the impact of participative management perceptions on

The Impact of ParticipativeManagement Perceptions onCustomer Service, iVledical Errors,Burnout, and Turnover IntentionsIngo Angermeier, FACHE, chief executive officer, Spartanburg Regional HealthcareSystem, Spartanburg, South Carolina; Benjamin B. Dunford, PhD, assistant professor,Krannert School of Management, Purdue University, West Lafayette, Indiana; Alan D.Boss, PhD candidate, Robert H. Smith School of Business, University of Mar^'land,College Park, Maryland; and R. Wayne Boss, PhD, professor, Leeds School of Business,University of Colorado at Boulder

E X E C U T I V E S U M M A R YNumerous challenges confront managers in the healthcare industry, making itincreasingly difficult for healthcare organizations to gain and sustain a competi-tive advantage. Contemporary management challenges in the industry have manydifferent origins (e.g., economic, financial, clinical, and legal), but there is growingrecognition that some of management's greatest problems have organizational roots.Thus, healthcare organizations must examine their personnel management strategiesto ensure that they are optimized for fostering a highly committed and productiveworkforce. Drawing on a sample of 2,522 employees spread across 312 departmentswithin a large U.S. healthcare organization, this article examines the impact of a par-ticipative management climate on four employee-level outcomes that represent someof the greatest challenges in the healthcare industry; customer service, medical errors,burnout, and turnover intentions.

This study provides clear evidence that employee perceptions of the extent towhich their work climate is participative rather than authoritarian have importantimplications for critical work attitudes and behavior. Specifically, employees inhighly participative work climates provided 14 percent better customer service, com-mitted 26 percent fewer clinical errors, demonstrated 79 percent lower burnout, andfelt 61 percent lower likelihood of leaving the organization than employees in moreauthoritarian work climates. These findings suggest that participative managementinitiatives have a significant impact on the commitment and productivity of indi-vidual employees, likely improving the patient care and effectiveness of healthcareorganizations as a whole.

For more information on the concepts in this article, please contact Dr. Boss [email protected].

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I n today's era of rapidly changingtechnology, an aging and less-insured

population, and a flurtuating economy,healthcare organizations face more chal-lenges than ever. A survey indicates thathealthcare executives are constrainedto do more with fewer resources, whichmakes it difficult to sustain their orga-nization's viability and mission (Prybil2003). One industry observer aptlynotes that "it would be difficult to con-ceive of a field that is and will be subjectto greater scrutiny, greater demandsand greater changes than the Americanhealthcare system" (Litch 2005, 20).

Many factors underlie contemporarychallenges in healthcare management,but there is growing awareness amongscholars and practitioners that thegreatest challenges have organizational,rather than clinical or financial, roots(Ramanujam and Rousseau 2006). Forinstance, in one study, more than threequarters of CEOs identified "workforceissues" as a primary challenge in man-aging healthcare organizations (Prybil2003). Improvements in patient safety,employee performance, and retentionof key talent have become more difficultas healthcare personnel confront greaterdemands and heavier workloads (Ra-manujam and Rousseau 2006).

In response to these challenges,healthcare executives must implementmanagement strategies that will enablethem to optimize investments in hu-man capital to sustain a competitiveadvantage, Two archetypal managementstrategies have been previously identi-fied by organizational scholars (Arthur1994). First, autocratic (or authoritarian)management strategies endeavor to re-duce labor costs by emphasizing controland efficiency through specialized roles

and strict rule enforcement. In contrast,participative management strategies en-deavor to increase employee productiv-ity by rewarding performance, fosteringemployee commitment, and decentral-izing decision making to give employeesmore voice in work decisions (Arthur1994). Two decades' worth of researchin the United States and abroad dem-onstrates that while autocratic manage-ment strategies are effective in certainconditions, participative approaches aretypically associated with greater long-term corporate performance (Arthur1994; Delaney and Huselid 1996; Miahand Bird 2007). Yet to date, little partici-pative management research has beenconducted in healthcare, and fewer stud-ies have examined the sorts of employ-ee-level outcomes that are indicativeofthe industry's greatest contemporarychallenges.

This growing disconnect betweenexisting empirical research and cur-rent problems in healthcare manage-ment represents an important gap inthe literature. Therefore, the purpose ofour study was to examine the impactof participative-management employeeperceptions on four critical employee-level outcomes: customer service,medical errors, burnout, and turnoverintentions. To that end, the study drewon a large sample of employees spreadacross more than 300 departments in alarge healthcare organization based inthe southeastern United States. -L,

P A R T I C I P A T I V E C L I M A T E :THE L I K E R T O R G A N I Z A T I O N A LP R O F I L EParticipative management practices haveexisted for more than a century, butthey expanded in scope and in practice

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THE IMPACT OF PARTICIPATIVE MANAGEMENT PERCEPTIONS

during the 1970s as organizationsrecognized the benefits of redesigningmanufaauring jobs to minimize rep-etition and give employees input intomatters tbat influenced their work (Katz,Kochan, and Colvin 2007). As moreorganizations experimented witb par-ticipative management, organizationaltheorists sought to understand tbeprocess by wbicb tbey could improveorganizational effectiveness. Subsequentresearch bigbligbted two employeeperceptions tbat are fundamental to tbesuccess of participative management ini-tiatives (Pierce, Rubenfeld, and Morgan1991). First, information must flow freelyto and from employees in tbe organiza-tion, sucb tbat tbey are given adequateinformation about tbeir work and tbattbeir upward input on work-related mat-ters is given legitimate consideration(Rosen and Quarrey 1987). Second,employees must perceive tbat tbey bavean adequate degree o( control over tbeirwork and the decisions tbat affect tbeirwell-being (Pierce, Rubenfeld, andMorgan 1991). Wben employees feelempowered, tbey will perform better,be more committed to the organization,and be less likely to leave, all of wbicbcollectively influence tbe effectiveness oftbe organization (Kanter 1993).

Ukert (1967) developed a typologyand measurement scale (see Metbodssection) of organizations based on tbeautboritarian-participative climatecontinuum. Tbe Liken Profile of Organi-zations draws on employee perceptionsof six climate dimensions (leadersbip,motivation, communication, decisionmaking, goal setting, and control) tbatare aggregated to determine tbe degreeto wbicb an organization is participativein its climate. System 1 organizations

are considered to bave an exploitive,coercive, and "autboritarian" manage-ment style, wbereby information flowsonly from tbe top down and is viewedwith suspicion by employees. System 2organizations are labeled "benevolentautboritarian," wbereby some degreeof bottom-up communication is al-lowed but "only [tbe informationtbatj tbe boss wants to hear." System3 organizations are "consultative" intbat they set goals and issue directivesafter discussing tbe matter witb subor-dinates. Finally, System 4 organizationsare considered "participative," wberebycommunication is completely open andflows upward and downward and tbedecision making is sbared between em-ployees and management (see Figure 1for additional description).

Researcb has demonstrated tbatemployees form distinct participative-climate perceptions and tbat tbese per-ceptions are associated witb outcomestbat include organizational structureresults (Reigle 2001 ) and corporateperformance (Miab and Bird 2007).However, to date, little if any researcbbas linked participative-climate percep-tions to employee-level outcomes. Intbe following section, we examine bowparticipative-climate perceptions affectcustomer service, medical errors, burn-out, and turnover intentions.

Customer ServiceCustomer service is central to organi-zational effectiveness, particularly inbealtbcare institutions wbere employees'interactions witb patients bave a strongeffect on patient satisfaction, bealtbcarequality, and brand loyalty (McManus2007). Researcb demonstrates tbat cus-tomer service bas a stronger impact on

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FIGURE 1Likert's Profile of Organizations

u

Participative—System 4lotivation accomplished tliroiigh group panicipalion and involvement in

setting goals, improving methods, and appraising progressExtensive interaction exists with a high degree of confidence and trustCommunication down, up. and with peers is extensive and accurateDecision making Is widely done throughout the organization, based uponcomplete and accurate informationGoals are established by group participation

Consultative—System 3Motivation accomplished through reward, occasional punishment, and someinvolvementModerate interaction exists between subordinates and superiors with a fairamount oí confidence and trustQuite a hit of communication tlowing down and upGoals are set and orders are issued after discussion with subordinates

Benevolent Authoritarian—System 2Motivation accomplished through reward and potential punishmentLittle interaction between subordinates and superiorsFear and caution on the part of subordinatesCommunication is mostly downwardInformation the boss wants to hear flows upwardPolicy decisions are made at the top, orders are issued, and the opportunityto comment may exist

Exploitive Authoritarian—System 1Motivation accomplished through fear, threat, punishment, andoccasional rewardLow trtist and dissatisfaction with the organizationInformation from the top down is viewed with suspicionInformation is withheld by subordinates

Adapted from Liken (1967).

patients' "likelihood of recommendingservices" than clinical performance (c.f.McManus 2007). Participative-climateperceptions are likely to influence em-ployees' customer service performance

in healthcare organizations becauseemployees in participative climates tendto be more engaged in and more satis-fied with their jobs (Spreitzer 1995) andthus are more likely to be motivated

130


to go the extra mile for their patients.Moreover, employees in participativeclimates generally face fewer organiza-tional constraints and personal risks thatmay prevent them from providing highlevels of customer service. Thus, we hy-pothesized that employees who reporthigher participative-climate perceptionswill have higher customer service ratingsby their supervisors.

Medical ErrorsAs noted earlier, patient safety has be-- ome a key concern among healthcareorganizations and is often considereda key performance indicator in orga-nizations (Ramanujam and Rousseau2006). Poor nurse (and other caregiver)performance has been linked to patientmedical complications following sur-gery, falls from injuries, and death rates(Evans 2008). Estimates suggest thatbetween 44,000 and 98,000 patients inthe united States die each year becauseof treatment errors, costing healthcareorganizations between $17 and $29 bil-lion (Kohn, Corrigan, and Donaldson1999). Participative-climate perceptionsare likely to influence medical error ratesin healthcare organizations becausemany medical errors stem from mis-communications (Pepper and Towsley2007). Indeed, one study indicates thatpoor employee communication is themost common cause for surgical er-rors that result in patient injuries anddeath {Materials Management in Health

Care 2007). In more participative workclimates, information is more likely toflow among employee groups, thus re-ducing the prohability of medical errors(Zacharatos, Barling, and Iverson 2005).Hence, we hypothesized that employees

who report higher participative-climateperceptions will have committed fewermedical errors.

) . ' • .

BurnoutBurnout is a widespread problemamong nurses and other caregivers inthe healthcare profession because ofthe nature of healthcare work and theincreasing demands placed on theseprofessionals (Ramanujam and Rous-seau 2006). Burnout is problematicbecause it has been linked to numerousnegative outcomes, including reducedperformance, turnover, absenteeism,and patient care quality (Taris 2006).Healthcare employees in highly par-ticipative work climates are less likelyto burn out because they have moredecision-making authority to reducejob demands, more resources to bufferstress, and a greater access to informa-tion that may reduce tbeir workloads.Therefore, we hypothesized that em-ployees who report higher participative-climate perceptions will experiencelower levels of burnout.

Turnover IntentionsHealthcare organizations are facing anunprecedented shortage of nurses, phy-sicians, specialists, and other caregiversas a result of an aging workforce andthe stressful nature of healthcare work(Prybil 2003).Turnoverof key talentnot only diminishes healthcare qualitybut is also costly. Replacement of de-parted nurses can range from $90,000 to$145,000 per nurse, depending on skilllevels and specialties (Atencio, Cohen,and Gorenberg2003). Participative-management climates are likely to bestrongly related to employees' intentions

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to stay in the organization becauseparticipative management practicesprovide employees with more accessto information, more support, and agreater ability to influence decisions thataffect them. Employees in participativework climates, thus, are more likely tobe satisfied by their work, more resistantto work strain, and less likely to look foremployment elsewhere (l^schinger etal. 2002). In fact, participative manage-ment has been linked to lower turnoverrates in previous research (Arthur 1994;Delaney and Huselid 1996). Thus, wehypothesized that employees who re-port higher participative-climate percep-tions will be less likely to have inten-tions to leave the organization.

METHODS

Participants and ProcedureLarge healthcare organizations are awell-suited laboratory in which to studyparticipative management because oftheir multiple departments that haveunique identities and cultures. A health-care system in the southeastern UnitedStates with 5,000 employees and 312departments provided the participantsfor our study. We used multiple sourcesof data for this project, includingemployee-opinion surveys and otherarchival data.

We obtained employee person-nel records from the human resourcesdepartment, which provided individualperformance ratings, demographic vari-ables, e-mail addresses, and employeeidentification (ID) numbers. EmployeeID numbers were needed for several rea-sons. First, we used them to verify, forsecurity purposes, that participants who

logged into the independent and secureserver were indeed employees of thehealthcare system, as they used their IDas a username to access the online sur-vey. Second, because we could identifyparticular responses, we would be ableto provide employees with their indi-vidual results, should they desire to seethem. We assured participants that theirresponses would be kept strictly confi-dential and that under no circumstanceswould anyone inside the organizationhave access to their data or be able toindividually identify them.

The survey was administered onlineover a two-week period during lune2007, and all employees were solicitedfor participation. One week before thesurvey link was sent, a "pre-notice"(Dillman 2000) e-mail was sent to allemployees. This e-mail came from thechief executive officer and briefly de-saibed the upcoming study (noting thatits purposes were to better understandemployee opinions and to help improvethe quality of work life), encouragedemployees to participate, and assuredemployees that the data would godirectly to the researchers and that thehealthcare systeiTi would not have accessto individual responses. One week later,the e-mail that contained a link to theonline survey was sent to all employees.Three e-mail reminders were sent overthe subsequent two weeks to employeeswho had not yet completed the survey.

We obtained responses from atotal of 3,757 employees, resulting ina response rate of 75.1 percent. Forthe purpose of testing our hypothesesregarding medical errors, we excludedmanagers and administrative personnelwho did not have contact with patients.

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We also excluded observations withincomplete employee-opinion surveydata or missing customer service evalu-ations, resulting in a final sample thatconsisted of 2,522 employees. On aver-age, respondents to the survey were 42.4years old, with a mean organizationaltenure of 8.8 years. Approximately 84percent ofthe respondents were femaleand 77 percent were Caucasian. In termsof education, 13 percent of participantshad a high school diploma or less, 59percent had some college but no four-year degree, 20 percent had a four-yearcollege degree, and 7 percent eitherwere in graduate school or had receiveda master's, professional, or doaoraldegree. The positions represented in thesample were nonmanagerial with directpatient contact, including nurses, nurseassistants (e.g., licensed practical nurse,nurse tech, personal care aide), technicalservices personnel (from medical labo-ratory, rehabilitation, radiology, respira-tory therapy, etc.), professional servicespersonnel (from speech therapy, phar-macy, physical therapy, occupationaltherapy, etc.), and physicians.

MeasuresIndependent variable. Participativemanagement was measured using theLikert Profile, an 18-item questionnairedesigned to measure organizational cli-mate along six dimensions: leadership,motivation, communication, decisionmaking, goal setting, and control pro-cesses. The possible scores on each ques-tion range from 0 to 20. Scores wereaveraged across all measures (a = .97).The average score on the Likert Profilefalls into one ofthe four typologies oforganizations; System 1—expioitive

authoritarian (0-4.99), System 2—benevolent authoritarian (5.00-9.99),System 3—consultative (10.00-14.99),and System 4—participative (15.00-20.00). The number of employees whorepresented each category was as fol-lows: System 1 (n = 33), System 2 (n =509), System 3 (n = 1,193), and System4(n = 787).

Dependent variables. Employee customerservice scores were taken from the 2007annual performance evaluation con-ducted by the organization in Augustof each year. Employees are rated bytheir managers on a series of perfor-mance standards, ranging from "fallssignificantly below the standard" (1)to "exceeds the standard" (10). Perfor-mance standards for customer serviceinclude Integrity: doing the right thingand responding to customer needspromptly; Friendliness: showing thatyou care, being polite, and respectingothers; Appreciation: praising, thank-ing, and acknowledging customers andcoworkers; Trust: relying on each other,working as a team, and being loyal;Excellence: identifying opportunities forimprovement and developing solutions;and Openness; being available to othersand listening carefully to concerns.

Medical errors were measured usinga single question from the loint Com-mission: "Have you ever made a sig-nificant medical error?" Participantsanswered this question with either no(O)oryes(l).

Burnout was assessed usingMaslach's Burnout Inventory (Maslachand Jackson 1982), a 23-item scalethat measures three subdimensions ofburnout, including depersonalization.

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personal accomplisbment, and emo-tional exbaustion. Depersonalization(D) reflects a tendency to view individu-als as tbings or objerts and to distanceself from otbers. Personal accomplish-ment (PA) indicates tbat an individualsees self as doing poorly on work tbatis wortb doing. Lastly, emotional ex-baustion (EE) reveals individuals wboare exposed to Stressors at or beyondtbeir comfortable coping limits. Tbesesubdimensions are combined to pro-duce burnout "pbases," ranging from1 (low burnout) to 8 (bigb burnout)(see Goodman and Boss 2002 andGolembiewski and Munzenrider 1988for a tborougb explanation of bumoutphase calculation). Low burnout con-sists of phases 1 to 3, medium burnoutis pbases 4 and 5, and bigh bumoutincludes phases 6 to 8. A high burnoutscore (bigb scores in all tbree bumoutsubdimensions) means tbat an individ-ual is considered to bave an advancedform of burnout. A low burnout scoremeans tbat an individual is consideredto feel only a single subdimension ofburnout or none at all. Our alpba reli-ability for burnout is .78.

We measured employees' turn-over intentions using Rosse and Hulin's(1985) scale. The scale includes onequestion and two statements: "Howlikely is it tbat you will actively lookfor a new job in the next year?" (1 =not at all likely; 7 = extremely likely), "Ioften tbink about quitting," and "I willprobably look for a new job in tbe nextyear" ( 1 = strongly disagree; 7 = stronglyagree). Responses to tbese three itemswere summed to aeate a total score,ranging from 3 to 21, witb a bigberscore suggesting a greater intention toquit (a =.88).

Control variables. To address tbe pos-sibility of spurious relationsbips, wecontrolled for age and tenure, inasmucbas customer service, medical errors,burnout, and turnover intentions maybe related to botb participative man-agement climate and tbe demographicvariables.

RESULTSTbe descriptive statistics and correlationsamong all study variables are shown inTable 1. Tbe correlational results indi-cate tbat participative management waspositively related to customer serviceperformance and was negatively relatedto medical errors, bumout, and turnoverintentions, providing some prelimi-nary support for our bypotbeses. Weconducted additional analyses, includ-ing analysis of variance (ANOVA) andbinary logistic regression analysis.

Tlie distinction between aparticipative-management climate andan exploitive autboritarian system canbe seen clearly in Figures 2 tbrougb 5.Tbe ANOVA results confirmed tbat asignificant difference exists betweenparticipative-management systemsfor the dependent variables customerservice (F = 35.75, p< .01), burnout (F =126.28, p < .01), and turnover inten-tions (F= 146. 67, p<.01). Bonferronipost boc analysis sbowed that the differ-ences between eacb of tbe four systemswere significant at tbe .05 level forcustomer service, bumout, and turnoverintentions, except between levels 1 and2 for burnout and customer service,wbich is likely caused by the small num-ber of individuals witbin tbe System 1category.

Inasmucb as medical errors weremeasured witb a binary variable, we

134

TABLE 1Means, Standard Deviations,

Variable

and

THE IMPACT OF

intercorrelations for

M s.d.

PARTICIPATIVE

Study Variables

1 2

MANAGEMENT

3

PERCEPTIONS

4 5

1. Participative management2. Customer service

3. Medical error

4. Intention to quit

5. Burnout

12.797.71

.20

7.62

3.81

3.501.43

.40

4.88

2.59

.97

. 21* '

-.07**

-.41**

-.40* •

—

-.07**

-.12**

-.12**

—.05*

.06**

.88

.46** .78

N = 2.522 with lislwise deletion of missing data. Scale reliabilities appear along the diagonal in italics

* p< .05 (two tailed).

•* p< .01 (two-tailed),

used logistic regression rather thanANOVA to test our prediction thatparticipative-management climatewould be negatively related to medicalerrors. Logistic regression results sup-ported our predictions (B = -.046, p< .01), controlling for age and tenure.

The likelihood of having committeda significant medical error was lowestamong employees who rated their workclimate as Participative (System 4) andwas highest among employees whorated their work climate as ExploitiveAuthoritarian (System 1). We found that

FIGURE 2Average Participant Customer Service Scores, by Management System

Exploitive Benevolent Consultative ParticipativeAuthoritarian Authoritarian

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FIGURE 3

Percentage of Respondents Who Have Committed a Significant Medical Error, by Management System

30%

25%

20%

23.6%

18.4%

0%

Exploitive Benevolent Consultative ParticipativeAuthoritarian Authoritarian

11.2

31.3

54.5 48.5

FIGURE 4

Percentage of Respondents in Different Levels of Burnout, by Management System

100%

80%

60%

40%

20%

HighMediumLow

Expioitive Benevoient Consultative ParticipativeAutiioritarian Authoritarian

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FIGURE 5Average Participant Scores on Turnover Intentions, by Management System

Exploftive Benevolent Consultative ParticipativeAuthoritarian Authoritarian

the odds of committing a significantmedical error for employees in Benevo-lent Authoritarian (System 2) climateswere 1.3 times larger than the odds ofcommitting an error for employees inParticipative (System 4) climates.

In summary, our ANOVA andlogistic regression results supportedeach of our hypotheses. Employees whoreported higher participative climateperceptions received higher customerservice ratings from their supervisors,reported committing fewer significantmedical errors, experienced lower levelsof burnout, and were less likely to haveintentions to leave the organization.Specifically, employees in highly partici-pative work climates provided 14 per-cent better customer service,' committed26 percent fewer errors, demonstrated79 percent lower burnout, and felt 61percent lower likelihood of leaving the

organization than employees in moreauthoritarian work climates.

D I S C U S S I O NIn an era of uncertainty where demandsoften outnumber organizational re-sources, healthcare organizations maybe inclined to adopt authoritarianmanagement systems in an effort to cutcosts, maximize efficiency, and central-ize authority. Participative managementsystems offer an alternative approach,focusing instead on improving thecommitment and productivity of em-ployees through pay for performance,open-book management, decentralizeddecision making, and job enhance-ment. Studies have linked participa-tive management systems to corporateperformance and other corpora te-1 eve Ioutcomes, but little research has beenconducted to examine the impact of

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participative management on employee-level outcomes, particularly in health-care organizations.

The results of our study clearly showthat employee perceptions about par-ticipative management have a favorableimpact on customer service, medicalerror rates, burnout, and turnover inten-tions. On each ofthe four outcomes inthis study, employees who believed theywork in climates that are more participa-tive in nature far surpassed their coun-terparts who perceived they work in au-thoritative climates. These findings addto the existing literature that indicatesparticipative management improvescorporate performance (Arthur 1994)and extend the role of participativemanagement to include employee-leveloutcomes in a healthcare setting.

Our findings give rise to a numberof practical implications. The mostimportant prescription to follow fromour analysis is that organizations shouldendeavor to enhance the likelihood thattheir employees perceive their workclimates as participative rather than au-thoritarian. Organizations can developmore participative work climates inseveral ways. First, providing meaning-ful information and control to employ-ees can enhance employee participation{Rosen and Quarrey 1987). Open-bookmanagement practices entail sharingorganizational performance metricswith employees on a regular basis,making them more cognizant of prog-ress and more motivated to help reachorganizational goals. Employee involve-ment programs enable employees tohave a voice in decisions that affecttheir work and thus encourage them tosuggest ways to improve services and

production processes. Sharing meaning-ful organizational information sends asignal that management trusts employ-ees, which in turn motivates employeesto use the information to benefit thecompany (Ferrante and Rousseau 2001).Second, allowing employees to par-ticipate in decision making regardingday-to-day work practices and to havesome control over operational processesengages employees and persuades themto share tacit knowledge they mightotherwise withhold (Rousseau andShperling2003). Finally, performance-based rewards (such as merit pay andgain-sharing plans) that are linked toboth individual and organizational per-formance metrics motivate employees towork hard on behalf of the organizationand to perform tasks that may be aboveand beyond their job descriptions.

LimitationsAlthough our research has a number ofstrengths, in terms of both contributionsto the literature and methodology, ithas some limitations. First, this study'sfocus on a single organization placesconstraints on the generalizability ofits findings. We acknowledge that thefindings may be different in other typesof organizations or may be a functionof unknown characteristics unique tothe particular organization in this study.Future research should investigate therelative importance of different dimen-sions of ownership across a broad rangeof healthcare organizations and amonga broad range of employee groups.

Second, the study did not spe-cifically investigate the organizationalpractices that lead to employee percep-tions of participative management.

138


Tbus, altbough our results provideevidence that perceptions of participa-tive climates are dominant predictors ofemployee attitudes and behaviors, tbesedata do not offer specific explanationson bow those perceptions can be en-hanced. Future researcb sbould examinetbe impact of specific types of participa-tive practices on outcomes such as infor-mation sharing, decentralized structures,and autonomous job design.

Finally, the study was primarilycross-sectional in nature, although somestudy measures were taken at differenttime periods (e.g., customer service mea-sures lagged the survey variables by twomontbs). Tbus, we cannot completelyrule out tbe possibility of reverse causal-ity in relationsbips between participativeclimate and employee outcomes. Better-performing employees (in terms of goodcustomer service and fewer errors) andemployees wbo are less bumed out andless likely to leave are possibly moreinclined to perceive tbat tbey workin participative work climates. Futureresearcb using longitudinal designs isneeded to clarify tbe direction of causal-ity between tbese variables. Time-seriesdesigns may also be belpful in exploringbow employees' participative manage-ment perceptions cbange over time.

C O N C L U S I O NHealtbcare organizations face an in-creasingly competitive and resource-constrained environment tbat makessustaining a competitive advantage moredifficult. Agrowingbody of practition-ers and researcbers bas acknowledgedtbat many of tbe industry's most vexingproblems bave organizational ratbertban clinical or financial origins (Prybil

2003; Ramanujam and Rousseau 2006).Tlius, it bebooves bealtbcare organiza-tions to adopt personnel managementpractices tbat foster a committed andbigbly productive workforce. Tbis studyprovides strong evidence tbat employeeswho perceive that their workplace cli-mate is participative demonstrate bettercustomer service, commit fewer medicaierrors, are less burned out, and are lesslikely to leave tbe organization. As notedearlier, employees in bigbly participa-tive work climates sbowed 14 percentbetter customer service, 26 percent fewererrors, 79 percent lower burnout, and 61percent lower likelibood of leaving tbeorganization tban employees in autbori-tarian work climates. Tbese findings pro-vide empirical support tbat participativemanagement is an effective approacbto building a bigbly committed andproductive workforce. Creating a cultureof empowerment is pivotal to overcom-ing tbe many cballenges tbat confrontbealtbcare organizations today.

I

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Tm; IMPACT OF PARTICIPATIVH MANAGEMENT PERCEPTIONS

P R A C T I T I O N E R A P P L I C A T I O

John A. Miller ¡r., FACHE, president and chief executive officer, AnMed HealthSystem, Anderson, South Carolina

I n more than three decades of being a healthcare executive, 1 have been blessed towork with colleagues who believe the key to organizational success is a nurturing

culture. Our executive team has always endeavored to effectively communicateand encourage participation and involvement by employees. I lowever, this articleemphasizes in vivid empirical terms that efforts to "encourage" participative manage-ment may not be enough.

Most organizations conduct employee satisfaction surveys. I am not aware,however, of efforts to correlate results from these employee surveys to improvedcustomer satisfaction, reduced medical errors, decreased employee stress, and in-creased employee retention. This study has taken intuitive employee hypotheses andeffectively demonstrated their implications for key organizational outcomes (i.e.,customer service, medical errors, burnout, and intention lo quit) that are desirable,if not critical, in today's environment.

Many "autocratic" managers may not even realize how they are being perceivedby their staff. "Participative" managers may have this leadership style primar-ily because oftheir own personality traits. In either case, I suspect that neither ofthe two styles has been addressed or developed by their organizations. This articledemonstrates the benefits of having participative interaction with employees. If thismanagement strategy is successfijl, employee perceptions (and, we hope, real practiceas well) will help promote all aspects of productivity improvement and the overallsuccess ofthe organization's mission.

Many healthcare organizations have actively engaged in various quality improve-ment initiatives (e.g.. Six Sigma, Lean). For each of these quality tools to work, thedesire to constantly improve must be instilled in the labor force. In my organization,we have decision support systems for our finance and other quantifiable processes.This article illustrates that having a system for culture management—an approach toproviding eniployee support—has a significant impact on many desirable operation-al and clinical quality outcomes.

The authors readily admit that one of the limitations of their study is that it didnot specifically investigate management practices that lead to employee perceptionsof participation. Nevertheless, this study is an excellent step forward. I am optimisticthat this effort will inspire healthcare executives to proactively pursue culture man-agement, which supports participative leadership.

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the impact of participative management perceptions on

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