Toward a high-performance management system in health care, Part 5: How high-performance work practices facilitate speaking up in health care organizations

Health Care Manage Rev. Oct/Dec 2020;45(4):278-289. doi: 10.1097/HMR.0000000000000228.


Background: Employees' reluctance to speak up about problems and/or make suggestions for improvement is a noted barrier to quality and patient safety improvement in health care organizations. High-performance work practices (HPWPs) offer a framework for considering how management practices can encourage speaking up in these organizations.

Purposes: We aimed to explore how implementation of HPWPs in U.S. health care organizations could facilitate or remove barriers to speaking up. We were interested in improving understanding of how HPWPs could influence manager behavior and organizational policies and practices to encourage, support, and foster speaking up among employees.

Methodology/approach: We examined case study data from five health care organizations purposely selected for their use of HPWPs. Interview transcripts from 67 key informants were inductively and deductively analyzed to explore how speaking up was characterized.

Findings: We found that speaking up was recognized as an important factor impacting quality improvement and/or patient safety initiatives across all five organizations. Management efforts to facilitate speaking up included both direct practices, such as using structured communication processes and reporting systems, and complementary practices that supported speaking up. Both direct and complementary practices were aligned with the HPWP model, with sites showing evidence of supporting the frontline, engaging staff, developing talent, and having effective leaders fostering efforts to encourage employees to speak up.

Practice implications: Both conceptual evidence and qualitative evidence supporting the applicability of HPWPs as a management model for systematically facilitating speaking up in health care organizations were presented in this study. Application of an evidence-based framework enabled consideration of an organizational rather than employee perspective and provided examples of specific management practices that have been successfully implemented to facilitate speaking up. This research furthers the growing body of evidence supporting the applicability of HPWP implementation as a valuable strategy for impacting quality and safety in health care organizations.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Communication*
  • Delivery of Health Care / organization & administration*
  • Efficiency, Organizational
  • Health Facilities / standards*
  • Humans
  • Leadership*
  • Patient Safety
  • Quality Improvement*
  • Quality of Health Care / organization & administration*