, 2011; Veld et al., 2010 & West et al., 2002) suggests that abilities and
skills of managing people and operations are key for better performance and ensuring quality
of healthcare. Furthermore, management practices(i.e. HRM and OM practices in our case) in
health service organizations of developed countries in general (Flood,1994;Michie &West,
2004) and hospital sector in particular (Bloom, Propper, Seiler & Van Reenen, 2009) are
closely linked to employee and patient outcomes. As indicated in our research model (see
figure 1) , HR practices and OM are linked with employee performance(EP) and patient
outcomes, EP in turn is linked to patient outcomes. However, researchers (McConnell et al.,
2014 & Bloom et al., 2009) argue that the link between management practices, health
professionals’ performance and patient outcomes remains elusive. Such elusiveness is the
result of managerial factors including behavioral operations (which explore the interaction of
human behaviors and operational processes), HRM, characteristics of hospitals (public or
private, general or specialized hospitals), that of employees (attitude and behaviors) and
patient characteristics (Jacobsson, 2012; Graban, 2012&Bloom et al., 2014).
HRM practices deal with managing employees focused on acquisition, building their
capacities for empowerment or enhancing their ability, attitudes, behaviors, performance
appraisal, motivation geared towards enhancing individual and organizational performance
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(Boselie et al 2002; West et al 2006; Veld,2012). Operations management is guided by
organizational principles (which will be explained in detail in section 2.2.1 of this paper). It
deals with process management including quality improvement (Jacobsson, 2012). OM also
requires proper managerial decision making (Goldstein et al., 2002), for instance to improve
management and healthcare production processes.
OM and HRM have
often been considered separately and not in combination
(e.g. Neumann&Jan, 2010). In practice, they have interface on managerial issues of making
decisions on employees, financial and other operational processes. T h e two subjects were
studied by separate academic communities and publishing in
disjoint sets of journals. Yet,
OM and HRM practices are intimately related at a fundamental level. I n p r ac t ic e ,O M
p r a c t i c e s often moderate the effects of HRM activities such as pay, training,
communications and staffing(Boudreau et al., 2002 and Boselie et al., 2005) . Thus the
and HRM
cannot exist without one another (Boudreau et al., 2002). In order to fill these
gaps of separate consideration of HRM and OM, the present study found combining them is
relevant for practical context of inseparable nature of these two dimensions of management
Previous researchers (e.g.Bloom&Van Reenen,2010&2006 and Bloom et al.,2009) identified
18 management practices executed in the various Western manufacturing firms and hospitals.
These and related studies(e.g. Osho,2014 & Gilbert et al, 2010 ) identified introduction of
modern HR practices including attracting, managing and retaining human capital,
performance review, rewarding high performers and removing poor performers, OM
techniques (e.g. target(goal) setting, monitoring(process tracking) as key management
practices. But the studies lack clarity on the importance of OM practices and how these are
linked to HRM as well as how they influence employee and patient outcomes.
McConnell et al.(2014) and Bloom et al.(2006&2014) for example shown that management
practices vary considerably among hospitals in the developed countries due to variations in
context of organizations. The scholars added that these practices in turn affect employee
outcomes and quality of healthcare service. Moreover, researchers (West et al.2002&2006)
acknowledge the link between managerial practices, employee and patient outcomes, yet they
gave emphasis to clinical and financial outcomes than functional and service outcomes. For
example, Bloom et al.(2014) declared that management practices are strongly associated with
better clinical and financial outcomes of hospitals . Furthermore, Bloom et al.(2014) &Bloom
et al.(2009) shown that better management practices are strongly correlated with better
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employee performance which is measured by both non-financial and financial outcomes
including quality of health care . In conclusion, there are different dimensions of management
practices, and effective execution of these practices should consider contexts of the
organization or companies for better enhancement of employee performance. When all the
dimensions of management practices, particularly those related to operations management
and HRM are effectively executed, they ply pivotal role in improving the outcomes of
employees and that of hospitals for enhancing quality healthcare and patient outcomes.
This study is guided by the theoretical model designed as a conceptual framework of the
research. As can be seen from the conceptual model (Figure 1) , almost all operations systems
involve people, the list of specific OM results that
might be affected by human behavior is
virtually unlimited-a comprehensive list is not feasible and not expected from this review as
well. Scholars (e.g. Foropan&Prentice, 2008; Jaspers et al., 2011 & Boundreau et al., 2002)
viewed that dealing with the interface
between OM and HR by examining how human factors
OM results. This in turn helps understanding how operational considerations affect HRM
outcomes (e.g. employee attitudes, behaviors, motivation and job satisfaction) and
3.2 Operations management practices and patient outcomes
As depicted in Figure 2, operations management and HRM practices are interconnected,
study of such interconnection between these two practices is very important in health care.
Previous research shows that the health care sector is using operations management practices
that were developed in manufacturing sector to reduce waste, improve employee
performance, and ultimately enhances patient outcomes (Graban, 2009&2012 and Li, et al,
2002). Jacobsson (2012) and Subramanian and Ramanathan(2012) defined the concept as a
recent reincarnation of earlier fields of scientific, industrial and production management,
concerned with management of organizational activities that produces goods and/ or delivery
of services required by its customers. It also encompasses decision-making, the design and
management of the transformation process in service organizations (such as hospitals) and
quality improvement that create value for customers (Goldstein, Ward, Leong & Bulter,
2002; Van de Klundert, 2009 and Loch & Wu,2007) .
Extant literature (e.g. Goldstein et al., 2002; Jacobsson, 2012) identified the most important
principles of operational management and they added that these principles can be transferred
to health service organizations so as to improve healthcare production processes, i.e., to
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ensure swift even flow of patient and enhance quality of patient care. Enactment of these
principles would help addressing challenges that healthcare providers are facing with high
demand for healthcare and economic constraints. Jacobsson (2002) and Spear (2005)
suggested the following principles of operations management to be implemented for better
outcomes of employees and health service organizations (hospitals).
Elimination of everything that doesn’t add value to customers
Elimination of unnecessary steps in the process
Standardization of work practice(work practice is defined as how work is organized ,
Boxall & Macky,2009, P.7)
Separation of patient flows, i.e. addressing the question of why performance of
similar healthcare activities differ
Synchronization of patient flow
Multi-disciplinary teamwork with health professionals(physicians and nurses)
Capacity planning, i.e. matching resources to demand
Visualization of the patient flow( seeing the whole or complete picture and allowing
employees to see their activities and performances as vital parts)
Focus on the patient process
Effective operations management is not a “one time” task; it requires proper managerial
decision making (Goldstein et al., 2002). Capturing and documenting data is the first step
down the pathway of successful operations management (D`Souza&Sequeira, 2011). If a
hospital is tasked with a agoal of improving quality of care and maximizing patient outcomes,
sound operation management practice should be in place (Jacobsson, 2012). These
researchers shown that modern operations management promotes developments in
technology which allow the redesign of medical processes in healthcare chain, i.e. changing
‘traditional’ operations management with long waiting time and long duration of treatment.
Furthermore such a practice reduces discomfort and complaints of patients, enhances the
cooperation of staff from various disciplines, improves healthcare procedures well planned
and enhances accomplishment of quality interventions (Spear, 2005). If OM in healthcare is
properly executed, it can support business processes to manage medical supply chains and
simplifies the role of employee performance aspects in process execution (Kaplan et al,
2010;DeVaries&Huijsman,2011& Subramanian&Ramanathan,2012). It also promotes the
improvement of the utilization of scarce resources (Jacobsson, 2012). Health operations
management also examines the patient experiences from start to finish, continuously making
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changes to improve everything from the management of supplies and scheduling diagnosis or
admissions to the flow of patients and the design of facilities (Goldstein et al., 2002).
Jaspers,Smeulers,Vermeulen&Peute( 2011) and others
(Randor,Holweg&Waring,2011;Radnor, 2011; Kaplan, et al., 2010 ) suggest that modern
management techniques (e.g. Kaizen, Balanced Scorecard) which were rooted in the
manufacturing industry of developed countries can be adopted to hospital settings to
improve quality of management practices and better performances (Graban, 2012 & Griffith
et al., 2009). Though these techniques require the underlying condition of readiness of
management and employees, they can reduce waste, satisfy customers and increase value-
adding activities without increasing cost of the service (Randor et al., 2011& Jaspers et al.,
Li et al. (2002) identified that OM decisions could fall under long term structural decisions
(e.g. service expansion, facility management, patient admission, patient length of stay),
intermediate operation decisions(e.g., work force management, continuous improvement,
outpatient demand management including flow of patients) . Better OM practice is key for
enhancing employee and hospital performance because it deals with setting the strategic
direction in managing customer-focused services (D`Souza&Sequeira, 2011) such as
healthcare delivery.
In sum, the practice of operations management in hospitals can improve efficiency of
decision making processes and operations as well as increase employee performance. This in
turn can improve quality of patient outcomes and satisfaction. The next section will be on the
second aspect of management practice, i.e., HR practices linked to employee performance
and patient as well as organizational outcomes.
3.3 The link between HR practices, employee performance and patient outcomes
Though there is no consensus on the concept and aspects of HRM), researchers in the field
(Boselie, 2010a&b; Veld, 2012; Van den Broek, 2014; Guest1997,2001&2002) defined it as
“involving all management decisions related to policies and practices aimed at achieving
individual, organizational and/or societal goals.” While Boxall(2012), Boxall&Purcell(2008)
and Boxall & Macky (2009) described HRM as managing both work and employees in an
organization, hence HRM practices are is essentially concerned with the management of
people at work, work practices(i.e. the way work is organized) and employment practices (i.e.
how people are employed to do the work, i.e all the practices used to
recruit, deploy,
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motivate, consult, negotiate with, develop and retain employees, and
to terminate the
employment relationship. They added that the work and employment practices embedded in
an HR practices affect
performance at different levels. On one
level, they influence the
abilities (A), motivations (M) and opportunities (O) to
perform of individual employees, i.e.,
the ‘AMO’ model of individual performance (Boselie, 2012;
Guest, 2002&
Huselid, 1995).
On the other level, the work and employment practices influence performance of
According to Paauwe (2004&2009), Arthur (1994) and Huselid (1995), bundles of HR
practices include acquisition, training, empowerment, deployment and motivation activities
that are intended to enable employees perform better and contribute to organizational goals.
Townsend&Wilkinson,2010&Townsend,Wilkinson&Allen,2011( cited in Van den Broek
,2014) and Veld(2012) also shown that employees are of crucial importance for the
performance of healthcare organizations like hospitals .
Scholars (e.g., Boselie, 2012; Guest, 2002&2011 &Veld, 2012) contend that for a full of the
contribution of HR practices we need theory: the resource based view (RBV) and human
capital theory( for example in terms of employee knowledge and skills) help to structure our
understanding of HRM and performance. Moreover, meta analysis of 104 articles with a list
of 26 different HR practices by previous researchers (e.g. Boselie et al., 2005) further
identified the three dominant theoretical frameworks that can be distinguished within the HR
practice, namely the contingency framework, the resource based view (RBV) and the ‘AMO’
theory. These theoretical frameworks add values in providing relevant information on the
epistemological and ontological assumptions the researchers have about the subject that they
bring with them to their research (Jiang et al., 2012b & Veld et al. 2010).
AMO framework is the
most influential model in the study of the link between HRM and
(Guest,2002;Boselie et al., 2005 and Boxall,2012)
and it shows the right
combination of abilities (A), motivation (M) and opportunities (O) of and for
that is
good performance (Appelbaum et al., 2000). In addition, Buchan
(2004) highlighted on the principle of AMO a so-called “prime building block”
of HRM. He added that there must be sufficient employees with the necessary
ability (skills, knowledge and experience) to do the job; there must be adequate
motivation for them to apply their abilities; there must be the opportunity for
them to engage in “discretionary behavior”- to make choices about how their job.
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AMO model is thus focused on individual level factors, and can be seen as complementary
to both the Contingency theory and the RBV which are briefly discussed above.
According to Veld(2012) AMO model suggests that employees perform well
they are able to do so (they can do the job because they possess the necessary
knowledge and skills);
they have the motivation to do so (they will do the job because they want to and
are adequately incentivized);
their work environment provides the necessary support and avenues for expression
(e.g. the opportunity to be heard when problems occur).
Thus Performance = f employee’s ability, motivation and opportunity to participate
Van den Broek (2014) in her study shows that boosting our understanding of processes
related to HR practices in health sector is very relevant. However, the critique here is the
most common debate that the “black box through which HR practices are thought to impact
performance remains insufficiently specified (Fauth, Bovan&Mills, 2009; Veld, 2012). The
black box is how HR practices affect employee and organizational performance, which is
something that is addressed in this research. Earlier researchers specific HR practices, often
termed as high performance work systems (HPWSs) or work practices
(Boxall,2012;Paauwe,2004&2009;Guest 2002&2011;Combs et al.,2006; Etchegaraye et
al.,2011; Veld et al.2010;Boxall&Macky,2009;Boselie et al.,2005&Messersmith et al.,2011),
they explained HPWSs as :
……a group of separate but interconnected HR practices designed to enhance employees’
skills and efforts. Measurement of HPWSs include comprehensive approaches to recruiting
and selection, pay for performance, and other incentive-based compensation plan,
communication or information sharing, performance appraisal, and training in both generic
and company specific skills. HPWSs operate by influencing employee skills, motivation,
promotion and opportunities to contribute towards high performance.
HR practices can also enhance organizational citizenship behavior (OCB) that relates to
contextual or extra-role behaviors of employees and attitudes closely linked employee
commitment to organizational goals and job satisfaction (Boselie, 2010b;West et al, 2002 &
Veld, 2012). This in turn adds significant value to increase employee performance
and patient outcomes (Gilbert, De Winnie&Sels 2010;Hutchinson
&Purcell,2008&Buchan,2004).According to Messersmith et al.(2011) OCB includes
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altruism (helping co-worker), courtesy(alerting others about changes in their work) ,
sportsmanship (refraining from complaints about trivial matters), conscientiousness(carrying
out duties beyond minimum requirements), and civic virtue(participating in the governance of
the organization). Studies show that OCB is linked to AMO model, which focuses on
employees’ abilities, employees’ competence and their opportunity to participate (Boselie et
Some writers contend that comprehensive knowledge is lacking on why HR practices
contribute to performance in the complex healthcare settings (Boselie, 2010b&Boselie,2012)
. One of the reasons for this is could be essentially due to complexity of health care services
to the public (Petros 2014; Buchan,2004;Stepaniak,2010;
Van den
Broek,2014&Jiang et al.,2012a
) and human capital intensive nature of hospitals
(Veld et al., 2010).
HR practices are transmitted through the process and ways they influence employee attitudes,
abilities, motivations, and opportunities(Boxall,2012 and Boxall & Macky, 2009). For
instance, Nishi &Wright(2008) developed process model of HRM which shows the
causal chain .The model proposes that (1) intended HR practices(i.e., HR policy and
strategies), leading to (2) actual HR practices (i.e., really executed), leading to (3) perceived
HR practices(attitude of employees), leading to (4) employee reactions (employee outcomes),
and leading , finally, to (5) organizational performance . Managers can play important role in
implementing the actual HR practices for better performance. Yet there can be major gaps
between management intention and management action that are damaging to employee
attitudes and behavior and ultimately to performance outcomes, a problem that can exist in
any model of HRM (Boxall et al., 2011& Veld, 2012) .
Studies also show that variability in HRM exists not only between organizations, but also
within organizations and it brings employees back into the equation between HRM and
performance, which is according to Paauwe, a ‘conditio sine qua non’ for advancing the
field as a respected discipline (Veld et al., 2010&Paauwe, 2009). In this connection, Boselie
et al 2005 identified (table 1) very important HRM activities and outcomes that show how
employee performance is connected to HR activities and outcomes which are expected to
positively (+ve) influence on organizational performance (Elise,Sophie&Luc, 2013 and
Hutchinson &Purcell, 2008). As can be seen from the table, the scholars shown how these
practices positively affect performance(e.g. productivity, service quality, customer
satisfaction) in the western countries.
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Buchan (2004) found that HR practices are important to the success or failure of health
system including hospitals, though such importance has, until recently been overlooked. With
regard to measures related to HR and performance in healthcare, Buchan further added that
getting HR policy, practices and management “right” has to be at the core of any sustainable
solution to health system performance. Many of the previous studies (e.g., Veld, 2012;
Buchan, 2004; Bloom et al., 2014; Voorde, 2012& Baluch et al., 2013) have shown
interesting linkage between HR practices (aspect of management practice) and employee
performance. Yet, others (e.g. Baluch et al., 2013&Rademakers et al., 2011) didn’t clearly
show which dimension of management practices are linked to employee performance and
patient outcomes (Koopmans, 2014&Aiken et al, 2012).
In the HRM field, different types of outcomes are identified by some scholars (e.g. Veld,
2012, Boselie et al. 2005) who made a distinction between three common typologies, i.e.
financial outcomes (e.g. profits, sales, return on invested capital), organizational outcomes
(e.g. product, service quality, innovation, effectiveness), and HRM outcomes (e.g.
attitudinal, cognitive and behavioral outcomes among employees). Some other literature
focused on healthcare field (e.g. Stepaniak,2010; Kunkel et al., 2007& Rademakers et al.,
2011) applied Donabedian's model to analyze healthcare outcomes from the three
perspectives of quality indicators. These indicators are structure (what do we need to have to
be able to achieve quality patient care), process (what do we need to do to achieve quality)
and outcome (what do we need to achieve) measures of quality of patient care (Stepaniak,
2010). Though such model offers concrete information, earlier studies often not well
established complete relationship between the stated three indicators (Kunkel et al., 2007).
This study attempted to diagnose what is going on in the hospitals using well established set
of OM and HR practices and their linkages with employee performance and patient
In addition, study on Goal setting theory and performance, researchers (e.g.Frank, et al.,2008
citing Locke & Latham,2002 and Scotti et al., 2007) shown that people with specific and
challenging goals perform better than those with vague goals at all. Thus, goal theory
assumes that there is a direct relation between the definition of measurable organizational
goals and employee performance: if employees know what their goals are, they are
motivated and committed to exert efforts, which increases their performance. This claim is
now supported by a large pile of empirical evidence from developed nations (Guest
2002;Boselie, 2010b; Osho, 2014; Peccei, 2004; Boxall et al.,2011& Hyde et al., 2009) but
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got scant attention in the developing nations.
In summary, HRM practices are among the most critical dimensions of management
practices to boost employee ability, skills, opportunities and competence for high
performance . From the above sub-section, we can conclude that effective and contextually
innovative implementation of bundles of HR policies enhances employee outcomes.
Consequently, this in turn has linkage with better performance of employees and ultimately
linked to improved patient outcomes including patient satisfaction. The next section will be
discussing on the link between Operations management and HRM practices and their
association with employee performance and patient outcomes.
3.4 OM-HRM linkage
Previous empirical research (e.g., Boudreau, Hopp, McClain&Thomas, 2002 and
Neumann&Jan,2010) on operations management (OM) and human resources management
(HRM) have
historically been very separate fields. In practice, OM and HR
interact primarily on administrative issues regarding payroll and other matters. Yet,
and HR are intimately related at a fundamental level (Boudreau et al., 2002).
T h e s a m e a u t h o r s c o n t e n d t h a t operations are the context
that often explains
or moderates the effects of human resource activities such as pay, training,
and staffing (Boselie et al., 2005). Human responses to operations management systems often
explain variations or anomalies that would otherwise be treated as randomness or error
variance in traditional operations research models.
At a fundamental level, the
OM and HRM
cannot exist without one another. OM
policies can only be carried out by people and HRM
policies are only effective if they
foster people doing organization-critical tasks (i.e., operations).
And the connection is not
just theoretical. As many of our industry stories suggest, considering
HRM in formulating
OM policy, and vice versa, can be good management practice. But observing philosophical
connections or implementation synergies is not the same as
providing an integrated
OM/HRM framework. Our review of the two fields indicates a great
many gaps in our
understanding of the links between them.
Boundreau et al.( 2002 ) who studied the OM/HRM interface argue that effective management
of the link between OM and HRM help us identify opportunities on this interface,
understand the link ( Figure 2) and they propose a framework of
factors required by people
to perform their jobs. The following framework is linked to the AMO model in HRM-
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performance research (discussed somewhere in this article).
Capability: The knowledge,skills and abilities necessary to execute an action
with the objectives of the organization.
Opportunity: When individuals are provided or encounter situations in which
actions can
be executed with the desired effect.
Motivation: The drive to execute those actions, created by a perception that
they are
linked to desired outcomes and rewards.
4. Employee performance and patient outcomes
4.1 The definition of employee performance
Different scholars conceptualized and measured employee performance differently. In this
regard, many researchers (e.g. Campbell et al., 2006; Janssen&Yperen, 2004& Koopmans et
al., 2014) conceptualized employee performance as behaviors and outcomes that employees
engage in or bring about that are linked with and contribute to organizational goals. They
classified performance into task performance ( job performance), innovative
performance (intentional generation and realization of new ideas and actions) and contextual
performance (i.e,OCB). Al-Hamayan,Shamrudin, Subramaniam &Islam (2013) on the other
hand defined the concept employee performance in hospital sector as effectiveness of
employees in accomplishing their tasks and responsibilities related to patient care . These
writers further underscored that patient and hospital outcomes are directly related to
employee outcomes.
It is well documented in the literature that employees (health professionals in this study) are
the most important asset of any organization (Broek, 2014; Jaspers et al., 2011 and Guest,
1997&2001). Janssen&Yperen (2004) and Leggat et al.(2010) shown that employees
perform well when they are committed to the organizational goal and satisfied with their
jobs. Earlier studies show that when employees have positive attitudes towards their work
and good behaviors as well as satisfied with their job, they show high work engagement,
their performance has direct effect on the quality of patient outcomes (Leggat et al.,
2010;Graban, 2009&2011; Zineldin,2006; Joosten et al., 2009;West et al, 2006 &Baluch et
al., 2013) . In conclusion, employee performance, especially in healthcare, is more than just
important; it can affect patient safety and quality of care.
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4.2 The link between employee performance and patient outcomes
According to Frank, 2008 (citing Locke &Latham,2002) in Goal Setting theory and
performance, if employees know what they are aiming for through operations management
support and HR practices, they are motivated to exert more effort. Motivation in turn
increases employees’ performance (West et al 2006 &Veld,2012).The other theory could be
that of Donabedian’s triad framework(2005) which asserts that employees when well
equipped with the required knowledge, ability and professional competence, their
performance can enhance the quality of patient care and hospital outcomes. For many
scholars (e.g. Mercer&Rynolds,2002;Aiken et al., 2012;Mainz, 2003;Koopmans et al.,
2014;&Alhamayan et al., 2013) employee performance in hospital may include the number of
patients treated, treating patients with smile, employee attitudes and interaction with patients,
diagnosis and prescribing behavior, empathic communication, caring and follow up,
accountability for treatment, responsiveness and efficient service delivery.
Many studies (e.g. Boselie, 2010b; Baluch et al., 2013; Frank, 2008; Boselie et al.,2002 &
Aiken et al.,2012) identified that employee performance often plays a mediating role in the
link between management practices and patient outcomes. The literatures added that
employee performance plays a crucial role to a hospital performance because employees are
strategic assets and hospitals with above average performance tend to have better quality
performance (Jaafreh& Al-abedallat, 2013; Glickman et al., 2007&Li, et al. 2002). These
studies suggest improved performance of employees lead to better quality healthcare services.
This result could happen if the employee performance is improved through better
management functions played through OM and HR practices with employee empowerment,
motivation and incentive systems (Boundreau et al., 2002; Gunnarsdottir, 2009&Flood,
Previous empirical studies (e.g. Boselie et al,2002;West,2001;West et al,2002&2006)
shown that health professionals’ performance could be determined by various factors such
as those related to employees themselves(e.g. knowledge, attitude towards the work and
management practices, motivation, skills and job satisfaction), patient characteristics(e.g.
disease conditions, socio-demographics and life styles). It can also be related to managerial
and organizational factors(e.g. policy, management practices, characteristics of hospitals,
complexity of the work, resource availability, etc).
Recently, the role of patients has been recast as the “customer” (West et al , 2002;
Veld,2012& Van de Klundert, 2009), resulting in different expectations from health care
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professionals. Given the fact in the developed world that patients nowadays are highly
valued , better informed and expect more services, health professionals are expected to act as
service providers. This implies that they should look from a different angle to their
relationship with the patients, and that they need to rethink their long established positions.
Some scholars (e.g. Veld, 2012) contend that the restructuring of healthcare (reform) not
only has implications for the positions of health professionals, it also does have an
impact on the design of work processes and operations. Moreover, the introduction of
(integrated) care pathways does imply that professionals more often need to cooperate and
collaborate with other disciplines, resulting in more multidisciplinary team work.
Studies also s h o wn that health professionals are expected to be able and motivated to
work together across organizational boundaries to improve performances and quality of
outcomes in hospitals (Lusk&Fater, 2013& Mesadeghard, 2013). Furthermore,
professionals working in health care setting highly value ‘to help others’ and ‘to do some
rewarding work’. These values should fit with a positive climate for quality of patient care.
Employee attitude, knowledge, skills, norms and values associated with delivering high-
quality patient centered care towards patients often results in enhanced employee outcomes
(Jaspers et al., 2011&West, 2001). The major employee outcomes for some scholars like
Veld (2012) include organizational and work unit commitment of professionals, job
satisfaction, OCB, lower intention to leave and ability to make decisions. Hence, improved
employee performances, resulting from better management practices are associated to
improved patient outcomes and quality of healthcare.
Past studies identified employee performance as a multi-dimensional construct, consisting of
distinct sets of behaviors, vary with sector and occupations (Rich,
Zepine&Crowford,2010;Van Greunage,2012&Starfield,2011). In the healthcare industry, it is
more than just important , it can affect patient outcomes and measured in terms of quality
healthcare delivered by employees (McConnell et al., 2014;
Buchan,2004&Donabedian,2005). These measures of performance are identified from
relevant literature from the developed world (e.g. Koopmans et al., 2014;Hyde et al., 2009;
Stepaniak, 2010; Kunkel et al., 2007; Veld, 2012; Salanova, Agut, & Peiro,2005;
Mercer&Rynolds,2002; Fauth,Bevan&Mills,2009 & Van de Klundert, 2009 citing Bowers et
al., 1994; Parasuraman et al., 1985 & Swer, 2008). They were curiously selected in this study
with contextual and practical relevance to the present study because they were in the higher
priority areas of health policies and performance measurement indicators of developing
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nations but not well researched so far. Brief explanation of these performance indicators are
depicted as follows:
Empathy, often considered as HR outcome, is the employee’s attitude and behavior of
caring with courtesy to patients with professional interaction and commitment of willing
“to go the extra mile” to achieve excellent performance (Mercer&Rynolds,2002& Van de
Klundert,2009). It has moral, emotive, moral, cognitive and behavioral components.
Clinical empathy, for example, involves an ability of employees to understand the
patient’s situation and feelings (and their attached meanings); to communicate accurately;
to act or behave on that understanding with the in a helpful(therapeutic way) . Empathy as
a key measure of employee performance can be improved through effective interventions
including effective implementation of OM and HR practices (Mercer&Rynolds, 2002)
and it can positively influence patient outcomes.
Reliability is the ability of health professionals in providing quality health services
accurately measured as per KPI or planed targets(services) of the hospitals , in the right
number, at the time scheduled (right waiting time),make accurate diagnosis, care and
treatment or meet patient needs, and behavior of maintaining error-free records of the
Effectiveness is providing quality healthcare based on scientific knowledge and
professional manner to all patients who could benefit and refraining from underuse or
overuse the service. It also deals with performing as per the set goals of meeting patient
The reason behind focusing on the above elements of employee performance is that many of
the previous studies (e.g.Veld, 2012; Koopmans et al., 2014; Hyde et al., 2009; Stepaniak,
2010&Kunkel et al., 2007) didn’t show how these outcomes result from and linked with the
management practice and influence patient outcomes. In addition, documentation on these
constructs is scant in the health care and developing nations.
Some of the earlier studies, added that employee performance is mainly concerned with
professionals’ civility virtue towards patients , treatment of patients with courtesy, empathy,
delivery of quality healthcare as per the set standards, waiting time and number of patients
treated ( Fauth et al., 2009&West et al., 2002). While Salanova et al.(2005) who gave high
emphasis on empathy and excellent performance, further identified the following outcomes as
measures of employee performance reported by customers:
Employees understanding of customers’ specific needs (empathy).
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Employees’ ability to “put themselves in the customers” place (empathy).
Employees are able to “tune in” to each specific customer (empathy).
Employees “surprise” customers with their excellent service (excellent performance).
Employees diagnose more than usual for customers (excellent performance).
Employees deliver an excellent service quality that is difficult to find in other
organizations (excellent performance).
There is scant evidence on quality dimensions of healthcare outcomes, as an aspect of
organizational outcome, which was a call for further research (Van de
Klundert,2009&Bunchan,2004), the link between health professionals’ performance and
patient outcomes in hospitals(Kunkel et al., 2007;West 2001 &West et al., 2002).
Bloom et al. (2014) and McConnel et al.(2014) identified that effective management
practices, through people management and operational practices, can positively influence job
performances which in turn affect patient outcomes. Hence improved performances are key
to enhance customer outcomes including reducing length of stay and mortality rates,
improving job satisfaction and patient satisfaction towards patient outcomes (Rich,
Zepine&Crawford, 2010).
In conclusion, there is lack of consensus on the concept, measures and indicators of employee
performance, the major reason could be performances of employees vary according to the
specific occupation, nature of job sector, industry, and essentially due to variations of
contexts of the country and companies in which individuals are working. Despite these
variations, there is common understanding that health professional’ or employee performance
is individual’s efforts, behaviors and commitments of executing the designated roles, tasks
and activities so as to contribute to the goals of organizations with customer values.
Healthprofessionals’ performance is influenced by management practices and it also directly
affects or contributes to the improvement of patient outcomes in hospitals.
The next section will be presenting the review of theoretical and empirical evidences on
patient outcomes.
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5. Healthcare outcomes
5.1 An overview of quality of healthcare delivery system
Health service research literature (e.g.Jaspers et al., 2011; Stepaniak,2010& Kunkel et
al.,2007) shown that, the goal of health service is to protect and improve the health of
individuals and population. These studies in citing the Institute of Medicine (IoM) report
“Crossing the Quality Chasm: A New Health System for the 21st Century” described many
problems in the quality of United States health care delivery system. The report suggests that:
“Health care services should be:
1. Safe: Avoiding injuries to patients from the care that is intended to help them.
2.Effective: providing services based on scientific knowledge to all who could benefit, and
refraining from providing services to those not likely to benefit (avoiding underuse and
overuse, respectively)
3. Patient-centered: providing care that is respectful of and responsive to individual customer
or patient preferences, needs, and values, and ensuring that patient values guide all clinical
4. Timely: reducing waits and sometimes harmful delays for both those who receive and
those who give care.
5. Efficient: avoiding wastes, including waste of equipment, supplies, ideas, and energy
6. Equitable: providing care that does not vary in quality because of personal characteristics
such as gender, ethnicity, geographic location, and socioeconomic status” of patients or
According to Mitchell et al.(1998), Jaspers eta al.(2011) and Aiken et al.(2012) whatever the
outcome of interest, be it clinical, technical, service or functional outcome of patient care, the
goals of healthcare are the maximization of good outcomes(high quality healthcare) and the
minimization of poor outcomes. This can be best accomplished within the framework that
facilitates the assessment of the quality of healthcare (Luxford, 2011&Donabedian, 2005).
Our focus on the most important dimensions of patient outcomes depicted in the conceptual
model(vide figure 2.1) is due to the fact that many of the previous studies extensively
assessed financial outcomes and organizational productivity(e.g.Boselie,2010b; Veld, 2012;
Bloom et al., 2014) separately than combining clinical and functional outcomes . In addition,
some studies separately focused only on clinical dimension of outcomes (e.g. West et al.,
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2002 &2006) rather than considering service quality outcomes. As healthcare is a broad
concept (Van den Broek,2014; Petros, 2014 & Veld,2012) that involves not only clinical
outcomes(e.g., mortality, in-hospital complications, readmission ) but also promoting
functional status, patient wellbeing, service quality, quality of life and patient satisfaction,
which are very important in measuring patient and hospital outcomes. In reality and as per the
IoM’s “Crossing the Quality Chasm” report(Stepaniak,2010& Kunkel et al.,2007), healthcare
outcomes are inseparable our focus of combining clinical, functional and service quality
outcomes in this study is an innovative approach and very important from practical contexts
and concerns
Furthermore, some researchers in the developed countries (e.g. Donabedian,2005;
Stepaniak,2010; West,2001 & Mitchell et al., 1998) have outlined three constructs from
which inferences can be made regarding quality: structure(e.g. HRM practices, policy,
resource allocation), operations management process of activities and outcomes. The
researchers further suggest that information from these constructs can be used to assess
quality if they are causally related: “structure leads to process and process leads to outcomes”
However, emphasis on the management of healthcare quality has shifted over time from
structure to process to outcomes. Hence outcomes are the results of structures and processes.
For instance, for Mitchell et al. (1998) outcomes have been limited to what is termed as
5Ds: death, disease, discomfort and dissatisfaction. Only recently has there been an
impetus to include more positive patient outcomes such as improved health status, functional
ability, and perceived health related quality of life.
The quality of health service is usually judged by outcomes and perceived by patients through
patient satisfaction survey, specifically, the immediate and long - term effects on the health of
the individual and communities they serve (Petros, 2014; Zineldin, 2006& Stepaniak,2010).
The quality of health care services offered to patients often fails to meet or exceed
expectations of customers and standard performance indicators in many countries (Frolich,
2012; Lusk&Fater, 2013). Although many causative factors can be mentioned, management
practices, poor ability and motivation of employee could be among the major determinants of
such a failure of meeting customer expectations.
A study conducted in three Greek hospitals (Karassavidou et al, 2011) identified the link
between healthcare quality improvement and health professional performance, resource
allocation and customer satisfaction towards quality of patient care. While accountability
(responsibility for the delivery effective patient care); assurance of the quality of clinical
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services (Stepaniak,2010&West et al, 2002) and innovation(Broek , 2014) are identified as
core dimensions of the clinical governance cycle in health care
5.2 Dimensions of patient outcomes from hospitals context
Any hospital, by principle, strives to improve quality of healthcare system and patient
outcomes including clinical-, functional- and service outcomes (Mainz, 2003& Baluch et al.,
Clinical outcomes are highly linked with HR practices and efforts of health professionals
(Baluch et al., 2013&West 2002&2006). These outcomes may include mortality, hospital
length of stay, waiting time, quality of life, overall survival, patient satisfaction which are
measurable changes in the quality of care that result from managing healthcare in hospital
(West et al., 2006). Though variations in clinical outcomes may be observed, constant review
of these outcomes establishes standards against which to continuously improve all aspects of
management practices and quality of clinical care (Otte-Trojel,Bont et al, 2013& Van de
Klundert,2009). Clinical outcomes can be measured by activity data on healthcare service
such as hospital re-admission rates, or other forms of measurement. They can be recorded and
reported by health professionals or administrators can also be reported by patients or their
families (Baluch et al., 2013).
According to Salge &Vera(2009), patient’s functional outcomes, which are also connected to
the management techniques and employee performances, may vary by individual, depending
on characteristics of the patient, illness and associated medical complications, quality of care
and the patient's characteristics (age, life style, family and financial resources). These
researchers identified the major functional outcomes, which are measured at both admission
and discharge, include mental and physical functional state of a patient (e.g. talking, hearing,
moving from bed to chair, walking, and bathing, sleeping, eating and smiling).
Service quality outcomes, which could result from (operational and HR) managerial practices
and employee performance, include health care delivery related ones including quality
diagnosis, treatment, patient-centered care by service providers (Zineldin, 2006 and Headley
& Miller,1993) . The service providers are health professionals (e.g. physicians, nurses,
midwives, etc) and healthcare organizations. Healthcare service quality has multidimensional
properties. Thus such a service quality outcomes can be the results of individual employee
and hospital performance (Stepaniak, 2010; Van Greunage et al, 2012&Zafirpoulos, 2010).
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Service quality outcomes are commonly measured by feedbacks from customers, i.e., patient
satisfaction survey using tools such as SERVQUAL scales which will be explained more in
the subsequent chapters. SERVQUAL is a reliable and extensively tested method for
measuring perceived quality of service offerings (Headley & Miller, 1993& Zineldin, 2006).
The authors added that performance-based measures of service quality significantly affect
patient satisfaction, which affects employee performance as well.
6. Discussion
With regard to the link between management practices, employee performance and patient
outcomes, this section is the core of the paper which intends to discuss and analyze the whole
conceptual model developed to guide this study. The study on the link between OM, HR
practices and employee performance and organizational performance such as quality of
health care outcomes is an important topic in the organizational sciences (Veld,2012,
Spear,2005 &West et al., 2006). Yet, little research has been conducted examining this
relationship in hospital settings.
The findings of a study conducted in Europe, i.e. UK hospitals (West et al., 2002), for
instance, revealed strong associations between HR practices and individual performance as
well as organizational outcomes including patient mortality generally. It has identified key
measures of health outcomes. These were deaths following emergency surgery, deaths
following non-emergency surgery, deaths following admissions for illness, re-admission rates
and a mortality index.
Some research findings show that working in teams in health services is associated with
lower levels of stress. It has also identified that the quality of team working processes is
linked to ratings of effectiveness and innovation in quality of patient care , healthcare teams;
and that of multidisciplinarity in teams is strongly associated with innovation in patient
care(Van Greunage et al, 2012;West 2002&2006) .
Previous empirical research in the field suggest the need to continuously improve and
innovate management practices(OM and HRM) so as to improve individual and
organizational outcomes including quality of healthcare as well as patient satisfaction in
hospitals. Moreover, some studies indicate that improving quality of health services leads to
improve functional outcomes of patients (Van Greunage et al, 2012; Lusk&Fater,2013).
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Though some scholars found that outcomes may not predict health service quality ( Otte-
Trojel et al, 2013; Van de Klundert , 2009;Starfield,2011&Van Greunage,2012) , patient
outcomes are related within and between themselves while effective management practices
and improved performance of health service providers determine patient outcomes (Kunkel et
al.,2007) .
7. Conclusions
This is the first review of Western literature conducted between June 2014 and July 2015 to
show the link between management practices, employee performance and patient outcomes in
hospitals and to inform decision makers committed to improve health professionals’
performance and patient outcomes.
From the findings of the present study, we have learnt that hospitals are complex and human
capital intensive service organizations. Operations management and HR management
practices should be designed and executed from the context of the competitive environment,
complex expectations (e.g. opportunities of training, conducive work conditions, motivation,
recognition, performance monitoring, promotion, incentives, and satisfaction) of health
professionals and dynamic needs of patients or customer values.
The contribution of health professionals or employees is instrumental for improved
performance of hospitals in achieving the goals of standardized quality health services as per
the KPI and patient satisfaction. Without effective health operations management and
execution of bundles of HR practices in hospitals, it would be hardly possible to achieve
better performance of health professionals, high quality in healthcare and improved patient
Modern management practices are crucial for maintaining and sustaining health
professionals' performance, improving efficiency and effectiveness in delivery of quality
health services and patient outcomes.
Finally, hospital managers and administrators should design evidence-based interventions for
implementing integrated operations and HR management practices for better performance of
health professionals, resulting in improved quality of health services and patient outcomes in
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Competing interest
The authors declare that they have no competing interests.
Authors’ contributions
All authors contributed to the study design. PPG conducted the review, analysis and prepared
the first draft. JVB read, commented and approved the final manuscript. JVK guided the
overall study , commented and approved the manuscript.
The authors are grateful to those who supported in providing information and materials for
the review.
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Figure 1: Conceptual model of the research (Adapted from different literature, March 2013)
Figure 2. The OM/HR Interface adapted from Boundreau et al.( 2002 ) .
  +ve  +ve
Table1.HRM activities in relation to HRM outcomes and performance (Boselie et al. 2005)
HRM activities
HRM outcomes
Employee satisfaction
Employee Motivation
Employee Retention
Employee Involvement
ee Commitment
Service quality
Customer satisfaction
HR practices
Clinical and
functional patient
Service quality
perceived by patients
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Full-text available
Job performance refers to how effective employees are in accomplishing their tasks and responsibilities related to direct patient care. Improving the performance of employees has been a topic of great interest to practitioners as well as researchers. The aim of the study is to analysis the impacts of job performance level on nurses' performance working in public hospitals. In order to achieve the study objective, a survey conducted. Questionnaires distributed to the public sector hospital's manager in Saudi Arabia. The findings of the study turn out to be true; the study will contribute to both theory and practice. Through the present study, the researcher expects the findings to shed light on the research conducted regression to analysis the impacts of job performance level on nurses' in public sector hospitals in Saudi Arabia.
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We theorize that engagement, conceptualized as the investment of an individual's complete self into a role, provides a more comprehensive explanation of relationships with performance than do well-known concepts that reflect narrower aspects of the individual's self. Results of a study of 245 firefighters and their supervisors supported our hypotheses that engagement mediates relationships between value congruence, perceived organizational support, and core self-evaluations, and two job performance dimensions: task performance and organizational citizenship behavior. Job involvement, job satisfaction, and intrinsic motivation were included as mediators but did not exceed engagement in explaining relationships among the antecedents and performance outcomes.