...satisfied patients, ultimately loyal customers. Specifically, we investigate the chain of events through which high-performance work systems (HPWS) and customer orientation influence employee and customer perceptions of service quality and patient satisfaction in a national sample of 113 Veterans Health Administration ambulatory care centers. We present a conceptual model for linking work environment to customer satisfaction and test this model using structural equations modeling. The results suggest that (1) HPWS is linked to employee perceptions of their ability to deliver high-quality customer service, both directly and through their perceptions of customer orientation; (2) employee perceptions of customer service are linked to customer perceptions of high-quality service; and (3) perceived service quality is linked with customer satisfaction. Theoretical and practical implications of our findings, including suggestions of how healthcare managers can implement changes to their work environments, are discussed.

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Healthcare managers seek to improve overall system effectiveness by strengthening their value chain, thereby increasing customer retention and market share. Better knowledge of conditions in the work environment that drive service-quality excellence and customer satisfaction is valuable to healthcare managers. It is becoming clear that strategic human resource practices that result in high-performance work environments are linked with important organizational outcomes--such as service quality, customer satisfaction, and loyalty--in a wide variety of commercial industry contexts (Dean 2004). Evidence also is accumulating that customer-oriented work climates produce superior service quality and customer satisfaction, operating independently (Henning-Thurau 2004) or in conjunction with high-performance human resource practices in proprietary firms in retail services industries (Schneider, White, and Paul 1998; Yoon, Beatty, and Suh 2001).

In contrast, the mission, design, and resource constraints of health services organizations may differ meaningfully from those of firms operating in the broader services domain, and many health services providers are public or not-for-profit entities rather than for-profit enterprises. It should be noted, however, that the existence and magnitude of such differences may be anchored more in a priori beliefs than in empirical evidence (Rainey and Bozeman 2000). The goal of this study is to determine whether the research evidence regarding the importance of work climate can be extended to the healthcare industry. We investigated the chain of events through which aspects of work climate, specifically high-performance work systems (HPWS) and customer orientation, influence employee and customer perceptions of service quality and their ultimate impact on patient satisfaction in 113 Veterans Health Administration (VHA) centers.

The roles of HPWS and customer-oriented work climates as catalysts for superior service quality and increased patient satisfaction have received little empirical investigation within the healthcare environment. This study offers empirical justification for the dimensions of the work environment that contribute to high performance in a healthcare setting and yields findings that can be used to guide healthcare managers in their efforts to design and enhance their organizational practices.

In the following sections, we provide the theoretical foundations of our linkage model, define the constructs and measures used, present our results, and discuss the practical implications and limitations of our research.

THEORETICAL FOUNDATION

Linkage research examines and tests the "chain of events" that is set into motion when a strategic or operational intervention is introduced by management. The origins of linkage research are rooted in the research of Benjamin Schneider and his coinvestigators, who demonstrated that employee perceptions of human resource practices were connected to customer perceptions of their service experience in retail banking, lames Heskett and his collaborators added momentum and depth to the genesis of linkage research by extending Schneider's models to include an emphasis on customer loyalty and profitability (see Pugh et al. 2002 and Dean 2004 for excellent overviews of the subject). Despite considerable progress in specifying and empirically testing various linkage models, the specific matrix of strategic human resources management (HRM) practices that drive the "chain reaction" remains unsettled. Progress may lie in adopting a systems view of HRM that considers the overall configuration of HRM practices that best fit particular strategies (e.g., enhancing service effectiveness), rather than examining the effects of individual practices on organizational performance (Bowen and Ostroff 2004). Extending our understanding of how such an array of HRM practices may interact with the creation of a customer-oriented work climate to spur the chain reaction is also desirable. Figure 1 shows the conceptual model to be tested in this study. Next, we discuss the theoretical and empirical underpinnings associated with each path in our model.

[FIGURE 1 OMITTED]

Linkages Among HPWS, Customer Orientation, and Employee Perceptions of Service Quality

HPWS, also referred to in the literature as high-involvement work systems and high-performance organizations (Nadler and Gerstein 1992; Lawler, Mohrman, and Ledford 1995), represents an interrelated and aligned set of core characteristics, including involvement, empowerment, trust, goal alignment, training, teamwork, communications, and performance-based rewards. Organizations that provide enabling work environments will have employees who can devote their efforts to meeting the needs and expectations of customers, thereby improving service quality (Pugh et al. 2002; Schneider and Bowen 1985). The work of prior investigators offers compelling empirical evidence that bundling complementary sets of human resource practices closely resembling HPWS (e.g., facilitative management, resources, training, communications, teamwork, aligned goals, rewards) positively affects employees' perceptions of their ability to deliver high-quality services to their customers in a variety of for-profit, retail service settings, including insurance (George 1990; Hallowell, Schlesinger, and Zornitsky 1996), banking (Schneider, Parkington, and Buxton 1980; Schneider and Bowen 1985), and telecommunications (Batt 2002). In the healthcare context, nurse perceptions of their ability to serve patients have been conceptually linked to their work conditions (Newman, Maylor, and Chansarkar 2001), and employee development practices have been empirically connected with hospital staff productivity (Goldstein 2003). Accordingly, the assumed connection between HPWS and employee perceptions of service quality occupies a root position in our posited chain of linkages.

Customer orientation is defined as the importance that...

NOTE: All illustrations and photos have been removed from this article.



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