The Joint Commission Journal on Quality and Patient Safety
Afterword
Improving the Health Care
Work Environment:
Implications for Research,
Practice, and Policy
T
o conclude this issue, we review the articles’ main
implications for practitioners and policy makers,
along with some important challenges for further
research.
Future Research
Although we have learned a great deal about the health
care work environment and its impact on quality and
patient safety, significant challenges remain for research.
As several of our authors note, greater rigor is needed in
research designs. Moreover, further investigations and
research syntheses are required to confirm important, but
still tentative, findings—including the influence of the
physical environment on staff, effects of organizational cli-
mate on patient outcomes, and the influence of patient
acuity on requirements for minimum safe staffing.
Greater breadth and depth are needed in research,
including examination of working conditions among
ancillary health occupations, which have been studied less
often than have nurses and physicians. Research is also
needed on environments beyond acute care. Attention is
warranted to potential mediators of effects of working
conditions, such as the skill mix of the care team, physical
settings of care, medical and information technologies,
supervisory behavior, patient characteristics, and many
other largely underdocumented features of the clinicians’
immediate work environment.
Research on health care organizations needs to consid-
er additional features of the work environment shown in
November 2007
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
Michael I. Harrison, Ph.D.
Kerm Henriksen, Ph.D.
Ronda G. Hughes, Ph.D., M.H.S., R.N.
Article-at-a-Glance
Future Research: Despite the gains to date, we need
better understanding of practices for implementing and
sustaining improvements in health care work environ-
ments and further study of organizational conditions
affecting implementation of improvements.
Practice: Limiting work hours, improving schedules,
and providing sleep hygiene training will help combat cli-
nician fatigue. Hospital crowding can be reduced through
systemwide improvement of patient flow and capacity
management, coupled with management support, mea-
surement, and reporting on crowding. Long-term solu-
tions to nurse staffing shortfalls include process redesign to
enhance efficiency. Improvement of organizational cli-
mate, human resource management, and interoccupation-
al relations will also contribute to staff retention.
Evidence-based enhancements to patient rooms and other
physical features in hospitals contribute directly to safety
and quality and also affect staff performance.
Policy: Landrigan and his colleagues call for external
restrictions on residents’ work shifts. Clarke examines
prospects for mandated nursing-staff ratios. Public report-
ing on staffing, crowding, and other risks may incent
change. Reporting and pay for performance require stan-
dardized measures of targeted conditions. Organizations
promoting care quality can help spread safe work prac-
tices; they can also support collaborative learning and
other strategies that may enhance implementation of
improvements in work environments.
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 The Joint Commission Journal on Quality and Patient Safety
other industries to affect individual productivity, staff
retention, and organizational performance. For example,
human resource management research1 documents the
impacts of “high performance work practices,” which
deserve more attention in health care. These practices
include incentive compensation, adequate compensation
levels, training, personnel selectivity, internal promotion,
human resource planning, flexible work assignments,
and grievance procedures; similar but less well-document-
ed effects are reported for teamwork, performance apprais-
al systems, and information sharing. Research should
focus on the practices themselves, as well as on staff
perceptions of them, as reflected in organizational climate
surveys.
Researchers also need to pay closer attention to system
interactions within work environments, describing unin-
tended, emergent features of interventions, such as new
information technologies and redesigns of care processes.
In addition, research needs to reveal multilevel interac-
tions and effects—such as effects of pay and reward poli-
cies on actual safety behavior and alignment between
improvement practices and organizational strategies.2,3
Researchers should also address fit among system improve-
ment practices and effects of bundling mutually reinforc-
ing interventions and management practices.1,4,5
Finally, and perhaps most critically, we need to know
more about how, where, and when such improvement
practices work. There is insufficient research on practices
for implementing and sustaining improvements in work
environments and a shortage of syntheses of practical
implementation experience.6 Research outside of health
care may provide some answers.7 In addition, many agen-
cies, including the Agency for Healthcare Research and
Quality, actively support and disseminate implementation
research (see, for example, http://www.innovations.ahrq.
gov/). Nonetheless, further knowledge is needed on the
logistics of introducing and sustaining complex improve-
ment interventions, such as redesign of patient flow and
reduction of waste in work processes.
Practice
What implications do the articles in this issue have for sys-
tem leaders, managers, and frontline practitioners seeking
to improve the safety and quality of clinical work?
Although there are many outstanding issues, the research
82 November 2007
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
findings and accumulated experience cited here and in ear-
lier reviews justify action on many fronts.
The articles provide persuasive portraits of the risks to
safety and quality from inadequate nurse staffing levels,
fatigue among residents and nurses, and emergency
department (ED) crowding. Nurse turnover adds to these
problems and is intensified by them. We now review some
actions that system leaders and managers can take to alle-
viate such threats to patient safety and quality.
REDUCING CLINICIAN FATIGUE BY LIMITING
HOURS AND REDESIGNING WORK SCHEDULES
After calling for limits on the length of work shifts (see
Policy Implications, below), Landrigan and his colleagues
provide explicit recommendations for redesigning shifts
within these limits in ways that best reduce nurse and
physician fatigue.8 They also present programs for compre-
hensive fatigue management, including education on sleep
hygiene and use of techniques for coping with fatigue.
REDUCING CROWDING BY IMPROVING HOSPITAL
FLOW
The systems that participated in the learning networks
described by Siegel and colleagues made demonstrable
progress toward improved flow and reduced crowding.9
Successful change strategies enhanced transitions between
EDs and inpatient units and improved management of
overall hospital capacity. Performance management and
demand forecasting supported these change strategies.
Successful implementation of these strategies requires sus-
tained management attention and organizationwide com-
mitment to transparency in data reporting.
COPING WITH NURSE-STAFFING SHORTFALLS
As Clarke points out, providers can mitigate effects of
nurse shortages through human resource management
practices and process redesign.10 To start, managers need to
obtain accurate data about the degree of staff shortfalls in
their organizations as a whole and within care units. Then
they can benchmark their organization against others in
terms of staff level and nurse-sensitive outcomes.
Managers can deploy temporary staff when shortfalls
occur. Longer-term solutions involve streamlining care
processes with the help of information technology to
reduce wasted nurse effort and documentation time.
Volume 33 Number 11 Supplement
 The Joint Commission Journal on Quality and Patient Safety
Hospitals might also “mistake proof ”11 some care process-
es and thereby reduce their sensitivity to staffing levels.
REDUCING NURSING TURNOVER AND SAFETY
HAZARDS BY IMPROVING SUPERVISORY AND
MANAGEMENT PRACTICES
Studies of Magnet hospitals and organizational climate
research demonstrate that good human resource manage-
ment enhances the satisfaction and well-being of nurses
and sometimes contributes directly to the safety and
health of their patients.10,12 Helpful practices include em-
powering nurses, fostering teamwork, and developing con-
structive relations among professions. Moreover, the same
management, workforce, and work-design practices that
enhance safety also encourage nurse retention.5
IMPROVING SAFETY AND QUALITY THROUGH
EVIDENCE-BASED DESIGN
The implication of the article by Henriksen and col-
leagues is that teams planning construction or renovation
of health care facilities should include people with expert-
ise in evidence-based design.13 Planners should carefully
weigh the potential benefits for safety and other quality
dimensions of the many specific design innovations
described in the article against costs, implementation
challenges, and potential side effects.
GENERAL IMPLICATIONS
The sociotechnical approach, presented in the
Introduction,14 contains some more general implications
for practice. First, problems that appear intractable at one
system level can sometimes be successfully handled at a
higher level. For example, ambulance diversions and ED
crowding can be reduced by improving patient flow in the
hospital as a whole.9 Second, collaborative learning among
provider organizations may strengthen incentives and
capacity for improvement. Third, providers can sometimes
act to reduce external constraints on their operations. For
example, a provider might cope with a tight local market
for new nurses by offering additional staff to nursing
schools or by providing part-time employment and on-site
training to advanced nursing students.10 Fourth, the
sociotechnical approach and the articles in this issue sug-
gest that decision makers and managers need to proceed
with care as they intervene to alleviate dangerous and
November 2007
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
undesirable features of the work environment: Steps to
alter one undesirable working condition may lead to unin-
tended outcomes for patients, staff, or the organiza-
tion.15–17 Past experience and research can help planners of
change anticipate possible interactions among proposed
interventions and current features of the work environ-
ment. For example, while planning for variable-acuity
rooms, managers might also plan to redesign nursing tasks
and improve work coordination. Unfortunately, many
important consequences of interventions emerge only
gradually during implementation and cannot be fully
anticipated. Hence, managers and clinicians need to mon-
itor emerging system effects of interventions. Repeated,
behavioral evaluations of interventions and consequences
are needed, along with frequent feedback to managers.17,18
Fifth, instead of tackling problems one at a time, orga-
nizations may produce more sustainable solutions by
introducing mutually reinforcing practices. For example,
planned reductions in clinicians’ working hours might
best be coordinated with improvements in handoff com-
munication, as Landrigan and colleagues note.8 These
steps could be further reinforced by using health informa-
tion technology to support care transitions and to reduce
time spent on clerical and administrative work.
Policy
Although the articles in this issue focused more on prac-
tice than policy, they nonetheless contain important sug-
gestions for policy makers. Landrigan and his colleagues
call on legislative, regulatory, and professional bodies to
introduce and enforce strict limits on the length of work
shifts for physicians and nurses.8 Clarke, on the other
hand, indicates that mandatory nurse-staffing ratios may
not yield the sought-after results and may have unintend-
ed consequences.10 He urges close attention to effects of
the mandates recently enacted in California.
Public reporting is another approach that regulators
and payers can use to promote reduction of risks in the
work environment.19 Clarke advocates greater transparen-
cy about nurse staffing.10 Siegel and colleagues urge report-
ing of standardized measures of patient flow and ED
crowding.9 Payers might also create incentives for demon-
strated work environment improvements, as they have for
quality outcomes and adoption of information technolo-
gy.20 Whether comparisons among institutions are used for
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 The Joint Commission Journal on Quality and Patient Safety
public reporting or for payment, such comparisons require
the development of precise, nationally agreed-on measures
of the key variables.
To help reduce the nursing shortage, Clarke urges states
and educational institutions to expand the capacity of
nursing schools.10 He points out that applications to nurs-
ing schools have risen recently, but capacities for admitting
students are limited by a shortage of nursing faculty.
Several articles encourage governmental and private
organizations to help spread practices that can improve the
quality and safety of health care work environments. These
practices include restructured work schedules and sup-
portive work-flow improvements, work redesign, steps
that enhance hospital flow, and evidence-based design of
the physical environment of care. In a similar vein, policy
and research bodies should consider further support for
learning collaboratives to spread work environment
improvements and support their implementation.
Conclusion
The articles in this issue identify ways that providers and
decision makers can act now to improve the quality and
safety of health care work environments. Demonstration
projects and initiatives by some leading institutions have
shown that it is possible to introduce work-system changes
and enhance outcomes. Sustained improvement requires
long-term organizational commitment, bundling of
mutually reinforcing steps, and organizational learning
during the change process. Regulators, payers, and policy
makers can also help create incentives for providers to
improve the work environment. At the same time, prac-
Michael I. Harrison, Ph.D., is Senior Research
Scientist–Organizations and Systems, Center for
Delivery, Organization, and Markets, Agency for
Healthcare Research and Quality (AHRQ), Rockville,
Maryland. Kerm Henriksen, Ph.D., is Human Factors
Advisor for Patient Safety, Center for Quality
Improvement and Patient Safety, AHRQ. Ronda G.
Hughes, Ph.D., M.H.S., R.N., is Senior Health
Scientist Administrator and Senior Advisor for End-of-
Life Care, Center for Primary Care, Prevention, &
Clinical Partnerships, AHRQ. Please address corre-
spondence to Michael I. Harrison, Michael.Harrison@
ahrq.hhs.gov.
84 November 2007
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
tice-based research should establish a stronger evidence
base for the most promising ways of implementing and
sustaining these improvements. J
The views expressed in this article are the authors’ and do not reflect those
of the Agency for Healthcare Research and Quality or the U.S. Department
of Health and Human Services.
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