Achieving high performance in healthcare institutions: a longitudinal perspective

doi:10.21203/rs.3.rs-3624654/v1

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Achieving high performance in healthcare institutions: a longitudinal perspective

https://doi.org/10.21203/rs.3.rs-3624654/v1

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Quality improvement of healthcare institutions has become increasingly important these past decades, mainly due to demographic developments. At the same time the sector is suffering from political and budgetary pressures which makes quality improvement a tall order. As a result, healthcare institutions have been searching for frameworks which can help them in difficult circumstance to improve their quality by increasing their dynamic capabilities and organisational competencies. This research set out to identify such a framework. On the basis of a review of the extant literature the HPO Framework was chosen and subsequently applied at three Dutch nursing home care institutions. In a period of three years the HPO Diagnosis was performed at the three institutions. This yielded information on their status on the way to high performance and attention points which they needed to address to help them further along their journey. Based on an analysis of the transformation process, the experiences and lessons learned from each institution were identified and summarised. All institutions had made progress and achieved better organisational results because of the application of the HPO Framework.

healthcare sector

nursing home care institutes

high performance organisations

longitudinal research

HPO

organisational improvement

Healthcare quality has been the topic of much research interest, both academically as professionally, as quality improvement of healthcare institutions has become increasingly important. There is a lot of pressure on these institutions to improve their efficiency and competitiveness in relation to cost-effectiveness, quality of care delivered, clinical outcomes, and patient satisfaction [1, 2]. After all, quality improvement in this sector leads to improvement of quality of life [2]. Unfortunately, healthcare institutions have been struggling with their sustainability - defined by [3] as maintaining quality and service coverage at an affordable cost – because of several megatrends in their environment [4, 5]. Specifically, healthcare costs continue to rise because of ageing populations which require more healthcare services, availability of advanced technologies that are more costly, increased citizen expectations of service quality delivery, populations getting unhealthier requiring more treatment, inflation increasing cost prices, and accreditation pressures requiring higher institutional quality [1, 3, 6, 7]. As a result, healthcare institutions have been prompted to improve their quality by increasing their dynamic capabilities and competencies [8, 9, 10].

For a long time, both in the literature and in practice the attention for quality improvement of healthcare institutions more or less equalled a focus on achieving higher patient care [11], meaning creating high performance healthcare such as comprehensive care delivery [12], high patient and family engagement [13, 14], a well-designed environment of care [13], and the importance of expertise-driven practice [15]. The topic of increasing the quality of the high performance healthcare institution received much less attention [11]. This is strange, as studies of low-performing and failing healthcare institutions revealed that the main causes for the problems are often organisational of nature: low leadership capability, leadership focused too much on avoiding penalties and achieving financial targets, a poor and closed or even hierarchical organisational culture, lack of a cohesive mission, and dysfunctional external relationships [5, 16]. Fortunately, a growing body of empirical research indicates that the performance of healthcare institutions can be related to the quality of the management practices they apply [11, 17]. Recent literature indicates that effective management and organisation of resources drive higher-quality patient outcomes, and that management practices have a higher impact on performance when they are implemented in a holistic approach using specific configurations [17, 18]. The objectives of the research described in this article is to, based on a review of the extant literature, identify a holistic and validated framework that can be used by healthcare institutions to identify, develop, and strengthen the management practices and related capabilities to achieve the desired quality improvement. Holistic, as the framework should take into account all management practices that can be of influence on institutional quality; and validated in longitudinal research so that healthcare institutions can be sure that the framework in question actually works in practice. If this study can discover and validate such a framework, its potential contribution will be twofold. Theoretically it will expand the literature on quality achievement in the healthcare sector; and practically healthcare institutions can use the identified framework in their own quest to quality improvement and high performance.

The remainder of this article is structured as follows. The next section discusses the results of the literature review, which is followed by a description of the high performance organisation (HPO) framework [19–21] with which an organisation can evaluate the capabilities it needs to achieve higher quality and a high performance culture. Then, the research approach – in which the HPO framework is tested at multiple healthcare institutions in order to evaluate its practical applicability and usefulness to generate improvements – is described. Subsequently, the research results are given and analysed. The article ends with a conclusion, research limitations and opportunities for future research.

The goal of the literature review was to find a framework with which healthcare institutions can evaluate their current capabilities and performance and that generates improvements so these institutions can increase their organisational quality and transform into a high performance organisation (HPO). An HPO is defined as an organization that achieves financial and non-financial results that are exceedingly better than those of its peer group over a period of 5 years or more by focusing in a disciplined way on that what really matters to the organization [22]. With the search terms ‘healthcare institution’ and ‘healthcare sector’ in combination with ‘high performance organisations’, ‘high performance’, ‘quality’, ‘quality improvement’ and ‘performance improvement’ the databases EBSCO, Science Direct and Emerald were searched. Only literature not older than fifteen years was included, to make sure that the reported findings were up-to-date and still valid in the rapid changing healthcare sector. This yielded 72 potentially relevant sources. These were studies to evaluate whether the research described was aimed at improving (management practices of) a healthcare institution. Studies that focused on the improvement of healthcare delivered to patients or on the improvement of a country’s healthcare systems were not included. This resulted in 47 relevant sources, described in Appendix 1. A summary of the literature review results is given in Table 1.

Table 1

Information on the types of literature sources
Source type	No. of sources	Themes discussed	No. of sources
Holistic	10	Improvement systems (TQM, Baldridge, lean)	13
Specific	37	Management/leadership capabilities	8
Framework included	4	High performance work system/practices	6
No framework	43	Organisational climate/culture	5
Longitudinal	11	Performance management system/BSC	3
Not longitudinal	36	Various (1 per source)	12

‘Holistic/specific’ denotes whether the research looked into the overall performance improvement of the healthcare institution and the capabilities needed for that (‘holistic’) or just into one aspect (‘specific’). ‘Framework’ indicates whether the literature source provides a framework that healthcare institutions can use when improving the quality of their institution. ‘Longitudinal’ points out whether the research described in the literature source was longitudinal of nature, i.e. whether one or more healthcare institutions were followed through time in their application of the research findings described in the source.

There was only one literature source, [23], that was holistic and longitudinal of nature, and contained a framework which healthcare institutions can use in their transformation to a higher quality level. Regarding this framework [24] state, based on an extensive literature review, that “across the HPO literature, we found only the HPO framework developed by de Waal as an example of scientifically validated conceptualization of HPO.” In addition, this framework has been extensively tested [25] and applied in the healthcare [23]. We therefore decided to use the HPO framework in our study. In the next section, this framework is described.

The HPO Framework [19–21] is a conceptual, scientifically validated structure which organisations can use for analysing how high performing they are and to decide which capabilities need to be strengthened in order to improve organizational performance and make it sustainable [26]. The framework was developed after an extensive review of 290 academic and practitioner publications on high performance. For each of the 290 studies elements that the authors indicated as being important for becoming a HPO were identified and categorized. Because different authors used different terminologies, similar elements were put in the same category. The resulting 189 categories were labelled ‘potential HPO characteristic’. For each of the potential HPO characteristics the ‘weighted importance’ was calculated, i.e. the number of times that it occurred in the examined studies. Finally, the characteristics with the highest weighted importance were considered the HPO characteristics. These 89 characteristics were subsequently included in an HPO survey which was administered worldwide and encompassed over 3,200 respondents. In this survey, the respondents were asked to indicate how well they thought their organizations were performing as to the HPO characteristics (on a scale of 1 to 10) and also how the results of the organization they worked at compared to those of peer groups. The data of the respondents was statistically analysed, yielding five factors all correlated with competitive performance [20–21]. Table 2 lists the HPO factors, Appendix 2 details the factors into characteristics.

Table 2

Overview of the HPO factors (description taken from [20])
HPO factor	Description
Continuous Improvement and Renewal	An HPO compensates for dying strategies by renewing them and making them unique. The organization continuously improves, simplifies, and aligns its processes and innovates its products and services, creating new sources of competitive advantage to respond to market developments. Furthermore, the HPO manages its core competences efficiently, and sources out non-core competences.
Openness and Action-Orientation.	An HPO has an open culture, which means that management values the opinions of employees and involves them in important organizational processes. Making mistakes is allowed and regarded as an opportunity to learn. Employees spend a lot of time on dialogue, knowledge exchange, and learning, to develop new ideas aimed at increasing their performance and make the organization performance driven. Managers are personally involved in experimenting thereby fostering an environment of change in the organization.
Management Quality	Belief and trust in others and fair treatment are encouraged in an HPO. Managers are trustworthy, live with integrity, show commitment, enthusiasm, and respect, and have a decisive, action-focused decision-making style. Management holds people accountable for their results by maintaining clear accountability for performance. Values and strategy are communicated throughout the organization, so everyone knows and embraces these.
Employee Quality	An HPO assembles and recruits a diverse and complementary management team and workforce with maximum resilience and flexibility. Employees are encouraged to develop their skills to accomplish extraordinary results and are held responsible for their performance, as a result of which creativity is increased, leading to better results.
Long-term Orientation	An HPO grows through partnerships with suppliers and customers, so long-term commitment is extended to all stakeholders. Vacancies are filled by high-potential internal candidates first, and people are encouraged to become leaders. An HPO creates a safe and secure workplace (both physical and mental), and dismisses employees only as a last resort.

The HPO research shows that there is a direct and positive relationship between the five HPO factors and competitive performance: the higher the scores on the HPO factors (HPO scores), the better the results of the organization, and the lower the HPO scores the lower the competitive performance. An organization can evaluate its HPO status by performing an HPO Diagnosis. This diagnosis consists of having management and employees fill in an HPO questionnaire, containing questions on the 35 HPO characteristics with possible answers on an absolute scale of 1 (very poor) to 10 (excellent), and then calculating the average scores on the HPO factors. The scores then provide the attention points where the organization has to take action to improve in order to become an HPO [20–21].

For this study a mixed method approach was used [27], in the form of several longitudinal descriptive case studies. Our research is looking into the effectiveness of an organizational improvement technique, the HPO Framework, and therefore utilises the improvement type of longitudinal research [28]. In addition, a longitudinal study is used in which repeated data collection from the same subject over a period of time take place [29], and it has a pre-planned research design in which the data collected during the study was planned beforehand [30]. The longitudinal nature consisted of conducting the HPO diagnosis twice at three nursing home care institutions. A descriptive case study describes the situation of an organisation, based on observing, collecting data and reporting on phenomena in that organisation. This format makes it possible for researchers to directly interact with people in their organisational context which leads to greater understanding of that context [31]. In the quantitative part data was collected using the HPO Questionnaire, while in the qualitative part semi-structured interviews were used [32] in order to gain an in-depth understanding of the use of the HPO framework at healthcare institutions [33].

4.1 The Nursing Home Care Quality Framework

This HPO research was part of a larger study into the implementation of the Nursing Home Care Quality Framework. The quality framework describes what good and effective nursing home care entails and how the provided care can be improved [34]. In the Arnhem region of the Netherlands, healthcare institutions providing nursing home care joined forces at the end of 2018 to tackle the implementation of the quality framework. The resources provided by health insurer Menzis were used to set-up various quality improvement programs. One of these programs was promoting vitality and job satisfaction of employees with the goal to improve the sustainable employability of healthcare employees, the idea being that healthy and happy employees enjoy their work more which has a positive attraction effect on the labour market. The carrier of this program became the HPO framework. Menzis chose the HPO framework because that provided a vision of how integrated business operations can be permanently raised to a higher quality level. Three Dutch healthcare institutions from the region, Jah-Jireh Woonzorg, RijnWaal Zorggroep and RST Zorgverleners, volunteered to participate in the program.

4.2 Jah-Jireh Woonzorg

Stichting Jah-Jireh Woonzorg is a foundation for elderly and needy Witnesses of Jehovah who are cared for by expert and like-minded employees in a loving and spiritual environment. The organization originated from a volunteer initiative whose main goal was to bring spiritual attention and religious experience into regular care. Jah-Jireh considers it important that Jehovah's Witnesses, who are in need of help due to old age or permanent disabilities, are cared for and supported with love and personal attention in a safe and familiar environment in which they feel valued and understood. Because their well-being is closely related to religious beliefs and social contact with like-minded people, ample attention is paid to these aspects. In the early years, the organization consisted of a number of enthusiastic volunteers in collaboration with a care provider who had an eye for this target group. Because the organization continued to think in terms of the volunteer model for too long, it turned out to be difficult to professionalize causing the organization to be working too much ad hoc. When HPO became possible from the Menzis transition resources, Jah-Jireh saw this as an opportunity to further develop and professionalize the organization.

4.3 RijnWaal Zorggroep

RijnWaal Zorggroep, with 700 employees in five locations, is active in the disciplines of nursing home care, neighbourhood nursing, and day care (individual guidance). In addition, the organization plays a major role in dementia case management in the region. In 2018, RijnWaal started the program ‘RijnWaal Vital and craftsmanship central’. In this project, all employees were asked which tasks they do and do not consider to be part of their profession, and which tasks outside their professional field do not energize them. With the results, a new organisational structure was built. The supporting disciplines were expanded so that the professionals can focus on what they are good at. Collaboration between all disciplines turned out to be the keyword here. HPO fits in very well with this new structure and way of working: getting the best out of the employees, and giving them opportunities, space and possibilities to do their work in the way they consider right and appropriate from the point of view if their professional standards, resulting in a pleasant and professional organization where employees enjoy working.

4.4 RST Zorgverleners

RST Zorgverleners is a reformed care organization where clients can go with care questions in the fields of maternity care, care and nursing, and domestic help. For the organization, the Bible forms the foundation on which norms and values and the way of working are based. This is expressed in the core values love & attention, reverence & respect and professional & service minded. RST stands for client-oriented, safe and affordable care, in an organisation where the employees are number 1, which means that they are vital and enjoy their work. The organization provides appropriate care by supplementing from its professional services what clients can do themselves within their own network. RST participates in HPO to gain inspiration and learn from experts and other organizations. The principles and characteristics of HPO provide content and structure to help an organization like RST - which wants to be a learning organization - a step further and to focus on matters that are important for this.

5.1 The first HPO Diagnosis (2019)

Figure 1 depicts the results of the first HPO Diagnosis at the three nursing home care institutions. These results are compared to the average HPO score for all respondents in the HPO database (in which all HPO data is collected) who work for nursing home care institutions, and to the threshold value for an HPO organisation (this value is 8.5, see [20]).

Figure 1 shows that the three participating institutions are quite close in their development toward HPO: between 64 and 70% on the way, which compares with the progress of the average Dutch nursing home care institutions (66%). At the same time, these institutions needed focused attention on the HPO factors in order to strengthen them to the HPO level (85% and higher). Based on the scores, semi-structured interviews were conducted with managers and employees at the three institutions, in order to identify the main areas of attention where they should focus their improvement efforts in order to make progress toward the HPO level. In summary, these attention areas were:

Jah-Jireh Woonzorg

Grow as leaders and managers. The differences between the perceptions of managers and employees, especially of the quality of management, are too large. Growing to HPO requires a different mindset and management style from the managers anyway, as style which needs to focus not taking over the work but coaching people to do it themselves and allowing them their mistakes.

Going from an attitude of ‘it's just work’ to working together for the Jah-Jireh organisation. Too many employees do their job but are not proactive and eager to learn. Management needs to ask the question what employees need to make the organisation better together, let them describe what will happen if things get better and what the clients will notice this and what it will do for the cooperation between the locations.

Align mutual expectations better. There are a lot of different expectations of and visions on the organisation and where it needs to go, creating uncertainty and much hoc or unfinished business. People need to engage in dialogue more (which means especially listening better to each other), share more financial and non-financial information, can actively contribute ideas, and be more often involved as group instead of relying on 1-on-1 conversations (which often creates gossip and ambiguity).

RijnWaal Zorggroep

Fulfil as management team the connecting role in the organisation. Employees see a management that is not (yet) a team and sends out various signals and messages. As management, invest in getting to know each other better and using each other’s strengths. Have robust discussions indoors, but speak with one voice to employees. Also develop ‘the big story of RijnWaal’ in which employees can believe.

Connect the organization. Locations operate like islands, and there is little mutual contact with the aim of learning from each other and exchanging ideas. To improve this, ensure that there are more joint consultations, let employees rotate across locations, and standardise processes throughout the organization as much as possible.

Help managers become HPO managers. Employees perceive varying levels of quality in managers, noting that non-achievers too often ‘get away with it.’ As managers, develop better coaching skills and then apply these extensively with the aim of empowering employees and cultivating a strong bond with them. Improve management reporting so managers can see how their locations/departments are doing.

Help employees to help the organisation. Employees mainly feel connected to their client, team, and location, but little or no connection with the RijnWaal organisation. In addition, their attitude of “just act normal, then you are already acting crazy enough” gets in the way of “going the extra mile.” Therefore as management discuss elementary matters with them, such as: RijnWaal’s vision, why insight into finances is important, why you have to work together in an organisation, and why you need to learn from other locations. Then ask what employees need to make RijnWaal better together.

RST Zorgverleners

Increase organizational commitment. Employees mainly feel connected to their client, team and location, but little or no connection with the RST organisation. In addition, their attitude of “just act normal, then you are already acting crazy enough” gets in the way of “going the extra mile.” Ask as management what employees need to work together to make RST a better organisation. Have them describe what happens: for the clients, for them, at the locations, across the locations?

Promote internal collaboration. There is little team consultation, there is too little time for meetings, learning sessions and training, and innovation and improvement have only just begun (and it appears to be difficult to involve employees in this).

Strengthen the learning process. Teach people that organising their own time well, sharing knowledge, being more consistent with clients, and giving feedback to each other is good for their clients, their own job satisfaction and for the organization. Learn from teams, whose planning process goes well, how it can be done well. Make (paid) time available for participation of employees in improvements.

After the attention points were communicated to the three institutions, they started working on these. All institutions installed so-called HPO Coaches [21], who are people from within the organization that take the lead in the HPO transformation so that the HPO knowledge and experience builds up inside the organization. Having HPO Coaches increases the motivation for HPO with the organisation as for its employees it thus becomes their transformation. The HPO Coaches spread HPO knowledge throughout the organization, igniting the HPO fire among managers and employees, are the pioneers in HPO transition activities, promote cooperation between locations and between managers, and take the lead in drafting the HPO Action Plan (which contains the priorities and interventions related to the HPO attention points).

5.2 The second HPO Diagnosis (2022)

In principle, it is advisable to perform an HPO Diagnosis every two years [21]. However, in the case of the three nursing home care institutions COVID-19 intervened forcing them to postpone the second diagnosis for one year. Figure 2 depicts the results of this second diagnosis. As RST Zorgverleners opted for only having managers participate in the diagnosis – reason being that while employees had just completed the employee satisfaction survey so were not that willing to fill-in another questionnaire and had struggled quite a bit with the HPO Questionnaire first time around resulting in a rather low response, management still wanted to get at least an inclination how RST stood with regard to HPO – for comparison purposes the scores of managers are shown and employees’ data are left out of this Figure.

Figure 3 shows the increase in average HPO scores and percentages improvement between the first and second HPO diagnosis for the three nursing home care institutions. This figure shows that – despite a challenging few years caused by rising healthcare costs because of the aging of the Dutch population, continuing cost reduction pressure, technological developments demanding investments, increasing legislation, COVID-19, and increased turnover of healthcare professionals [35, 36, 37] – all three institutions increased their HPO scores, albeit modest for a three year period. Pre-COVID an average increase of between 0.3 and 0.5 points per year could be expected [20, 21]. During the COVID pandemic this expected increase decreased to approximately 0.4 points per two years.

Figure 4 gives the percentages improvement for each of the HPO factors, for the three institutions. This data has been detailed in Appendix 2 for the HPO characteristics, where per institution the characteristics with the most improvement (i.e. more than 0.5 points) between the first and second HPO diagnosis are indicated. It is clear from Fig. 4 and Appendix 2 that at every institution all HPO factors have improved, but that the institutions seemed to have paid most attention to strengthening the characteristics related to their management and employees and the connection between the two (i.e. Openness & Action Orientation). This focus has been a good choice of the institutions, because research has shown that when people get along better with each other in an organisation, that this forms the basis of successful change in that organisation [38, 39].

Appendix 2 shows all three institutions have advanced on people being allowed to make mistakes (characteristic 12); being open to change (13); their managers being trusted (15), having integrity (16) and being a role model (17) and a coach to employees (20); and having a diverse workforce (29) in a secure environment (35). It seems that people in all three institutions started to spend more time together, paying more attention to each other, knowing each other's personal situation better, thus creating a safer and potentially happier workplace.

Just as in the first diagnosis, semi-structured interviews were conducted with managers and employees at the three institutions, in order to identify what after three years and the executed HPO Action Plan the progress is that has been made, and what the main areas of attention now are. In summary, these attention areas are:

Jah-Jireh Woonzorg

Many of the things that have been put in place during the HPO transformation process in the past three years have brought the organisation many advantages so that it is currently running a lot smoother. The new attention points are:

Dot the i's and cross the t's around (internal) coordination. This entails drafting clear job descriptions and a clear management style, and then paying a lot of attention to communicating these clearly in the organisation while also investigating where possible frictions in the organisation exist and discuss these.
Unite the organization. The differences in management styles and approaches and how managers are experienced by employees differs too much between locations. One manager is very nice but conservative, the other can be a good listener but sometimes does not act, while a third always quickly jumps into action mode. Unity in style and approach would create much tranquillity in the organisation.
Develop a vision for the future of nursing home care. This vision should encompass how that future will most likely affect Jah-Jireh’s organisation, operations, and people.

RijnWaal Zorggroep

The organization has become more structured, there is better expectation management of each other, a better composition of the teams, and more personal responsibility is felt and taken. There is a good atmosphere within the organization, people are willing to help each other, they experience a lot of freedom in their work, and there is a clear drive for improvement within the organization. The new attention points are:

Create even more connection between people and teams. As management team member, make sure to speak with one voice. As manager/team leader, be approachable and accessible, engage in dialogue, and regularly reflect on one’s own behaviour and actions, and always provide feedback on what is being done with our ideas, comments and problems. As employee, make sure to not only talk to each other but also to the manager/team leader so that one’s opinion is heard, and promote the ‘RijnWaal way of working’ (i.e. : uniformity across locations/teams in actions, processes, behaviour, dialogue).
Work increasingly more professionally. Only start projects if these can be finish and then indeed finish them, always close the PDCA cycle (Plan-Do-Check-Act, including root cause analysis), think in terms of solutions instead of problems, and work on reducing the quality difference between the teams.
Keep developing and growing as a person. Especially embrace feedback (both giving and receiving) as a way to learn and develop, spend time on one’s own professional development (training, courses), and stay in regular contact with other teams in order to learn from each other.

RST Zorgverleners

HPO has been incorporated in the organisation’s continuous quality improvement efforts as the main improvement technique and mindset, without calling the improvement projects necessarily HPO projects but rather quality improvement projects. In these projects there has been specific attention for further digitization of the organisation, better and more structured performance feedback, continuous attention for the development of employees, and empathically involving employees in all activities taking place in RST. The new attention points are:

Prepare the organisation for the future. Take the vision/strategy/policy plan as a starting point and talk to people about the future of RST, the 'dot on the horizon' in 5 years' time, what kind of organization RST will be. Always include 'the dot' when making decisions. Determine what RST needs with regard to the future workforce. Continue to take room for reflection (especially at managerial level).
Strengthen internal collaboration. Investigate the usefulness, necessity and possibilities of cooperation between the department, in order to create ‘the optimal client journey’. Look at standardization of implementation. Better record case histories for easier sharing and learning. Organise knowledge sharing between teams and within teams to increase quality for clients.
Integrate the PDCA cycle into everything a person does. Plan: prioritize and align plans more closely and act on that priority and alignment. Do: simplify the processes and be less ad-hoc, more structured, with a focus on finishing activities/projects. Check: always review results compared to agreements and talk to each other about this. Act: go from reactive improvement to proactive improvement.

Table 3 provides an overview of the attention points, per nursing home care institutions, for both HPO diagnoses.

Table 3: Attention points per healthcare institution

1^st HPO diagnosis

2^nd HPO diagnosis

Institution

Connection

Professionalism

Connection

Professionalism

Future

Jah-Jireh

- From ‘it's just work’ to working together for the organisation

- Grow as leaders and managers

- Better align mutual expectations

- Unite the organization

- Dot the i's and cross the t's around (internal) coordination

- Develop a vision for the future of care

RijnWaal Zorggroep

- Connect the organisation

- Take as MT the connecting role in the organisation

- Help executives become HPO managers

- Help employees to help the organization

- Create connection between people and teams

- Work more and more professionally

- Keep developing and growing as a person

RST Zorgverleners

- Increase organizational commitment

- Promote internal collaboration

- Strengthen the learning process

- Strengthen internal collaboration

- Integrate the PDCA cycle into everything a person does

- Prepare the organization for the future

It is interesting to notice from Table 3 that the attention points for all three institutions initially can be categorised into two groups:

Connection: dealing with promoting and strengthening internal cooperation between individuals, between teams, and across the complete organisation
Professionality: focusing on working more professionally (i.e. using the. PDCA cycle and better coordination across functions and processes)

while during the second HPO Diagnosis a third attention point appears for all institutions:

The future: making the organization more future-oriented and thus ready for the future, and preparing people on the future by urging them to develop themselves professionally.

What can be learned from this is that dealing with attention points requires an extensive period of time, which is in line with [21] who states that becoming high performance takes time especially because the attention points are often ‘hard nuts to crack’, i.e. issues that cannot be solved overnight. Thus it comes as no surprise that the original two categories of attention points are still valid three years later. Another learning point is that, as the HPO transformation progresses, the attention of the organisations shifted from the ‘here and now’ towards the future. This helps them prepare for what is coming in the always (politically) turbulent healthcare sector, and also in going from a fire-fighting and reactive to a proactive mindset and way of working. The institutions are then better able to deal with external factors.

After the second HPO Diagnosis, the directors of the three nursing home care institutions reviewed and analysed the HPO transformation process by looking at the advantages of the HPO Framework and the lessons learned during the transformation process. In addition, they stated whether they are continuing with the HPO transformation.

Jah-Jireh

Advantages. There is more peace of mind in the organization, understanding and insight into each other's work, willingness to cooperate, awareness among employees and management about what is going on in Jah-Jireh, and focus on the clients. Especially management is less governed by the issues of the day and takes a longer-term view of the organisation. More people are now capable which makes Jah-Jireh less dependent on the director, and the organisation has become less hierarchical. There is a better atmosphere in the organisation and compliments and regular small gifts are regularly provided to employees. Management no longer take employees for granted, resulting in an organisation which it is more fun to work for.
Lessons learned. Jah-Jireh has locations that geographically are far apart, with different employee populations and cultures. This requires an HPO transformation approach that is tailored to the context of each location, something which takes more effort but is necessary to do. Jah-Jireh started out with one HPO Coach which turned out to be not viable in the long term as it made the organisation vulnerable to the circumstances of that Coach (illness, COVID). The HPO transformation should directly start with an adequate number of Coaches, otherwise the organisation will suffer a delay in its transformation process. Another lessons learned is that an HPO transformation takes time as both managers and employees need to be given time to get used to the new ways of thinking and working, and to see the benefits of these.
Continue with HPO? Jah-Jireh will continue with HPO as it helps the organisation and its people to not fall back in the old, inefficient ways of working and patterns of behaviour.

RijnWaal

Advantages. More cooperation between the various departments in the organisation creating better performance and more fun at work: quite a few employees who left RijnWaal have returned as they see RijnWaal as a fun place to work. People have become more aware of what is going on in and what is important to the organisation. They are more competent as they reflect regularly on their own role and performance. Employees feel more freedom to say what they think. Absenteeism has gone from 12 to 5 percent. People pay more attention to each other and compliments and gifts are regularly exchanged. Because everyone feels more involved and responsible, RijnWaal has been able to sharpen its vision and its focus on the client.
Lessons learned. HPO is very effective when it is part of a greater quality movement within the organisation, in this case the ‘RijnWaal Vital’ program. Within this program the best parts of HPO can be taken to help strengthen the program. Having employees as HPO Coaches was not very effective as these focused too much on their own HPO efforts while not paying enough attention to taking managers and employees along the HPO journey. Appointing managers as HPO Coaches turned out to be the game changer for the HPO transformation. These Coaches were able to bring more integration into the HPO efforts in RijnWaal and acceleration in the transformation process.
Continue with HPO? RijnWaal will continue with HPO, albeit not under the name of HPO but as part of the ‘RijnWaal Vital’ quality program in the organisation, while cherry-picking the elements that will help the organisation the most at that specific moment in time.

RST Zorgverleners

Advantages. RST now focuses more on things that really matter and stops with topics that are less important. HPO has added structure in drafting and working with the annual plan, and helped to add accents to the things in that plan was working on. HPO helped RST to change from a hierarchical management culture to placing responsibility increasingly lower in the organization. HPO also helped to professionalise the organization.
Lessons learned. In the beginning of the transformation HPO was experienced as ‘something added’ on top of the regular work, it should have been integrated more within the daily activities. HPO philosophy did not necessarily match with how people think in healthcare: care professionals are not so much triggered by a well-structured and organized organization and smooth business operations, that is of concern to management while their focus is on care giving. Therefore introducing HPO in a healthcare institution takes more time and ‘marketing of the message’ so people understand the goal of HPO and how it will benefit them in their dealings with clients. It also means that the change process has to be given sufficient time as healthcare professionals need to time to get used to the new way of working. Another observation was that the HPO questionnaire can be seen as somewhat abstract and complex for the average healthcare professional. Initial participation in the Nursing Home Care Quality Framework project was decided somewhat in isolation by RST’s director, while it would have been better to first create good support from employees from the start. Eventually, HPO was integrated with what everybody was doing and in that way it got support and a foundation within the organisation. An important move in this respect was to appoint every manager to be an HPO coaches. Initially several employees volunteered to become HPO coach but they were hesitant to fill in that role toward their managers which meant they were not very effective. When managers became coaches the transformation process got a real boost. At a certain point people started saying, in relation to HPO: “but we already are working like that”. As that point, management knew that HPO started to become accepted in the sense that it was anchored in the business. No longer it was needed to mention HPO as a separate concept, it had become part of the quality goals in the annual plan and subsequent quality improvement activities of RST.
Continue with HPO? RST will continue with HPO, albeit not necessarily calling it that in the organisation, as it keeps especially management sharp and brings the organisation further in its development.

When looking at the experiences of the three nursing home care institutions it is possible, despite their different circumstances and nature of the organisation, to distinguish a number of common threads in the advantages they experienced and their lessons learned. These threads can function as advice to other healthcare institutions contemplating a quality improvement impulse for their organisation. The common advantages of the HPO transformation are:

there is more focus on what is important to and therefore less ad-hoc firefighting in the organisation;
the organisation has become more professional and capable;
the organisation has become less hierarchical and more of a heterarchy (more responsibility to lower levels);
there is more cooperation between the departments in the organisation;
there is more focus on clients; and
the organisation has become a better workplace where people have more fun.

These findings match with the benefits reported in previous HPO research, such as [23, 40-43].

Also in the lessons learned during the HPO transformation red threads can be distinguished:

there has to be a adequate number of HPO Coaches who should be of the right function level (i.e. managers);
take your time with the transformation, as people need to get used to the new ways of thinking and working;
integrate HPO activities as much as possible with the daily activities taking place in the organisation;
the transformation approach has to be tailored to the cultural context (i.e. sector, location) of the organisation; and
in the healthcare sector it is wise to make the HPO transformation part of a larger quality improvement process, instead of a stand-alone initiative (which people often will feel as extra on top of their regular work).

Many of these lessons learned have also been found in previous evaluatory HPO research, such as [[21, 40, 43].

This research set out to identify a holistic and validated framework that can be used by healthcare institutions to identify, develop, and strengthen their management practices and related capabilities to achieve quality improvement in their processes and higher performance results. On the basis of a review of the extant literature the HPO Framework [19, 20] was chosen and applied at three Dutch nursing home care institutions. In a period of three years at the three institutions the HPO Diagnosis was performed which yielded information on their status on the way to high performance and attention points which they needed to address to help them further along their journey. Based on an analysis of the transformation process, the experiences and lessons learned from each institution were identified and summarised. The three participating nursing home care institutions concluded that can the HPO Framework turned out to be a useful framework to help them to identify where they were at and what is needed to become high performing. In fact, all three institutions have taken steps to strengthen their organisation on the basis of the outcomes of the HPO Diagnoses. Therefore, it can be stated that this research achieved its objective to identify a holistic and validated framework useful for healthcare institutions to improve themselves. As such, the theoretical contribution of this research is that it expands the literature on evaluation and improvement of the quality of healthcare institutions as well as the literature on high performance organisations in general. The practical contribution consists of healthcare institutions now have available a validated framework that can help them in a practical way with achieving quality improvements and high performance.

There are several limitations to our study, that in themselves offer opportunities for future research. The first limitation is that, although this was a longitudinal study, the time frame of the study could have been extended, specifically to evaluate whether the three nursing home care institutions are able to reach and subsequently keep hold of the HPO status and what the institutions actually did in order to achieve this. Secondly, it is important to be careful with generalizing these research results to the overall healthcare sector. Three cases in general is not enough yet to state that the researched phenomenon, in this case the application of a quality improvement framework, could be valid in multiple settings [44]. Future research should, therefore, endeavour to extend the number of cases using the HPO transformation approach and should also increase the number of different organizations from different sizes and operating in different subsectors of the healthcare sector to evaluate whether the HPO Framework also turns out to be useful for these subsectors. Another interesting avenue of research is to collect the findings from multiple applications of the HPO Framework in the healthcare (sub)sectors, to evaluate whether certain interventions when using the framework are more successful than others.

Funding: funding was received for this research from WzW, Arnhem, the Netherlands, as part of a larger study into the implementation of the Nursing Home Care Quality Framework.

Conflicts of interest/Competing interests: no conflicting interests

Data availability: not available as the respondents of the participating healthcare institutions were promised confidentiality.

Code availability: not applicable

Authors' contributions: lead author undertook the research, wrote, and updated the article; all co-authors participated in the research and reviewed the manuscript.

Research protocol: the research entailed collecting data from respondents working at the three case institutions through a questionnaire and interviews; permission for this data collection was obtained from the management of the case institutions and of the funder WzW; participants were free to participate or not and the interviewees all consented being interviewed; no medical research was performed; the research was executed according to the research guidelines of the Ethical Committee WzW (recorded in Addenda to the regional action program ‘Worth to work for!’ for the V&V regions of Arnhem and Food Valley).

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No competing interests reported.

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Achieving high performance in healthcare institutions: a longitudinal perspective

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Abstract

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1. INTRODUCTION

2. LITERATURE REVIEW

3. THE HPO FRAMEWORK

4. RESEARCH APPROACH

4.1 The Nursing Home Care Quality Framework

4.2 Jah-Jireh Woonzorg

4.3 RijnWaal Zorggroep

4.4 RST Zorgverleners

5. RESEARCH RESULTS AND ANALYSIS

5.1 The first HPO Diagnosis (2019)

5.2 The second HPO Diagnosis (2022)

6. ANALYSIS

7. CONCLUSION, LIMITATIONS AND FUTURE RESEARCH

Declarations

References

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