Amulti-level examination of quality-focused human resource practicesand firm performance: evidence from the US healthcare industry

Mesut Akdere*

Department of Administrative Leadership, University of Wisconsin-Milwaukee, Milwaukee, WI, USA

In today’s business world, the role of quality has become ever more significant fororganizations to compete in a global marketplace. Based on the quality managementtheory, this study empirically examines the relationship between quality-focusedhuman resource practices (QHRP) and organizational performance outcomes. Datafrom 69 healthcare organizations indicate a strong support for this relationship.A Human Resource (HR) system focused on quality management was directly relatedto multiple dimensions of organizational performance outcomes (i.e., intangible –employee satisfaction and customer satisfaction – and tangible – profit). Specifically,two measures of QHRP, knowledge management and strategic management, werefound to be positively related to the financial performance of firms implementingquality management. Process management is found to be negatively related toemployee satisfaction. General Human Resources were positively related to bothemployee and customer satisfaction. Employee focus of the firms is also positivelyrelated to employee satisfaction. In addition, employee satisfaction is also related toboth customer satisfaction and financial performance while customer satisfaction isfound to be positively related to employee satisfaction. The findings indicate agenerally strong positive relationship with the organizational performance outcomes.The results of this study are particularly important in showing HR’s contribution to theorganization’s bottom line.

Keywords: knowledge management; leadership; performance; process management;quality management; strategic management

Introduction

The challenge of becoming a strategic partner and participating in the strategic planning of an

organization has been significant for Human Resource (HR) scholars and practitioners as a

way to help the organization gain competitive advantage. In many HR departments, strategic

partnering has become one of the goals of the overall HR function and serves as a source of

motivation and rationale for HR’s bottom line contribution to organizational performance.

In their annual reports, most organizations state that their people – employees – are their

most important assets (Barney and Wright 1998). However, a major challenge for the field of

HR remains in finding ways to effectively and efficiently utilize organizations’ human

capital. Similarly, HR needs to move beyond performing the many administrative and legally

mandated tasks that traditional personnel functions have performed to adding value through

directly improving the performance of the business (Lawler 2005).

Organizations are becoming flatter, more decentralized, and are moving from

individual-based to team-based methods of production (Arvey and Murphy 1998). In an

ISSN 0958-5192 print/ISSN 1466-4399 online

q 2009 Taylor & Francis

DOI: 10.1080/09585190903142399

http://www.informaworld.com

*Email: akdere@uwm.edu

The International Journal of Human Resource Management,

Vol. 20, No. 9, September 2009, 1945–1964

era when business and workplace conditions and dynamics change so rapidly and

competition is at its peak, organizations find themselves in a constant struggle to achieve

higher quality and increase performance in order to be productive, and meet customer

expectations. Consequently, quality management and performance improvement

initiatives in today’s business environment and workforce have emerged as tools for the

goal of achieving organizational competitiveness, strategic alignment, innovation,

adaptability, and the maximum utilization of human capital available to the organization.

Achieving but one of these goals has proven to be insufficient: managing quality that

does not lead to better performance or improving performance that lacks quality does not

work – and should not be treated separately (Anderson, Rungtusanatham and Schroeder

1994; Sousa and Voss 2002).

The challenge of performance improvement has been intensified with the struggle

to manage quality in the workplace. Broadly defined, quality is the conformance to

requirements (Crosby 1979). Increased competition, international trade, and globalization

have led multinational companies to focus on the concept of quality in the last few

decades. The increasing role and significance of quality in business led many

organizations to conclude that effective quality management can enhance their

competitive abilities and provide strategic advantages in the marketplace (Anderson

et al. 1994). Consequently, many organizations – ranging from large to small,

manufacturing to service, profit to nonprofit – adopt available quality improvement and

management tools to change their existing work designs, performance improvement

efforts, and strategic planning.

It may be argued that successful implementation of quality management initiatives

will positively affect employee achievement and output, customers’ product acceptance,

and organizational survival. Quality management processes and tools enable individuals to

manage the development, introduction, and support of quality improvement process (Dale

and Bunney 1999). According to Wesner (1995), quality management is needed to help

employees use their knowledge and skills to effectively manage today’s modern

organizations. Quality management processes and tools impose a certain set of disciplines

(Dale and McQuarter 1998) in which they assist organizations to improve effectiveness by

building, modifying, and sustaining positive and direct interactions. Consequently, the

applications of quality management help organizations to efficiently utilize and optimize

their limited resources, especially their human capital. In a related vein, it may be argued

that quality management processes and tools, when integrated in HR practices, can help

employees reduce work-related errors and redundancies through increasing collaboration

and cooperation, and creating synergy at all levels of the organizations and among all

employees.

In summary, quality management approaches call into question the traditional reactive

approaches to HR. It argues for a more proactive, performance-focused approach in which

HR professionals adopt quality management to become strategic organizational partners

(Briggs and Keogh 1999) to manage a set of resources such as human capital skills,

employee commitment, culture, and teamwork that are most likely to be sources of

sustained competitive advantage into the next century (Barney and Wright 1998). HR

functions integrated with quality management processes and tools will highlight the role

and responsibility that HR professionals play as a strategic business partner in the

organization. This is directly relating HR to improving performance and increasing

productivity.

The ultimate goal of research in this realm is to assist organizations to succeed in their

performance improvement efforts. The purpose of this research is to empirically

M. Akdere1946

investigate the relationship between quality-focused Human Resource practices and

organizational performance outcomes in long-term healthcare organizations. In this

study, organizational performance is considered an outcome of Quality-focused Human

Resource Practices (QHRP), and quality is treated as a process that is expected to lead to

higher performing organizations.

Theory and hypotheses

A number of theoretical approaches have been developed to explain the role and outcomes

of quality management within organizations. Anderson and colleagues (1994) propose a

theory of quality management which underlies Deming’s management method. ‘The

proposed theory is based upon conceptual synthesis of Deming’s writings, available

literature on the Deming management method, observations of practice, and more

specifically, on the result of a Delphi study on the Deming management method’ (p. 473).

Figure 1 illustrates the proposed theory of quality management. According to this theory,

quality management involves a number of organizational functions including visionary

leadership, internal and external cooperation, learning, process management, continuous

improvement, employee fulfillment, and customer satisfaction.

Visionary leadership refers to the role of top management in defining and establishing

a long-term vision of ‘an organization’s development, communicating this vision,

implementing a plan of action, and inspiring and motivating the entire organization

toward the fulfillment of this vision’ (p. 482). The next two constructs of the theory –

internal and external cooperation, and learning – are defined within the organizational

system theory perspective. First proposed by Bertalanffy (1968), systems theory is

‘simply a theory concerned with systems, wholes, and organizations’ (Ruona 2001,

p. 114). Systems theory is constructed on the notion that systems are open to, and interact

with, their environments, and are capable of acquiring new properties through

emergence, which may result in continual evolution. As a result, systems theory proposes

the arrangement of and relations between the parts, connecting them to the whole. When

applied to an organizational setting, systems theory focuses on the organization as a

whole, emphasizing the input-process-output cycle within a larger context. Within this

organizational system approach, internal and external cooperation can be defined as

Figure 1. A proposed theory of quality management underlying the Deming management method.Source: Anderson, Rungtusanatham and Schroeder 1994.

The International Journal of Human Resource Management 1947

‘collaboration among different individuals, groups, or organizations, where all entities

are engaging in noncompetitive, mutually beneficial, win-win activities’ (p. 483).

Internal, within this context, refers to all units/departments of an organization. External,

on the other hand, involves the organization and its suppliers of products and services.

The second construct of this organizational system is learning. It is ‘the ability and

willingness of the organization to engage in learning or knowledge-seeking activities at

the individual, group, and organizational levels (p. 485).

Process management construct of the proposed quality management theory refers to

‘a set of practices that combine methodological approaches with human recourse

management and these are implemented in order to manage and improve processes that

produce products and services’ (p. 486). Continuous improvement is a defining function in

quality management theory. It implies constantly striving to improve quality in all

products and services. It recognizes that quality concept is fluid and not static. In other

words, once an organization reaches the quality standards, there is always the risk that it

might deviate from this level of achievement. In addition, the defined quality standards

should also be subjected to the continuous improvement process, and be re-defined and

re-implemented organization-wide.

The next construct of the quality management theory is employee fulfillment. It is

defined as ‘the degree to which employees of an organization believe that the organization

continually satisfies their needs, arises fundamentally from employees being able to derive

pride of workmanship, satisfaction, and commitment from the work they do’ (p. 489). The

final construct of the quality management theory is customer satisfaction, highlighting

the importance of the customer. The notion behind customer satisfaction is that quality

management practices strive to achieve and exceed existing standards of quality in

products and services. Consequently, these standards of quality ultimately aim to achieve

customer satisfaction.

Organizations may be viewed as human systems. The domain of HR may be described

as the development and management of people in an organization through a framework of

activities and practices that design, develop, organize, support, and execute employees’

work – while ensuring compliance with legislation and regulations governing the

employer/employee relationship. As a result, fostering and maintaining professional

relationship between employers and employees and among employees themselves are

crucial in attracting, motivating, developing, maintaining, and retaining employees as well as

HR’s bottom line contribution to the organization. Bowen and Lawler (1992) proposed total

quality-oriented Human Resource Management and argued that quality management

provides Human Resource Management (HRM) with a golden opportunity to help move

from just HRM to strategic HRM. They concluded that ‘a major role in the quality

improvement efforts puts HR in a position to contribute directly and visibly to the bottom

line, add value to the company’s products and services in the same way that other functions,

such as sales, accounting, and production, add value’ (p. 31). Simmons, Shadur and Preston

(1995), on the other hand, provided a case study where quality management and HRM

practices are integrated in a large manufacturing company. They concluded that one of the

outcomes of this integration process was improved organizational competitiveness. They

further argued that there is a symbiotic relationship between quality management and HRM.

Drawing on the quality management theory, this study utilized the Human Resource

Practice Index (Macy and Izumi 1993) to construct the Quality-focused Human

Resource Practices (QHRP) model. Figure 2 illustrates the proposed relationships

between QHRP and organizational performance outcomes. QHRP model includes

leadership, knowledge management, strategic management, process management, general

M. Akdere1948

HR practices, customer focus, and employee focus. The organizational performance

component of this model, on the other hand, includes employee satisfaction, customer

satisfaction, and financial performance.

Anderson et al. (1994) argue that ‘many organizations have arrived at the conclusion

that effective quality management can enhance their competitive abilities and provide

strategic advantages in the marketplace’ (p. 472). It is important to note that the essence

of quality management is leadership and employees – humans of the organizations. Thus,

quality management should not be treated as a separate organizational process, but rather

as part of the Human Resource (HR) process in the organization. However, this model has

not empirically been tested due to the initial complications in basing the model on a sound

quality management theory. This paper attempts to achieve this through testing the

relationships between QHRP and organizational performance outcomes. This argument

provides the following hypotheses:

Hypothesis 1: There is a positive relationship between Quality-focused Human Resource

Practices (QHRP) and organizational performance outcomes of employee

and customer satisfaction.

Hypothesis 2: There is a positive relationship between Quality-focused Human Resource

Practices (QHRP) and financial outcomes of organizational performance.

Method

The survey method included two survey instruments: Organizational Quality Survey; and

Service Quality Resident Survey. Informed by prior studies, the main proposition of this study

is that QHRPs are vital to increasing organizational performance, productivity, and achieving

the strategic partnership of Human Resources (HR) with its host organization. This study is

about the ability of QHRP to improve performance in long-term healthcare industry building

upon the theoretical aspects of existing HR, quality management, systems, and performance

improvement theories. The questionnaire items used in the survey instruments are drawn from

existing instruments on quality management processes and Human Resource practices.

Data and sample

A sample of 69 long-term healthcare organizations and their patient residents was included

to assess QHRP at the individual and facility levels. Organizational Quality Survey

Figure 2. Quality-focused human resource practices (QHRP) and organizational performanceoutcomes framework.

The International Journal of Human Resource Management 1949

instrument was used for QHRP variables and employee satisfaction. The Service Quality

Resident Survey was used to measure customer satisfaction. Both surveys were

administered to all staff levels within each facility, including top management, shift

and professional nursing staff, and front-line staff (nursing assistants, dietary staff, and

housekeeping), and to all residents (customers) in these facilities during the data

collection. The population of this study was selected from the organizations which

implemented QHRP over a period of 2 years, and was composed of the employees of long-

term healthcare organizations and their resident patients in the US.

The study was conducted in 69 long-term healthcare facilities belonging to two large

long-term healthcare corporations operating in the US. The characteristics of these two

corporations were similar. They were both non-profit organizations which have been in the

long-term healthcare business for over 75 years. Given that almost 70% of all long-term

healthcare organizations are non-profit in nature (Rhoades and Sommers 2001; Strahan

1987, 1997), the implications of the sample of the study in limiting generalizability to the

broader long-term healthcare field was minimal.

The data were collected through surveys mailed to the employees and resident patients

in these long-term healthcare organizations. The response rate for the Organizational

Quality Survey was 3598 of 6425; for the Service Quality Resident Survey it was 1272 of

2494. The financial data used in this study were based on the organizational financial

records of the time the survey was conducted. The descriptive statistical analysis also

revealed some important information about the employees who participated in the study.

Almost 50% of the respondents, for example, were nurses. The majority of the respondents

were women (89.9%); and about 40% completed a high school degree.

Variables

The variables examined in this study were divided into two categories: QHRP as

performance driver-related independent variables and organizational performance

outcomes-related dependent variables. Therefore, based on the quality management

theory, the components of the independent variable of QHRP include organizational

leadership, knowledge management, strategic management, process management, general

HR functions, and customer and staff focus. The dependent variable of organizational

performance was represented by three sub-variables: employee satisfaction; customer

satisfaction; and financial outcomes-related variables. Employee and customer satisfaction

were based on employee and customer perceptions of satisfaction and measured by the

instruments used in this study. Financial performance-related outcomes were assessed by

the financial well-being of the corporations. The relationship between HR practices and

corporation financial performance has been documented in the literature (Black and Porter

1996; Neumark 2001; Ichniowski and Shaw 1999). By accessing the financial data of the

long-term healthcare organizations in which the study was conducted, the following were

obtained to measure the organizational financial performance outcomes: 1) operating

margin; and 2) net margin. The data helped understand how well organizations were doing

financially at the time of data collection, and helped determine the degree of relationship

between financial outcomes, the QHRP, and other organizational performance outcomes.

The assumption here is that when all of these variables function as expected, then it

would lead to certain organizational performance outcomes such as increased employee

and customer satisfaction, improved quality of care, and increased financial returns

on investment. Table 1 illustrates the items used in the survey to measure the QHRP

dimensions.

M. Akdere1950

Tab

le1

.It

emo

fth

esu

rvey

use

din

the

surv

eyin

stru

men

tm

easu

rin

gQ

HR

Pd

imen

sio

ns.

Quality

constructsandselected

item

srelated

tohumanresources

Factor

Scale

of

measurement

Number

of

item

s

†L

ead

ersh

ip(1

7)

†F

ocu

sed

vis

ion

ary

(ite

ms

La-

Ld

)In

terv

al4

†V

isib

lep

rese

nce

(ite

ms

Le-

Lg

)In

terv

al3

†S

up

po

rtin

gch

ang

e(i

tem

sL

k-L

n)

Inte

rval

4†

Co

mm

itm

ent

toq

ual

ity

(ite

ms

Lo

-Lr)

Inte

rval

4†

Co

mm

un

icat

ion

(ite

ms

Ls-

Lt)

Inte

rval

2†

Know

ledge

Man

agem

ent

(12)

†S

tru

ctu

re(i

tem

sK

Ma-

KM

d)

Inte

rval

4†

Use

(ite

ms

KM

e-K

Mh

)In

terv

al4

†B

ench

mar

kin

g(i

tem

sK

Mi-

KM

1)

Inte

rval

4†

Str

ateg

icM

anag

emen

t(5

)†

Str

ateg

icp

lan

nin

g(i

tem

sS

Ma-

SM

e)In

terv

al5

†P

roce

ssM

anag

emen

t(9

)†

Lea

rnin

go

rgan

izat

ion

(ite

ms

PM

a-P

Mc)

Inte

rval

3†

Pro

ble

mso

lvin

g(i

tem

sP

Md

-PM

f)In

terv

al3

†E

val

uat

ion

(ite

ms

PM

g-P

Mi)

Inte

rval

3†

Gen

eral

Hu

man

Res

ou

rce

Fu

nct

ion

s(2

0)

†S

up

erv

isio

n(i

tem

sH

R-H

RD

)In

terv

al4

†E

mp

ow

erm

ent

(ite

ms

HR

e-H

Rh

)In

terv

al4

†Jo

bd

esig

n(i

tem

sH

Ri-

HR

l)In

terv

al4

†C

oo

rdin

atio

n/c

om

mu

nic

atio

n(i

tem

sH

Rm

-HR

p)

Inte

rval

4†

Tra

inin

g&

dev

elo

pm

ent

(ite

ms

HR

q-H

Rt)

Inte

rval

4†

Cu

sto

mer

Fo

cus

(4)

†P

atie

nt

focu

s(i

tem

CF

a-C

Fd

)In

terv

al4

†E

mp

loy

eeF

ocu

s(4

)†

Wel

l-b

ein

g(i

tem

EF

c)In

terv

al1

†M

issi

on

and

val

ues

(ite

mE

Fi-

EF

k)

Inte

rval

3

The International Journal of Human Resource Management 1951

Validity and reliability

Additional assessment of the instruments relied on previous instruments that have

established validity. The analysis measurement items of this study were adapted from the

two instruments developed to assess quality management practices in long-term healthcare

organizations. The survey instruments were drawn and developed based on the quality

management theory. A panel of nationally renowned experts in the field of long-term

healthcare and quality management reviewed the instruments for validity purposes and

solicited additional components and items to the instruments. In addition, the research

advisory team participated in the validation of the study. A pilot study was conducted to

further ensure internal validity of the instrument. Using the Human Resource Practice

Index (Macy and Izumi 1993), out of 145 items of these two instruments, 71 items were

adopted from the Organizational Quality Survey instrument for the QHRP variables.

In that the two instruments were modified slightly, their reliability was assessed. For

the overall QHRP reliability, alpha values for the 71 scales ranged from þ .80 to þ .96.

Cronbach’s coefficient alpha value for employee satisfaction was þ .69, and þ .65 for

customer satisfaction, respectively. Table 2 reports reliability assessment for each

variable. The dependent variable financial outcomes of organizational performance were

measured by two financial indicators: operating margin and net margin. The data for each

facility were obtained from corporate financial annual reports.

Data analysis

Given the conceptual framework, the proposed research question under investigation

addresses the interrelationships between Quality-focused Human Resource Practices

(QHRP) and organizational performance outcomes. To investigate the research question

and test the hypotheses, the study used several methods of data analysis, including

descriptive statistics, hierarchical linear modeling (HLM), and stepwise multiple linear

regression. The frequency of responses was conducted to assess the distribution of the

participant organizations. Means and standard deviations were calculated for each item

and scale to assess potential central tendencies. Cronbach’s alpha was used to conduct

reliability analysis to determine the reliability of all scales adopted in the study. The

obtained alpha scores were then compared to the reliability estimates existing in

the literature. The level of significance was set at p , .01 and .05, respectively.

This study is interested in understanding how QHRP variables (leadership, knowledge

management, strategic management, process management, general HR functions,

customer focus, and employee focus) are associated with organizational performance

outcomes (employee and customer satisfaction, and financial). But given that scores on

QHRP, employee satisfaction, and customer satisfaction were gathered at the individual

level, and financial outcomes variables at the facility and corporate level, hierarchical

linear modeling (HLM) was used to investigate the impact of the QHRP on organizational

performance outcomes (Raudenbush and Bryk 2002).

Results

Descriptive statistics for all study variables are reported in Table 2. To control common

method variance, a cross-level design was used to eliminate the potential for response

bias. Bivariate correlation results for QHRP variables were significant at less than 0.001

(2-tailed) at both levels. Variance explained reports the proportion to which the HLM

model accounts for the variation of the data used in this study. The facility correlations

M. Akdere1952

Tab

le2

.M

ean

s,st

and

ard

dev

iati

on

s,re

liab

ilit

yes

tim

ates

and

corr

elat

ion

sfo

ral

lv

aria

ble

s.

Variable

Number

of

item

sMean

SD

aVariance

explained

1-a

2-b

3-c

4-d

5-e

6-f

Lea

der

ship

17

3.7

9.6

6.9

65

5K

no

wle

dg

em

anag

emen

t1

23

.61

.73

.95

65

.76

*–

.84*

Str

ateg

icm

anag

emen

t5

3.6

3.8

0.9

27

5.6

1*

–.7

4*

.70

*–

.72*

Pro

cess

man

agem

ent

93

.74

.75

.93

65

.61

*–

.65*

.51

*–

.59*

.54

*–

.61

*G

ener

alH

Rfu

nct

ion

s2

03

.66

.79

.95

52

.62

*–

.69*

.59

*–

.67*

.66

*–

.71

*.6

7*

–.7

4*

Cu

sto

mer

focu

s4

3.6

6.7

9.8

56

9.5

9*

–.7

9*

.68

*–

.80*

.65

*–

.81

*.7

0*

–.8

2*

.62

*–

.74

*E

mp

loy

eefo

cus

43

.93

.78

.87

73

.76

*–

.82*

.63

*–

.81*

.71

*–

.83

*.7

2*

–.7

9*

.75

*–

.77

*.5

9*

–.7

6*

*p,

.01

(2-t

aile

d).

(1–

6¼

Ind

ivid

ual

lev

el;

a–

f¼

Fac

ilit

yle

vel

).

The International Journal of Human Resource Management 1953

were reported to be higher than the individual scores. This was an expected outcome as

correlations are usually higher at group levels compared to individual scores. The results

are shown in Table 2.

Hypothesis 1 tested the relationship between the QHRP and satisfaction variables.

Each QHRP sub-variable is tested for a relationship with each satisfaction sub-variable,

respectively. First, in order to gauge the magnitude of variation between facilities in the

satisfaction sub-variable, the HLM analysis estimated the unconditional model baseline

with no predictors at either level for the dependent variable. Second, an initial model

testing the relationships between all QHRP and the satisfaction sub-variable is established.

Third, those QHRP variables reported to have significant relationships with the

satisfaction sub-variable are tested again for the final model. Fourth, after identifying

the QHRP variables with significant relationships to the satisfaction sub-variable, an initial

full model was formulated to test the level of relationships between the QHRP variables

that reported a significant relationship with the satisfaction sub-variables and all other

organizational performance outcomes variables. The fifth and final step included the final

full model analysis for all variables that presented a significant relationship in the previous

step with the satisfaction sub-variable under investigation. A separate HLM analysis

measuring the relationship with all QHRP variables was conducted for each satisfaction

sub-variable, respectively. The relationship between the QHRP sub-variables and

satisfaction sub-variables were measured using HLM data analysis method. Hypothesis

testing for both employee satisfaction and customer satisfaction was separately conducted.

Employee satisfaction

According to the unconditional employee satisfaction model, coefficient value for

employee satisfaction was reported as 3.738945. Standard deviation at the individual level

was .719 and .214 at the facility level. Chi square for standard deviation was 321.274 and

reported significant p value (p , .000). Two-tailed t-test for means was also significant

(p , .000). Overall, there was significant variation for employee satisfaction both at the

individual and facility levels.

According to the HLM analysis with all QHRP scores included at level-1, there was a

significant positive relationship between employee satisfaction and strategic management;

and a significant negative relationship with process management. Employee satisfaction

also reported a significantly positive relationship with general HR functions, and

employee focus. At the facility level (level-2), HLM reported a significantly positive

relationship between employee satisfaction and general HR functions, and employee

focus.

After eliminating the nonsignificant QHRP sub-variables, the final model to test the

relationships between employee satisfaction and the QHRP sub-variables was obtained. At

level-1 (individual level), there was a significant positive relationship between employee

satisfaction and strategic management. Process management, however, was reported to be

negatively associated with employee satisfaction. General HR functions and employee

focus were also positively related to employee satisfaction. At level-2 (facility level), there

was a significant positive relationship between employee satisfaction and general HR

functions, and employee focus. The analysis also reported that 87% variance was

explained by the QHRP sub-variables included in the final model at the facility level.

The relationship between employee satisfaction and other organizational performance

outcomes variables and the QHRP sub-variables which were reported to have significant

relationships with employee satisfaction were also tested. At the individual level, the

M. Akdere1954

QHRP sub-variables measured to be significantly positively associated with employee

satisfaction were strategic management, general HR functions, and employee focus. The

analysis on the relationship between employee satisfaction and process management,

however, resulted in a significantly negative relationship.

At the facility level, the initial model reported that the organizational performance

outcomes sub-variables of operating margin, net margin, customer satisfaction, and the

QHRP sub-variables of general HR functions, and employee focus were reported to have a

significantly positive relationship with employee satisfaction.

According to the final employee satisfaction full model, at the individual level, the

QHRP sub-variables of strategic management, general HR functions, and employee focus

reported significant positive relationships with employee satisfaction.

Again, in this analysis, process management yielded a significant negative relationship

with employee satisfaction. At the facility level, the financial performance outcomes

sub-variables of operating margin and net margin, customer satisfaction, the QHRP sub-

variables of general HR functions, and employee focus were significantly related to

employee satisfaction. Results are reported in Table 3.

Customer satisfaction

Based on the unconditional customer satisfaction model, coefficient value for customer

satisfaction was reported as 4.332910. Standard deviation at the individual level was

.74478 and .23538 at the facility level. Chi square for standard deviation was 187.46170

and reported significant p value (.001). Two-tailed t-test for means was also significant.

Overall, there was significant variation for customer satisfaction across facilities.

According to the HLM analysis of customer satisfaction and the QHRP scores, only

the QHRP sub-variable of general HR functions reported a moderately positive

relationship with customer satisfaction. The analysis also reported 92% variance explained

by general HR functions at the facility level. The relationship between customer

satisfaction and other organizational performance outcomes variables and general HR

functions were also tested using a full model. At the facility level, the HLM analysis

reported that there was no relationship between customer satisfaction and financial

outcomes of organizational performance. The relationship between customer satisfaction

and employee satisfaction, on the other hand, was also reported to be positively significant.

The analysis also reported that 80% variance was explained by general HR functions and

employee satisfaction variables included in the full model at the facility level. At the

facility level, the null hypothesis was rejected and the alternative hypothesis was accepted

in that there was a positive relationship between the QHRP sub-variable of general HR

functions and customer satisfaction as an organizational performance outcome variable.

Table 4 reports the customer satisfaction full model at the facility level.

Financial performance outcomes

Hypothesis 2 tested by two sub-variables: operating margin and net margin. Stepwise

multiple regression analysis was used to measure the level of relationship between

financial outcomes of organizational performance variables and QHRP variables at the

facility level. Stepwise multiple regression results reported significant relationships

between both of the financial outcomes of organizational performance and the QHRP sub-

variables. Therefore, the null hypothesis was rejected and the alternative hypothesis

was accepted; thus, concluding that there was a positive relationship between the QHRP

The International Journal of Human Resource Management 1955

Tab

le3

.R

esu

lts

of

hie

rarc

hic

alli

nea

rm

od

elin

gan

aly

sis

–fi

nal

emp

loy

eesa

tisf

acti

on

full

mo

del

.

Fixed

effects

Coefficient

Standard

error

tdf

p

Fo

rS

trat

egic

man

agem

ent

slo

pe,

b1

Inte

rcep

tg

2.0

90

.02

78

3.2

33

27

29

.00

2F

or

Pro

cess

man

agem

ent

slo

pe,b

2,

Inte

rcep

tg

22

.11

4.0

28

23

.98

42

72

9.0

00

Fo

rG

ener

alH

Rfu

nct

ion

ssl

op

e,b

3,

Inte

rcep

tg

2.4

16

.03

21

3.1

48

27

29

.00

0F

or

Em

plo

yee

focu

ssl

op

e,b

4,

Inte

rcep

tg

2.3

53

.02

71

3.0

31

27

29

.00

0F

or

Inte

rcep

t1

,g

13

.73

9.0

14

27

3.3

27

52

.00

0In

terc

ept

2,g

2

Financialperform

ance

outcomes

variables

Op

erat

ing

mar

gin

,g

01

1.2

27

.50

02

.45

55

2.0

09

Net

mar

gin

,g

02

1.4

73

.47

33

.11

15

2.0

03

Cu

sto

mer

sati

sfac

tio

n,g

06

.51

7.1

39

3.7

12

52

.00

1

QHRPvariables

Gen

eral

HR

fun

ctio

ns,g

07

.41

0.1

24

3.3

17

52

.00

2E

mp

loy

eefo

cus,g

08

.62

8.1

21

5.1

96

52

.00

0

Random

effects

Standard

deviation

Variance

component

df

x2

p

Inte

rcep

t1

,r 0

i.0

77

.00

55

21

09

.68

0.0

00

Lev

el-1

,r 1

i.0

49

6.2

45

M. Akdere1956

Tab

le4

.R

esu

lts

of

hie

rarc

hic

alli

nea

rm

od

elin

gan

aly

sis

–fi

nal

cust

om

ersa

tisf

acti

on

full

mo

del

.

Fixed

effects

Coefficient

Standard

error

tdf

p

Fo

rIn

terc

ept

1,b

04

.33

8.0

33

13

2.1

90

52

.00

0In

terc

ept

2,g

0

Fin

anci

alp

erfo

rman

ceo

utc

om

esv

aria

ble

sO

per

atin

gm

arg

in,g

01

1.2

86

1.1

54

1.1

14

52

.27

1N

etm

arg

in,g

02

21

.09

51

.25

62

.87

25

2.3

88

Em

plo

yee

sati

sfac

tio

n,g

06

.51

7.1

39

3.7

12

52

.00

1Q

HR

Pv

aria

ble

sG

ener

alH

Rfu

nct

ion

s,g

07

.47

3.1

74

2.7

25

52

.00

9

Random

effects

Standard

deviation

Variance

component

df

x2

p

Inte

rcep

t1

,r 0

i.1

94

.00

85

21

29

.91

2.0

00

Lev

el-1

,r 1

i.7

47

.55

7

The International Journal of Human Resource Management 1957

sub-variables of knowledge management and strategic management and financial

outcomes of organizational performance. The results are shown in Table 5.

Discussion

The purpose of this study was to investigate the relationship between Quality-focused

Human Resource Practices (QHRP) and organizational performance outcomes in a sample

of long-term healthcare organizations. Table 6 illustrates a summary of the relationships

between QHRP and organizational performance outcomes tested in this study.

First, at the individual level, there was a significant relationship between strategic

management and employee satisfaction. This suggests that long-term healthcare

organizations faced with the challenge of high employee turnover should utilize strategic

management at the business planning level and focus on quality management to develop

practices to increase employee satisfaction. This result corresponds to what Chua and

Janssen (1999) reported in that ‘quality management helped companies’ turnover

problems, reduced capital spending, made existing capacity available and new capacity

unnecessary, and produced greater results from investment when implemented

strategically’ (p. 15). In addition, a finding by Roulac (2001) examining corporate

business strategy suggested that organizational strategy could be integral to achieving

Human Resources’ objectives of attracting and retaining outstanding people through

employee satisfaction as well as enhancing productivity and achieving superior business

performance.

Second, the study reported a significant relationship at the individual level between

employee satisfaction and process management. Process management is often considered

Table 5. Stepwise regression analyses for financial performance outcomes and QHRP.

Variable Operating margin SEM Net margin SEM

Knowledge management .000 .093 .000 .095Strategic management .000 .081 .000 .083R 2 .103 .275

Table 6. Summary of significant (þ /2 ) relationships between QHRP variables and organizationalperformance outcomes variables.

Variables SatisfactionFinancial outcomes oforganizational performance

QHRP VariablesEmployeesatisfaction

Customersatisfaction

Operatingmargin

Netmargin

LeadershipKnowledge management þ þStrategic management þ þ þProcess management 2General HR functions þ þCustomer focusEmployee focus þSatisfaction variablesEmployee satisfaction þ þ þCustomer satisfaction þ

M. Akdere1958

to involve planning and administering the activities necessary to achieve a high level of

performance in key business processes, identifying opportunities for improving quality

and operational performance, and ultimately, customer satisfaction (Evans and Lindsay

2005). This study identified a negative relationship between process management and

employee satisfaction. This finding, however, is consistent with the existing literature on

process management which does not necessarily include employee satisfaction as a

potential outcome.

In another study of general managers and quality managers from 20 US companies,

Saraph, Benson, and Schroeder (1989) reported a relationship between process

management and employee satisfaction within the quality management framework.

Seungwook Park, Hartley and Wilson (2001) studied the Korean auto industry and its

quality management practices and performance results, and reported that the highest

performance rated companies were found to emphasize process management and

employee satisfaction to a greater degree than the lowest performance rated companies.

The finding reported in this current study in regards to the relationship between process

management and employee satisfaction does not, however, support the findings of the

aforementioned studies.

Based on the HLM analysis, there is a negative relationship between process

management and employee satisfaction. Even though a significant level of relationship is

reported in the analysis, the relationship is negative. One reason for a negative relationship

can be explained by the fact that unlike the previous studies, this study examined the long-

term healthcare organizations dealing with human care and maintaining human lives,

which is significantly different from the environment of an auto industry or engineering

production. What this study argues is that the reported negative relationship should be

taken into account to develop unique ways and techniques to approach process

management in long-term healthcare organizations in order to improve employee

satisfaction.

Third, the general Human Resource functions of supervision, empowerment, job

design, coordination/communication, and training and development were reported to be

significantly related to employee satisfaction both at the individual and facility levels. This

finding highlights the traditional contribution of Human Resource functions to employee

satisfaction and supports the results of Oliva’s study (2001) reporting significant

relationships with general HR functions and employee satisfaction. This study

investigated the employees’ reactions to work pressure in the service industry, which

was defined as a negative outcome of general HR functions, and suggested that ‘how a

service organization responded to work pressure was a critical determinant of service

quality, employee satisfaction, and the overall profitability of the service firm’ (p. 27).

The reasons for the significant positive relationship between general HR functions

and employee satisfaction are twofold. First, as a field that focuses on developing and

managing human expertise and resources within the organization, one of the goals of HR

should naturally be achieving employee satisfaction as a business outcome. Second, these

findings are also important for the field of long-term healthcare where organizations face

problems in regards to employee development and management, which often result in a

decrease in employee satisfaction. Little (2003) reported that, in achieving quality,

employee satisfaction was considered as crucial and influential as customer satisfaction in

twenty-first century business and management practices. The current study confirms this

trend and calls for further emphasis on general HR functions integrating quality

management process in long-term healthcare organizations. Hyer and Brown (2003), on

the other hand, conducted a longitudinal study of 16 firms over a span of more than 10

The International Journal of Human Resource Management 1959

years and investigated the concept of ‘work cells.’ Their study reported that general HR

functions, defined as work cells, had tremendous potential for improving productivity,

throughput time, cost, quality, and employee satisfaction. This study also supports Hyer

and Brown’s findings and highlights HR’s contribution to achieving a satisfied workforce.

Fourth, employee focus was reported to have a significant positive relationship with

employee satisfaction both at the individual and facility levels. This study argues that

valuing staff is an important factor in quality management and performance improvement,

and highlights the relationship between employee focus as one of the QHRP sub-

variables and employee satisfaction. In fact, it may be considered an expected outcome

that organizations practicing employee focus consequently achieve higher levels of

employee satisfaction. A study by Agus (2005) investigating the structural linkages

between quality management, product quality performance, and business performance in

the electronics industry in Malaysia suggested a similar finding in which employee

satisfaction was reported as an outcome of employee focus of the organization. In another

study, Riordan, Vandenberg and Richardson (2005) examined the relationship between the

perceived employee involvement and organizational effectiveness, and reported that

organizations with high levels of perceived employee involvement lead to organizational

effectiveness as measured through financial performance, turnover rate, and workforce

morale. Furthermore, building value through organization and people contributes to HR’s

return on investment (Ulrich and Smallwood 2005).

Fifth, customer satisfaction, and financial performance outcomes of operating margin

and net margin reported significant relationships with employee satisfaction. Existing

literature on the relationship between employee satisfaction and financial outcomes of

organizational performance presents similar results. Harmon et al. (2003) conducted an

action research study, examining how changes to the work environment affected quality

and cost of service within the US Department of Veterans Affairs (VA). They surveyed

112,360 employees, and asked for employee observations and opinions on a wide variety

of topics surrounding their work experiences. The study reported that employee

satisfaction was related to decreased cost. Similarly, Ahire, Golhar, and Waller (1996)

used a survey of 371 manufacturing firms, and examined the constructs of quality

management and then empirically tested and validated their model of quality management

framework. They reported significant association between employee satisfaction and

organizational business results. The current study also reports the same relationship within

the long-term healthcare context. Furthermore, the findings of this current study also

support the notion of investing in organizations’ most precious assets – their employees.

Sixth, at the facility level, HLM analysis reported only one significant relationship

between QHRP and customer satisfaction: general HR functions. A similar relationship

was also recently reported by Oakley (2005), who surveyed a sample of 5568 employees in

90 organizations in the US media industry and their customers which were over 37,000.

Examining the attitudes of employees, the study reported a direct correlation between

general HR functions and customer satisfaction, and customer satisfaction and financial

performance. It can be concluded that long-term healthcare organizations can utilize the

QHRP framework as a core business process to achieve employee and customer

satisfaction. This is important as customer satisfaction was reported to be related to

general HR functions within the organization.

Seventh, stepwise multiple regression analysis reported a significant relationship

between knowledge management and financial outcomes of organizational performance.

Shih and Chiang (2005) examined the impact of both corporate and human resource

strategies on knowledge management strategy, and their interactive influence on the

M. Akdere1960

effectiveness of the knowledge management. Using a sample of 147 Taiwanese large

companies in the banking, services, and manufacturing industries, the results of their study

reported a relationship between knowledge management and organizational financial

outcomes. In another study, Kyriakopoulos and de Ruyter (2004) investigated how

organizations utilized stored knowledge and acquired market information. Their study of

product development activities reported that there was a positive relationship between

knowledge management and financial performance outcomes.

The findings presented in these studies are very similar to those of this study.

Knowledge management is becoming increasingly important in the bottom line

contribution of HR practices to organizations. The finding of this study on the

relationship between knowledge management and financial outcomes of organizational

performance is even more meaningful for long-term healthcare organizations which suffer

dramatically as a result of high employee turnover and the consequent failure in the

organization-wide implementation of knowledge management practices.

Finally, the data analysis of stepwise multiple regression reported a significant

relationship between strategic management and financial outcomes of organizational

performance. Hatch and Dyer (2004) sought to identify the sources of wide and persistent

variations in learning performance in the semiconductor manufacturing industry. The

findings revealed a correlation between knowledge management and financial

performance outcomes. A recent study by Reeves and Ford (2004) sampled 81 healthcare

service providers listed in the same Standard Industrial Classification codes for Health

Services Organizations. Their findings reported that strategic management was

significantly related to financial outcome variables.

This study also reported a similar relationship between strategic management and

financial outcomes of organizational performance. Quality management focuses on the

execution of strategic management in healthcare which should address organizational

agility based on contingency plans, or if circumstances require a shift in plans and rapid

execution of new or changed plans. Furthermore, strategic management includes overall

organizational strategy to address changes in healthcare services and programs. In a

rapidly changing technologically advanced healthcare environment, organizations should

expect changes in services and programs as quality of care is rapidly increasing through

advancing technology. The findings highlight the need for long-term healthcare

organizations to capitalize on strategic management as a competitive and sustainable

advantage and adopt management practices that integrate strategic management as a core

business function within the QHRP framework.

Implications for human resource management practice and research

One of the goals of this study is to provide a framework for the field of Human Resources

(HR) to measure its contribution to organizational performance outcomes. The framework

validated in this study can serve as a reliable tool to link HR practices to organizational

performance within a quality management environment. The demand for higher performance

is a reality of today’s business. Using the QHRP framework, HR practitioners and scholars

can view and position HR as a major business process.

The survival of the field of HR as a strategic and competitive business partner lies in

its ability to develop new approaches and sound measurement systems to demonstrate its

financial benefit to organizations’ bottom line. This notion is supported by researchers in the

field. American Society for Training and Development reported that ‘only 3 percent of T&D

programs were evaluated for financial impact’ (Bassi, Benson and Cheney 1996, p. 12).

The International Journal of Human Resource Management 1961

Huselid (1995), on the other hand, pointed out the lack of systematic research investigating

HR’s ability to provide companies with a source of competitive advantage. Thus, the

framework validated in this study not only measures HR’s relationship with organizational

performance outcomes but introduces a new realm of practice and research by integrating

quality management as a major HR process. The findings of this study highlight and

recommend that the relationships between the QHRP and organizational performance

outcomes are all significant in contributing to the argument of HR’s bottom line

contribution to the organization. Furthermore, these findings present evidence that

investment in HR will very likely return to the organization.

This study further suggests that HR managers can advocate and champion the QHRP

framework as a strategic business process. A previous study by MacDuffie (1995) reported

strong evidence that supports the results presented in this study in which organizations

bundling HR practices into a system that was integrated with production/business strategy

outperformed companies using traditional mass production systems. In addition, education

managers and employees in the range and meaning of the expected performance

dimensions can help them recognize desired behaviors, evaluate performance accurately,

and provide meaningful feedback, as well as guide their own goal setting and performance

tracking (London, Mone and Scott 2004). Future research is needed to test this framework

for HR practices in other industries.

Acknowledgements

An earlier version of this research was named 2005 American Society for Training & DevelopmentDissertation of the Year Award.Prior versions of this research have been presented at: the 2006 American Society for Training &Development (ASTD) International Conference & Exposition, Dallas, Texas; the 21st Annual(2006) Society for Industrial and Organizational Psychology (APA Div. 14) Conference, Dallas,Texas; and the 2007 Human Resource Management Association of Southeastern Wisconsin SpringConference, Milwaukee, Wisconsin.I would like to thank my dissertation advisor Dr. Richard A. Swanson, and committee members,Dr. Sandra J. Potthoff, Dr. Ross E. Azevedo, Dr. Gary N. McLean and Dr. Rosmerie J. Park. Specialthanks to friend and colleague Dr. Toby M. Egan for his many helpful suggestions on this research.

References

Agus, A. (2005), ‘The Structural Linkages between TQM, Product Quality Performance, andBusiness Performance: Preliminary Empirical Study in Electronics Companies,’ SingaporeManagement Review, 27, 1, 87–105.

Ahire, S.L., Golhar, D.Y., and Waller, M.A. (1996), ‘Development and Validation of TQMImplementation Constructs,’ Decision Sciences, 27, 1, 23–55.

Anderson, J.C., Rungtusanatham, M., and Schroeder, R.G. (1994), ‘A Theory of QualityManagement Underlying the Deming Management Method,’ Academy of Management Review,19, 3, 472–509.

Arvey, R.D., and Murphy, K.R. (1998), ‘Performance Evaluation in Work Settings,’ Annual Reviewof Psychology, 49, 1, 141–168.

Barney, J.B., and Wright, P.M. (1998), ‘On Becoming a Strategic Partner: The Role of HumanResources in Gaining Competitive Advantage,’ Human Resource Management, 37, 1, 31–46.

Bassi, L.J., Benson, G., and Cheney, S. (1996), ‘The Top Ten Trends,’ Training and Development,50, 11, 28–42.

Bertalanffy, L., von (1968), General System Theory: Foundations, Development, Applications, NewYork: George Braziller.

Black, S.E., and Porter, L.J. (1996), ‘Identification of the Critical Factors of TQM,’ DecisionSciences, 27, 1, 1–21.

M. Akdere1962

Bowen, D.E., and Lawler, E.E. (1992), ‘Total Quality-oriented Human Resource Management,’Organizational Dynamics, 20, 4, 29–41.

Briggs, S., and Keogh, W. (1999), ‘Integrating Human Resource Strategy and Strategic Planning toAchieve Business Excellence,’ Total Quality Management, 10, 4–5, 447–453.

Chua, R.C., and Janssen, A. (1999), ‘Six Sigma: A Pursuit of Bottom-line Results,’ EuropeanQuality, 8, 3, 12–15.

Crosby, P.T. (1979), Quality is Free: The Art of Making Quality Free, New York: McGraw-Hill.Dale, B.G., and Bunney, H. (1999), Total Quality Management Blueprint (Business Blueprints),

Oxford: Blackwell Publishers.Dale, B.G., and McQuarter, R.E. (1998), Managing Business Improvement and Quality:

Implementing Key Tools and Techniques, Oxford: Blackwell.Evans, J.R., and Lindsay, W.M. (2005), The Management and Control of Quality (6th ed.),

Cincinnati, OH: South-Western College Publishing.Harmon, J., Scotti, D.J., Behson, S., Farias, G., Petzel, R., Neumam, J.H., and Keashly, L. (2003),

‘Effects of High-involvement Work Systems on Employee Satisfaction and Service Costs inVeterans Healthcare,’ Journal of Healthcare Management, 48, 6, 393–407.

Hatch, N.W., and Dyer, J.H. (2004), ‘Human Capital and Learning as a Source of SustainableCompetitive Advantage,’ Strategic Management Journal, 25, 12, 1155–1178.

Huselid, M.A. (1995), ‘The Impact of Human Resource Management Practices on Turnover,Productivity, and Corporate Financial Performance,’ Academy of Management Journal, 38, 3,635–672.

Hyer, N.L., and Brown, K.A. (2003), ‘Work Cells with Staying Power: Lessons for ProcessComplete Operations,’ California Management Review, 46, 1, 27–52.

Ichniowski, C., and Shaw, K. (1999), ‘The Effects of Human Resource Management Systems onEconomic Performance: An International Comparison of U.S. and Japanese Plants,’Management Science, 45, 5, 704–721.

Kyriakopoulos, K., and de Ruyter, K. (2004), ‘Knowledge Stocks and Information Flows in NewProduct Development,’ Journal of Management Studies, 41, 8, 1469–1498.

Lawler, E.E., III. (2005), ‘From Human Resource Management to Organizational Effectiveness,’Human Resource Management, 44, 2, 165–169.

Little, B. (2003), ‘The Twenty-first Century Business Frontier,’ Industrial and CommercialTraining, 35, 6, 263–268.

London, M., Mone, E.M., and Scott, J.C. (2004), ‘Performance Management and Assessment:Methods for Improved Rater Accuracy and Employee Goal Setting,’ Human ResourceManagement, 43, 4, 319–336.

MacDuffie, J.P. (1995), ‘Human Resource Bundles and Manufacturing Performance: OrganizationalLogic and Flexible Production Systems in the World Auto Industry,’ Industrial and LaborRelations Review, 48, 2, 197–221.

Macy, B.A., and Izumi, H. (1993), ‘Organizational Change, Design, and Work Innovation: A Meta-analysis of 131 North American Field Studies – 1961–1991,’ in Research in OrganizationalChange and Development (Vol. 7), eds. R.W. Woodman and W.A. Passmore, Greenwich, CT:JAI Press, pp. 235–313.

Neumark, D. (2001), ‘The Employment Effects of Minimum Wages: Evidence From a PrespecifiedResearch Design,’ Industrial Relations, 40, 1, 121–145.

Oakley, J.L. (2005), ‘Linking Organizational Characteristics to Employee Attitudes and Behavior,’Northwestern University Forum for People Management and Measurement, retrieved on 29October 2006, from: http://www.performanceforum.org/PFM/whitepapers.asp

Oliva, R. (2001), ‘Tradeoffs in Responses to Work Pressure in the Service Industry,’ CaliforniaManagement Review, 43, 4, 26–43.

Raudenbush, S.W., and Bryk, A.S. (2002), Hierarchical Linear Models: Applications and DataAnalysis Methods (2nd ed.), Thousand Oaks, CA: Sage Publications.

Reeves, T.C., and Ford, E.W. (2004), ‘Strategic Management and Performance Differences: Non-profit Versus For-profit Health Organizations,’ Health Care Manage Review, 29, 4, 298–308.

Rhoades, J.A., and Sommers, J.P. (2001), Nursing Home Expenses, 1987 and 1996, Rockville, MD:Agency for Healthcare Research and Quality.

Riordan, C.M., Vandenberg, R.J., and Richardson, H.A. (2005), ‘Employee Involvement Climateand Organizational Effectiveness,’ Human Resource Management, 44, 4, 471–488.

The International Journal of Human Resource Management 1963

Roulac, S.E. (2001), ‘Corporate Property Strategy is Integral to Corporate Business Strategy,’Journal of Real Estate Research, 22, 1/2, 129–153.

Ruona, W.E.A. (2001), ‘System Theory as a Foundation for HRD,’ in Foundations of HumanResource Development, eds. R.A. Swanson and E.F. Holton, San Francisco, CA: Berrett–Koehler, pp. 114–124.

Saraph, J.V., Benson, P.G., and Schroeder, R.G. (1989), ‘An Instrument for Measuring the CriticalFactors of Quality Management,’ Decision Sciences, 20, 4, 810–829.

Seungwook Park, R.G., Hartley, J.L., and Wilson, D. (2001), ‘Quality Management Practices andtheir Relationships to Buyer’s Supplier Ratings: A Study in the Korean Automotive Industry,’Journal of Operations Management, 19, 6, 695–712.

Shih, H., and Chiang, Y. (2005), ‘Strategy Alignment between HRM, KM, and CorporateDevelopment,’ International Journal of Manpower, 26, 6, 582–605.

Simmons, D.E., Shadur, M.A., and Preston, A.P. (1995), ‘Integrating TQM and HRM,’ EmployeeRelations, 17, 3, 75–86.

Sousa, R., and Voss, C.A. (2002), ‘Quality Management Re-visited: A Reflective Review andAgenda for Future Research,’ Journal of Operations Management, 20, 1, 91–109.

Strahan, B. (1987), Nursing Home Characteristics: Preliminary Data from the 1985 NationalNursing Home Survey, Hyattsville, MD: National Center for Health Statistics.

Strahan, B. (1997), An Overview of Nursing Homes and their Current Residents: Data from the 1995National Nursing Home Survey, Hyattsville, MD: National Center for Health Statistics.

Ulrich, D., and Smallwood, N. (2005), ‘HR’s New RIO: Return on Intangibles,’ Human ResourceManagement, 44, 2, 137–142.

Wesner, M. (1995), ‘A Journey of Change: The History of Team Building in Organizations,’Virginia Polytechnic Institute and State University, Dissertation Abstracts International.

M. Akdere1964