In a preliminary research study published about a year ago, we
described some aspects of the relations between employee opinions
and organizational performance measures. Of several organizational
performance measures examined, we found that employee opinions
and customer opinions were the most strongly and consistently
related. This information can be used to improve aspects of the
work environment by focusing on activities that have the greatest
potential return on investment. In this article, we share some
ways in which Kaiser Permanente organizational leaders are using
the information gleaned from linkage research.
Introduction
In the Spring 1998 issue of The Permanente Journal, we
presented the results of a preliminary research study aimed at
describing some aspects of the relation between employee opinions
and various organizational performance measures, including member
satisfaction.1 Our study showed a strong relation between
employee opinions and customer opinions. Notable relationships
were found between overall customer satisfaction (as measured
by the Satisfaction Tracking and Reporting (STAR) survey) and
employee opinions about doctors, organizational flexibility, and
training for customer service (as measured by the Employee Opinion
Survey). In that article, we promised to share some practical
implications of this work, and we have interviewed several people
within Kaiser Permanente (KP) to determine how information from
the article has been used. Interview data were collected from
people in KP Program Offices as well as in the California, Central
East, Hawaii, Northwest, Rocky Mountain, and Southeast Divisions.
Readers unfamiliar with the original research are directed to
the Spring 1998 issue1:pp 47-54 for specific findings.
Because of space and time considerations, a step-by-step narrative
describing each application is not feasible. Therefore, we hope
that the current article will generate further thinking and discussion
about the importance of employee satisfaction and customer satisfaction,
the relation between them, and the ways in which such information
may be used for organizational improvement. We share here some
interesting ways in which KP organizational leaders are using
the information from the linkage research study to pursue activities
that could benefit employees as well as customers.
Overall Reaction to Kaiser Permanente's Linkage
Research
Linkage research has generally elicited a positive reaction; interviewees
have expressed excitement about the findings as well as the direction
of the research. Kaiser Permanente has usually examined organizational
variables in relative isolation, as suggested by a "balanced
scorecard" approach, which consists of interrelated performance
measures of organizational success. For example, member satisfaction
is a KP organizational goal toward which we are all striving;
on a balanced scorecard, STAR scores would be a potential measure
of this satisfaction. Another KP organizational goal is related
to quality of care, and Health Plan Employee Data and Information
Set (HEDIS) measures may be used as an organizational measure
of quality. A balanced scorecard includes multiple performance
measures like these that are most likely correlated, yet it does
not explicitly address potential correlations. Linkage research
provides a method for explicitly examining these relations and
helps KP organizational leaders identify the employee opinions
that matter most and the aspects of customer satisfaction with
which these opinions correlate. Stated differently, linkage research
can help to focus activities of the organization in ways that
have the greatest return. This focus is particularly important
because multiple demands for improvement can be overwhelming.
However, not everyone shares this rosy view of linkage research.
Some have expressed valid concerns about the potential inappropriateness
of taking action on the basis of correlational data (which do
not confirm the direction of relationships). Concern has also
been expressed that the research may prove unable to sustain interest
and attract funding (eg, because of inadequate long-term vision,
sponsorship, and communication) and that linkage research may
be merely a passing management fad.
Given the financial pressure in some parts of our organization,
some might be inclined to consider a focus on the employee environment
as conflicting with other organizational priorities (eg, a financial
turnaround) while leaving unchallenged the assertion that employee
opinions are linked to organizational performance.
Applications of Linkage Research
Granted, these are potential obstacles. But we have found that
several KP Divisions have taken information gleaned from the linkage
research study and put it to use. We have categorized these applications
as:
- Survey Program Design and Implementation;
- Education, Communication, and Training;
- Model Development;
- Assessment of Progress on Strategic Goals; and
- Human Resources Strategy Development.
These categories are illustrated in Figure
1.
Survey Program Design and Implementation
Information from our preliminary linkage research study was first
used by the Employee Survey Resource Networka (ESRN)
to develop the People Pulse ("Pulse") survey, which
is essentially a shortened version of the Programwide Employee
Opinion Survey (EOS) currently being administered. The Employee
Opinion Survey (described in our Spring,
1998, TPJ article1) contains core
items covering 12 employee environment categories. Items for the
EOS were chosen on the basis of statistical characteristics, strategic
importance, supportive data, and ability to be benchmarked against
normative, historical, or comparative data.
Items for the Pulse survey were chosen primarily on the basis
of their linkage to customer satisfaction (as determined from
the preliminary linkage research study), employee commitment,
or other organizational performance indicators. Seventeen of the
current Pulse items were chosen on the basis of linkage research.
The Pulse survey is being used as an optional component of the
Health Plan/Hospitals Executive Incentive Plan but currently not
in a rigid, formulaic way. The survey is also being used in some
KP Divisions to assess whether our organization is achieving its
strategic goals (eg, increasing diversity and implementing the
Labor Management Partnership). Participation in the EOS and Pulse
Survey programs is also considered a Kaiser Permanente Business
Fundamental.b
Education, Communication, and Training
Linkage research results are also being used in an educational
effort to inform divisional leaders about the relation between
the work environment and employee opinions, as well as about the
importance of improving both. In this way, research results are
being used to communicate what the organization deems important.
At least one KP Division is using the linkage research results
to show the importance of using employee opinion data to improve
business performance. This message is especially important in
our current environment, where a focus on financial performance
can too easily mean that employee contributions are overlooked.
The message being delivered with linkage research findings is
that focusing on the employee environment may improve business
performance.
Another area of focus for organizations today is customer satisfaction.
One of the ways in which customer satisfaction can be improved
is by focusing internal attention on activities that enable employees
to provide optimum service and care. Such activities can take
the form of various training applications of linkage research.
To train employees at the managerial level, at least one KP Division
is using results of the preliminary linkage research study to
inform managers about specific actions they can take to improve
customer satisfaction and to achieve other organizational outcomes.
Management training materials and learning experiences are organized
in ways suggested by linkage research findings; for example, exercises
in group decision-making are related to how employee input can
be used to improve customer service.
The same KP Division has requested that customer service training
for frontline employees include information on the relation between
employee opinions and customer satisfaction. Customer service
training is structured to encourage employees to question the
service environment and procedures and to make changes in their
departments to improve service for KP members.
Model Development
As part of the organization's brand strategy (the KP Promise),
efforts are underway to develop a model of a superior workforce
and its relation to members' care experience. Development of this
model will identify some of the strategically important performance
indicators to be tracked through the Program over time. Examination
of the linkage research results has highlighted the fact that
the organization is currently missing some critical pieces of
performance information in the model. One such information gap
is the examination of which aspects of the physician environment
are linked to member satisfaction and other organizational outcomes.
Future linkage research can be expected to help close this gap;
accordingly, an interregional workgroup consisting of operational
and research leaders throughout the Program has been formed to
address these issues.
Although still in the developmental stage, this model is being
discussed in the Advanced Leadership Program, an intensive training
program for future leaders of the organization. Participants include
Medical Group directors, Board members, and Health Plan/Hospitals
senior leaders. Although the model is broad in scope, its goal
is to help develop the performance measures and activities critical
for achieving desired organizational outcomes.
Assessment of Progress on Strategic Goals
Linkage research findings have some indirect applications, such
as use of the Pulse Survey (a direct application) to track progress
on strategic goals (eg, employee diversity, superior customer
service, staff recognition, and high customer satisfaction). As
an example of how these goals are actually tracked, one KP Division
has determined that a 5% increase on EOS items assessing the extent
to which employees feel valued for their diversity is desirable.
Another KP Division is assessing employee opinions monthly to
track their relation to weekly reports of customer satisfaction.
Human Resources Strategy Development
In one KP Division, linkage research results are being used to
identify and expand specific practices that relate to customer
satisfaction. Statistical analyses identified employee environment
variables that most strongly relate to employees' assessment of
the extent to which they receive the support necessary to satisfy
our customers. These employee environment variables relate to
perceptions about several issues, eg, the importance of quality,
recognition of employees for doing good work, employee training
to help them deliver good customer service, employees' influence
over decisions affecting their work, and the extent to which employees
trust information they receive from their leaders. On the basis
of the statistical analysis, this KP Division has developed its
Human Resources strategy.
Future Directions for Linkage Research at KP
We plan to further examine our current data, and we hope to collect
more. One of our goals is to expand the database, particularly
to include physician opinions, and to determine whether the same
correlations hold with this population. We also plan to replicate
our preliminary research findings by using data from the entire
Program.
The question of causality and the stability of correlations over
time will also be examined. For example, one hypothesis that could
be tested is whether employee satisfaction leads to customer satisfaction,
whether that then leads to retention of employees and customers,
and (ultimately) whether satisfaction among employees and customers
leads to strong financial performance.
We will continue to hold discussions about ways in which linkage
research information can be used further to inform Human Resources
programs such as employee orientations, training, and selection.
At least one area of our organization is contemplating development
of a more balanced leadership accountability model that considers
both customer satisfaction and employee morale. At least one KP
Division is currently examining linkages at the team level.
We hope that research into the relations between organizational
variables will continue and that our organizational leaders will
creatively apply research findings to improve both the work environment
(for physicians and for other employees) and our business performance.
We believe that pursuing this research would be time well spent.
Despite the fact that the linkage research program is just beginning,
information generated from it is already being used in many areas
of our organization. This article does not attempt to present
an exhaustive list of the applications being developed throughout
the KP Program, but we nonetheless hope that the article will
stimulate ideas about how linkage research information can be
appropriately used within the organization. We welcome any and
all additional information about how linkage research is being
used in your team, module, department, facility, medical center,
service area, or KP Division.
a The mission
of the Employee Survey Resource Network is to provide oversight
for the Physician and Employee Survey program as well as to provide
consultative support for the Divisions as they administer surveys.
The ESRN consists of Kaiser Permanente staff, either from or representing
all Divisions, as well as external representation from a survey
research consulting firm.
b See your division HR Leader for more
information about the Business Fundamentals.
Related material presented at the 14th
Annual Meeting of the Society for Industrial and Organizational
Psychology, Atlanta, Georgia, April 30-May 2, 1999, as Abstract
48.
Related material published as: Kam SM, Brooks
SM. Touching the customer by understanding employees: preliminary
linkage research findings from four regions of Kaiser Permanente.
Permanente J 1998 Spring; 2(2):47-54.
Acknowledgments: We would like to acknowledge
the following individuals for contributing information upon which
this article is based: Leslie Francis, MBA/MHA; David Glass, PhD;
Lee Jacobs, MD; Kaki Jennings, MEd; Debra L. Lowry, MS; Albert
Mehl, MD; Patricia Peters, BSN; Robert H. Sachs, PhD; Randy
Scott, MA, SPHR; Kurt Shusterich, PhD; Jill Steinbruegge, MD;
Marilyn Weske, MEd
We would also like to acknowledge Deborah Konitsney,
PhD and Julie Kwan, PhD for their assistance in data collection;
Bob Jako, PhD for reviewing an earlier draft of the manuscript;
and two anonymous reviewers for their valuable comments on an
earlier version.
References
1. Kam SM, Brooks SM. Touching the customer by understanding employees:
preliminary linkage research findings from four regions of Kaiser
Permanente. Permanente J 1998 Spring;2(2):47-54.
