http://ajm.sagepub.com/American Journal of Medical Quality

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 DOI: 10.1177/1062860608314957

2008 23: 215American Journal of Medical QualityPrathibha Varkey, Sudhakar P. Karlapudi and Donald D. Hensrud

The Impact of a Quality Improvement Program on Employee Satisfaction in an Academic Microsystem  

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Quality improvement is a potential method toenhance employee satisfaction. This study describesthe impact of a program instituted to enhanceemployee satisfaction using the principles of high-performing microsystems. A shared leadership com-mittee, participatory meetings, suggestion boxes, andquality improvement projects were implemented aspart of the program. A follow-up survey 1 year afterimplementation of the program demonstrated anincrease in employee perception of the division’sdesire to improve service (16%), opportunities toexpand skills (17%), involvement in work decisions(25%), and the institution’s interest in employee well-being (17%). Key drivers of discretionary effort (4 of5), job satisfaction (2 of 6), and overall satisfaction (1of 8) with the institution showed statistically signifi-cant improvement in the study division as comparedwith the other divisions in which no such programwas implemented. Further research is needed tostudy systems changes that enhance employee satis-faction and their impact on patient and financialoutcomes. (Am J Med Qual 2008;23:215-221)

Keywords: microsystems; quality improvement; employeesatisfaction; total quality management; academic

INTRODUCTION

Employee and customer satisfaction contributesignificantly to the success of organizations.1 It iswell-known that an inverse relationship existsbetween employee satisfaction and customerturnover.2 This holds true in the health care indus-try as well. In a study of several hospitals,Kaldenberg and Regrut3 found employee satisfac-tion to correlate strongly with patient satisfaction(correlation coefficient .89). Robertson et al4

observed that nurses who perceived higher satis-faction with their jobs were more likely to offerpatients personal attention, choice, independence,supervision, and privacy. Haas et al5 report thatpatients of physicians with higher job satisfactiontend to be more satisfied with their care. In con-trast, insufficient recognition, lack of growthopportunities, inadequate decision-making oppor-tunities, poor relationships with managers, andpoor support services result in dissatisfaction andhigh turnover among nursing employees.6

In the framework of high-performing clinicalmicrosystems, quality improvement (QI) and totalquality management have the potential to trans-form health care institutions into healthier organ-izations characterized by financial success and ahealthy workforce.7,8 Nelson et al8 define a clinicalmicrosystem to be “a small group of people whowork together on a regular basis to provide care todiscrete subpopulations of patients.”8(p474) Commonfeatures of high-performing microsystems includehighly effective interprofessional teams, an explicitfocus on quality and meeting patient/staff needs,and a real-time flow of information necessary toachieve these objectives.

There is little published literature on successfulmethods to enhance satisfaction of all employees in ahealth care unit or organization. Studies of employee

215

AUTHORS’ NOTE: Dr Varkey is Associate Professor of Medicine,Preventive Medicine, and Medical Education, and Director of theQuality Improvement and Innovation Program, Division ofPreventive Occupational and Aerospace Medicine; Dr Karlapudiis a research trainee, Division of Preventive Occupational andAerospace Medicine; Dr Hensrud is Associate Professor ofNutrition and Preventive Medicine and Chair of the Divisionof Preventive and Occupational Medicine, Mayo Clinic College ofMedicine, Rochester, Minnesota. The authors have no conflicts ofinterest to disclose. Corresponding author: Prathibha Varkey,MD, MPH, MHPE, Mayo Clinic, Baldwin 5A, 200 1st SW,Rochester, MN 55905 (e-mail: Varkey.prathibha@mayo.edu).

American Journal of Medical Quality, Vol. 23, No. 3, May/June 2008DOI: 10.1177/1062860608314957Copyright © 2008 by the American College of Medical Quality

The Impact of a Quality ImprovementProgram on Employee Satisfaction in an Academic MicrosystemPrathibha Varkey, MD, MPH, MHPESudhakar P. Karlapudi, MBBSDonald D. Hensrud, MD

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216 Varkey et al AMERICAN JOURNAL OF MEDICAL QUALITY

satisfaction have traditionally focused on factorsthat influence nurses’9-14 and physicians’5,14,15 satis-faction. Berlowitz et al16 document a positive statis-tical association between the implementation of QIprograms and nurse and physician satisfaction in 35nursing homes maintained by the Veterans’ AffairsDepartment. Furthermore, nurses involved in QIprojects believe that participation enhances theirknowledge and skills, as well as positively influencestheir clinical practice.17

We describe the evolution of a QI program based onthe principles of high-performing clinical microsys-tems, implemented in the Division of Preventive,Occupational, and Aerospace Medicine (DPOAM) atMayo Clinic, Rochester, Minnesota, and its subse-quent impact on employee satisfaction.

METHODOLOGY

Background

The DPOAM is 1 of 12 divisions in the Departmentof Medicine (DOM) at Mayo Clinic, Rochester,Minnesota, and consists of 4 sections: executivehealth, community preventive medicine, aerospacemedicine, and occupational medicine. Each sectiondraws on a core team of physicians, nurses, clinicalassistants, appointment coordinators, receptionists,and secretaries to execute its functions in a semiau-tonomous fashion and to provide the highest qualityof health care. These sections are located in differentgeographic locations in the institution and cater tounique subsets of patient populations.

Over time, these differences resulted in lowemployee morale, a perception of silos in the division,and an increase in employee turnover. To addressthese immediate concerns and to create a continuousprogram of division-wide improvement, a QI pro-gram based on the principles of high-performingclinical microsystems was established in 2005. Thevision of this program was to transform the DPOAMinto an exemplary site for outstanding performancewith the dual aims of high quality and safe patientcare as well as professional satisfaction. In the firstyear of the program, special emphasis was placed onenhancing employee satisfaction.

The DPOAM Microsystem and the QI Program

Based on the principles of shared leadership,18 a QIcommittee was created ensuring equal representation

from allied health and physician leadership from eachof the work groups in DPOAM. This committee washeaded by a physician QI expert who functioned asthe program director. During the course of their firstmeeting, leaders concurred that collective effort andtransparency were key to the successful implementa-tion of the program.

A participatory research methodology19 was usedto gain insight into employee concerns. Two mem-bers of the QI committee and a human resources rep-resentative held meetings with employees in smallparticipatory work groups. The committee’s genuineinterest in improving work conditions and empower-ing employees to provide the best possible care topatients was emphasized. Employee concerns, com-plaints, and suggestions related to work issues werenoted in a narrative fashion.

Two prioritization brainstorming meetings wereconducted in which the QI committee deliberated onvarious employee and management concerns. Thecommittee collated its findings through affinity map-ping and prioritized the goals for 2006 into 5 cate-gories: (a) transparent and timely communication,(b) the creation of a social network, (c) the creation andcommunication of strategic and tactical goals for thesections and the division, (d) enhancement of patientaccess, and (e) reengineering outmoded practices.

The lack of a transparent and timely communica-tion medium within the division was noted as a majorfactor contributing to dissatisfaction among employ-ees. To address this issue, a division-wide e-mail dis-tribution list was created, and the decision was madeand implemented to use this list for the transparentand timely communication of all matters pertinent toemployees. In addition, suggestion boxes were placedin all 4 sections to facilitate ongoing dialogue withfrontline staff. Suggestions received via these boxesand actions taken in response were communicatedverbatim every month to all employees via the e-maildistribution list. In the first year of the program, atleast 60 different suggestions, most related toemployee satisfaction, were received and addressed.Some of these suggestions (eg, the addition of a newprinter in a particular work area) were addressedimmediately. Some suggestions involved clarificationof current division policies. Other suggestions werechanneled to the most appropriate supervisor, whodiscussed the concerns with division leadership andresponded via the e-mail distribution list.

A social committee was created to organize socialevents, with the aim of enhancing employee interac-tion outside the workplace. Employees and their

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AMERICAN JOURNAL OF MEDICAL QUALITY Quality Improvement and Employee Satisfaction 217

families were encouraged to participate in theseevents. Since its inception the committee has organ-ized several “themed” employee meetings, social gath-erings, and team-building activities in the division.

Within months of prioritization, the strategic andtactical goals of the division and its sections werearticulated and widely communicated at employeemeetings and via the e-mail distribution list. In addi-tion, employees were informed of various programsfor individual career advancement. Interestedemployees were provided detailed information aboutthese career advancement opportunities.

A significant number of unfilled appointment slotshad resulted in poor usage of employee work time. Adivision-wide rapid-cycle PDSA (plan do study act)project was implemented to address calendar man-agement and access issues, which resulted in thereengineering of physician calendars, leading toenhanced access and optimum usage of work time.

A pilot project using the principles of LEANmethodology was implemented to identify redundantprocesses in the executive health section. Thisresulted in the elimination of 80 outmoded andredundant practices. For example, the implementa-tion of an online preappointment patient question-naire significantly reduced the time spent by bothhealth care employees and patients. Previously,employees had spent many hours on the phone col-lecting preappointment data to schedule appropriateappointments.

Employee Satisfaction Survey

Job satisfaction is the positive emotional statebecause of the perceived appraisal of one’s work.20

This perception of satisfaction depends on the intrin-sic and extrinsic properties of the job21 and charac-teristics of the individual employee.22 To assessemployee satisfaction, surveys are conducted every 2years for all Mayo Clinic employees by an outsidevendor. Each survey contains 70 questions and aimsto assess employee perception of (1) discretionaryeffort (employees willing to do whatever is necessaryto provide excellent service),23 (2) job satisfaction,and (3) satisfaction with Mayo Clinic. For the pur-poses of this article, we use the term employee satis-faction to encompass all 3 measures mentioned.Multivariate regression analysis of survey questions(using the 3 measures as dependent variables) wasconducted to identify related questions that were keydrivers of these measures. Five key drivers wereidentified for discretionary effort, 6 for job satisfac-tion, and 8 for overall satisfaction with Mayo Clinic(Table 1, column 1).

Of the 70 questions, 57 questions requestedresponses ranging from strongly agree to stronglydisagree on a 5-point Likert-type scale. A favorableresponse was defined as either agree or stronglyagree. Four questions solicited responses rangingfrom very satisfied to very dissatisfied on a 5-pointLikert-type scale, and for these questions, a favorableresponse was defined as either very satisfied or satis-fied. Six questions solicited responses ranging fromvery good to very poor, and for these questions, afavorable response was defined as either very good orgood. Three questions solicited employees’ opinionsabout the survey.

A comparison of 2004 and 2006 employee surveyswas conducted to identify trends in employee satis-faction following implementation of the QI program.Statistical tests of significance comparing 2004 and2006 DPOAM data could not be performed becausethe DPOAM respondents in the 2 years were notindependent and change in individual responsescould not be delineated because of de-identification ofdata. A change of 10% was arbitrarily consideredimportant. Because no structured programs aimed atimproving employee satisfaction were initiated in theother 11 divisions of the DOM during the studyperiod, a retrospective analysis of 2004 and 2006 sur-veys for the DPOAM versus the other 11 divisionswas performed. Pearson’s χ2 test of statistical signifi-cance was performed to determine differences in sat-isfaction rates between the DPOAM and the otherdivisions of the DOM in 2004 and 2006.

RESULTS

The DPOAM employee response rate for the2004 survey was 85% (107/126) and 86% in 2006(101/117). Between 2004 and 2006, there was nosignificant increase in satisfaction to questionswhich directly measure discretionary effort (74%in 2004, 78% in 2006), job satisfaction (84% in2004, 86% in 2006), and overall satisfaction withMayo Clinic (82% 2004, 84% in 2006). Comparativeanalyses of DPOAM employee responses to the keydrivers in 2004 and 2006 demonstrated a favorableincrease of satisfaction by more than 10% for 1 ofthe 5 key drivers of discretionary effort, 1 of the 6key drivers for job satisfaction, and 2 of the 8 keydrivers of overall satisfaction with the clinic (Table 1).These include a 16% increase in employee perceptionof the desire to continuously improve service (74% in2004 to 90% in 2006), a 17% increase in employee per-ception of opportunities to expand skills (75% in 2004to 92% in 2006), a 25% increase in employee percep-tion of being involved in decisions that affect their

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Table 1

Employee Satisfaction Survey Data

PercentageDOM DPOAM DOM DPOAM change 2004, 2004, Pearson’s χ2 2006, 2006, Pearson’s χ2 (DPOAM),

Question %FR %FR P Value %FR %FR P Value 2004-2006

Discretionary effort: People where I work 68 74 .22 69 78 .06 +4are willing to do whatever is necessary to provide excellent service.

Drivers of discretionary effortIn my immediate work unit, we have a strong 78 74 .28 80 90 .01a +16b

desire to continuously improve serviceThere is a spirit of cooperation and teamwork 67 73 .22 65 78 .008a +5

within my work unitPeople where I work are willing to openly 50 52 .7 47 57 .04a +5

confront and solve problemsIndividuals in my work unit are held 50 59 .07 51 56 .33 −3

accountable for their actionsWhere I work, I believe employees treat 70 73 .71 70 81 .01a +8

each other with respect and courtesyJob satisfaction: Overall, I am satisfied with 82 84 .63 82 86 .28 +2

my job/career at Mayo Clinic.Drivers of job satisfaction

I am satisfied with the salary program at 49 50 .83 49 50 .92 0Mayo Clinic

My job makes use of my skills and abilities 81 81 .97 84 82 .62 −1Mayo Clinic provides me the opportunities to 80 75 .26 85 92 .05a 17

expand my technical/professional skillsI am recognized for my work contributions 55 63 .09 59 71 .01a 8I am satisfied with the balance between 65 70 .31 63 65 .69 −5

my work and personal lifeI feel I fit into the Mayo Clinic culture 83 82 .77 80 81 .77 −1

Overall satisfaction with Mayo ClinicConsidering everything, how would you rate 84 82 .62 81 84 .60 +2your overall satisfaction with Mayo Clinic as a whole at the present time?

Drivers for overall satisfaction with Mayo ClinicThe institution’s strategic plan is consistent

with its values and core principles 78 76 .64 78 80 .69 +4Overall, I am satisfied with my total 52 64 .01a 54 63 .06 −1

compensation package hereHow would you rate the clinic on taking a 54 52 .67 61 69 .09 +17b

genuine interest in the well-being of its employees?

How satisfied are you with your involvement 56 45 .02a 58 70 .01a +25b

in decisions that affect your work?My work gives me a sense of achievement 85 88 .43 86 89 .37 +1I can be myself 73 68 .35 73 70 .16 +2How satisfied are you with the overall medical 90 89 .89 87 87 .99 −2

care you or your family members receive?Do you believe the results of this survey will 43 43 .93 42 50 .11 +7

be used to make changes?

Abbreviations: DOM, Department of Medicine; DPOAM, Division of Preventive, Occupational, and Aerospace Medicine; %FR, percentage favorableresponse.a P values that are significant (≤ .05) (Pearson’s χ2 test was used to determine statistical significance).b >10% increase in satisfaction over time.

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work (45% in 2004 to 70% in 2006), and a 17%increase in employee perception of the institution’sgenuine interest in their well-being (52% in 2004 to69% in 2006). Favorable responses to questions relat-ing to spirit of cooperation and teamwork, problemsolving, respect, sense of achievement, recognition for work contribution, autonomy, and trust alsoincreased; however, the change was less than a 10%increase. In 2006, as compared with 2004, a decreasein favorable responses was observed in the areas ofwork–life balance, accountability, satisfaction withcompensation, and medical care for employees (allless than 10%).

In the 2004 survey, 2 key drivers of overall sat-isfaction showed a statistically significant differ-ence between DPOAM and the other divisions ofthe DOM. Satisfaction with total compensationwas 64% in DPOAM as compared with 52% in theother divisions (P < .01). About 56% of employees inother divisions were satisfied with their involve-ment in decisions that affect their work as com-pared with 45% of DPOAM employees (P < .02). Nosignificant differences were noted among the driv-ers of discretionary effort and job satisfaction.

In contrast, analyses of 2006 survey data revealedthat 4 of the 5 drivers of discretionary effort, 2 of the6 drivers of job satisfaction, and 1 of the 8 drivers ofoverall satisfaction received statistically signifi-cantly higher responses among DPOAM employeesas compared with employees of the other divisions.Ninety percent of DPOAM employees felt that thedivision had a strong desire to continuously improveservice as compared with 80% of employees fromthe other divisions (P < .01). Seventy-eight percentagreed that there was good teamwork and coopera-tion within the DPOAM as compared with 65% inthe other divisions (P < .008). Fifty-seven percent feltthat problems were discussed and solved in an openmanner in DPOAM as compared with 47% ofemployees in the other divisions (P < .04). Eightypercent of DPOAM employees perceived that theytreated each other with respect compared with 70%in the other divisions (P < .01). Ninety-two percent ofDPOAM employees perceived that they had oppor-tunities to expand their skills as compared with 85%in the other divisions (P = .05). Seventy-one percentof DPOAM employees perceived that they were rec-ognized for their work contributions as comparedwith 59% in the other divisions (P < .01). Seventypercent of DPOAM employees were satisfied withtheir involvement in decisions that affected theirwork as compared with 58% in the other divisions (P < .01).

DISCUSSION

It is well established that health care employeeswith higher job satisfaction provide higher-qualitypatient care and have greater numbers of satisfiedpatients.3-5 This relationship has prompted healthcare organizations to explore strategies aimed atimproving employee satisfaction. Although not stud-ied in the health care setting, Sainfort et al7 argue forthe use of QI methodology involving the continuousparticipation of employees in the creation of efficientorganizations with satisfied employees and patients.This study describes the implementation and impactof a QI program specifically instituted to enhanceemployee satisfaction using the principles ofhigh-performing clinical microsystems. Increases inseveral key drivers of employee satisfaction werenoted following the implementation of this program,as evidenced by employee responses to surveys con-ducted by an external organization.

Clinical microsystems are the building blocks ofhealth care systems and the design or redesign ofthese small frontline units that deliver care canresult in better outcomes for their parent organiza-tions.8,24 High-performing clinical systems are awareof the patients, people, processes, and patterns thatconstitute them and focus on process improvementto improve the clinical microsystem.24

The primary objective of the first year of the pro-gram was to enhance staff satisfaction. Following theframework of clinical microsystems, the QI programin the DPOAM engaged leadership representa-tives from all employee categories and work groupsto work together toward a common vision. The teammembers helped each other develop and execute theprogram goals, resulting in an atmosphere of sharedownership in which individual leaders used theirexperiences and expertise to enhance employee sat-isfaction in areas outside their usual jurisdiction. Asimilar program using the principles of shared lead-ership in a medical imaging department resulted in an increase in job satisfaction (44th percentile to 69th percentile) and a significant decrease inemployee turnover (40% to 14.5%).25

The QI committee also actively recruited employeeinput via participatory meetings and suggestionboxes. It is likely that employee participation in workgroup discussions resulted in enhanced trust, empow-erment, and teamwork, as well as improved commu-nication as described in other studies using thismethod.25,26 This was likely responsible for the 25%increase in employee perception of their involvementin decisions that affected their work. Based on

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informal staff feedback, the use of suggestion boxesfor gathering employee concerns was considered animportant factor for increased employee satisfaction.Although the impact of such an intervention has notbeen described in the literature, it has been used inother settings to gather anonymous information per-taining to work constraints among nurses, nursingassistants, and support staff.26 In addition to the par-ticipatory meetings and suggestion boxes, the themedand informal social activities likely contributed to theincrease in employee perception of the institution’sinterest in employee well-being.

Projects aimed at improving existing processes (eg,using rapid-cycle PDSA methodology to transforminefficient physician access systems, using LEANmethodology to eliminate outmoded processes) weresuccessfully implemented. This demonstrated man-agement’s commitment to improving work conditionsand enhancing the employee’s role in providing qual-ity patient care and likely explains the 16% increasein employee perception that the division had a strongdesire to continuously improve service.

Although factors such as spirit of cooperation andteamwork, problem solving, respect, sense of achieve-ment, autonomy, and trust did receive higher favor-able ratings, the increase was less than 10%. Thesecond year of the QI program is aimed at enhancingsatisfaction in these areas through team building andproblem-solving exercises, as well as recognitionawards.

Herzberg21 proposes that intrinsic properties(motivation factors), such as achievement, recogni-tion for achievement, the work itself, responsibility,and growth or advancement, and extrinsic properties(hygiene factors), such as company policy and admin-istration, supervision, interpersonal relationships,working conditions, salary, status, and security, influ-ence employees’ perceptions of satisfaction with theirjobs. The interaction between the objective proper-ties mentioned and individual employee characteris-tics results in the variable perception of satisfactionamong employees sharing similar job properties.22

Health care employee satisfaction is reported to be more closely related to communication, team-work, worker attitude, and management practices asopposed to issues relating to salaries, benefits, andphysical environment.3 This was similar to our expe-rience in this study.

There are several limitations to this study.Employee perception of satisfaction is a constantlychanging variable, and survey responses provide anapproximate estimate of employee satisfaction at the

time of the survey. Precise determination of satisfac-tion is complex and is influenced by several con-founding factors. Factors responsible for specificchanges in employee satisfaction can only be hypoth-esized but not confirmed. Appreciable improvementin employee perception of the 3 questions thatdirectly address discretionary effort, job satisfaction,and overall satisfaction with Mayo Clinic did notoccur following initiation of the QI program; how-ever, satisfaction with several key drivers of thesemeasures improved appreciably following imple-mentation of the QI program. Because of the de-identification of data, we were unable to performstatistical tests for change in satisfaction amongDPOAM respondents in 2006 as compared with2004. However, in comparing satisfaction rates in2006 between DPOAM and other divisions, therewas a statistically significant increase in satisfactionfor several key drivers among DPOAM respondentsas compared with those from other divisions wherethere was no increase in satisfaction rates for thesemeasures. Because the surveys are part of the regu-lar institutional surveys and are not conducted bythe DPOAM, we do not suspect any influence by themanner in which the surveys are conducted onemployee response over time.

Organizations and employers that do not addressissues influencing employee satisfaction face diffi-culty in attracting prospective employees, retainingcurrent employees, and have higher rates of absen-teeism.27 Although satisfied employees tend to bemore productive and committed to their employers,employee dissatisfaction can adversely influence per-formance, motivation, conflict, turnover, and absen-teeism, in turn compromising an organization’seffectiveness. As health care institutions look beyondtraditional methods to improve employee satisfac-tion, QI methodologies involving the continuousinvolvement and participation of all employees andmanagement can improve employee satisfaction.

CONCLUSION

Academic microsystems are especially unique as they have a triple obligation to patient care,research, and education, resulting in several poten-tial threats to daily operations and, hence, poor jobsatisfaction. QI programs inherently aim to improveexisting processes, which may lead to improving anorganization’s efficiency. In this study, the use of QImethodologies and the principles of high-performingclinical microsystems improved several key drivers

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of employee satisfaction. We believe that with ade-quate support from leadership, this framework canbe efficiently used to enrich employee satisfaction in academic microsystems. Further research isneeded to rigorously study systems changes thatenhance employee satisfaction in academic centersand the resultant impact on patient outcomes andthe bottom line.

ACKNOWLEDGMENTS

We thank Derek Gossman and Thomas Welch IIIfor their review and feedback on the manuscript.

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