Human Resources

New thinking
– HR and a transient work force

The traditional role of the Human Resources department is no longer suitable to attracting and maintaining the best performers for a particular department, especially when the workforce is as transient as it is in the Middle East. Dr Abrar Khan looks at organisational citizenship and organisational performance in the hospital context and suggests fundamental change is needed in the way the HR department works.

When one hears the words “human resources (HR)” in the context of a hospital, it conjures up images of a department advertising for positions, chasing CVs, arranging interviews, managing benefits, fine tuning compensation, and performing other such traditional functions. Whereas these functions and their efficient execution are important, the reality is that today much more is demanded from HR.

HR needs to stop fussing about benefits, vacation plans and so on and start focusing on issues that actually affect patient outcomes and the bottom line – they need to start managing human capital and help hospitals select, retain, and groom their cadre of rising stars[1-3].

Many companies will emphatically state “people are our greatest asset”, a hackneyed phrase, but true nevertheless. Regardless of this ostensible acknowledgement, how many companies, and in our case hospitals, actually manage, develop, and leverage their employees’ abilities in any way or form? Once the employee starts working, there is minimal contact with HR other than over the mundane issues mentioned above. In most hospitals, the HR function is centralised, giving them little insight into the nuances of each department’s microculture, specialised needs, and team members’ personalities.

True, each department head can shed light on these issues and clearly contribute to choosing the right employee. However, in most cases, clinical department heads do not have the time or the inclination to deal with such issues, and choices regarding employees are usually made based only on academic and clinical needs of the department. How a potential employee fits into the overall strategic mission of the hospital, and how this employee might interact with other team members to further this mission can be overlooked.

Additionally, it is important to continue to manage current and desirable employees in a way which keeps them engaged and productive. If such attention is not paid to potential and current employees, the hospital is doomed to be a mediocre one. Such attention is critically important in hospitals in the Gulf Cooperation Council (GCC), as acquiring and retaining good talent is relatively harder due to the inherently transient nature of the work force.[4]

Retain your rising stars

Why is it important for HR to manage human capital and help hospitals select, retain, and groom their cadre of rising stars? There are many reasons:

It is well documented that stellar performers are more likely to leave an institution than average performers. Thus, unless these performers are managed carefully, they do leave. The intangible and financial cost of such people leaving is enormous. What’s more, the cost of replacing such people, if that is possible, is even greater. Usually, these performers don’t leave because of financial reasons as they are already being paid quite well. Thus, an average amount of work put into managing and retaining such employees yields great benefits.

It is not uncommon for administrators in hospitals in the GCC to pay attention to an employee only when he/she resigns. Then hospital administration scrambles to find out what happened and what drove this valued employee to resign. Administration then hurriedly puts together some solutions which temporarily fix the problem. However, by the time an employee has been driven to resign it is usually too late. He/she may stay, but it is temporary and this person eventually leaves. After all, who would want to work hard and produce results in an institution which only realises you exist when you resign.

● Stellar organisations can be differentiated from average organisations by the presence or absence of organisational citizenship. Organisational citizenship exists when employees routinely go beyond their own responsibilities and help their fellow employees complete their tasks as well (see detailed discussion below). This can exist only in a carefully cultivated organisational culture, which in turn can only be nurtured when all employees are not only chosen carefully, but also managed carefully and appropriately.

● Increasing productivity requires engaged employees. Again, this is an especially problematic issue as the work force in the GCC by definition is transient. Disengaged employees will never give their best performance and will leave promptly at five pm no matter what else needs to be done that day. Organisational citizenship is essentially nonexistent in disengaged employees. Thus more effort in developing and managing these employees is needed.

● There is increasing competition in the GCC to acquire talented healthcare workers because of the recent emphasis in developing the healthcare sector. Thus, healthcare employees in any given hospital have an almost omnipresent choice to move to a neighbouring hospital or even a neighbouring country for higher pay and perhaps even higher satisfaction. Thus, it is important to manage these employees in a way which will make them feel valued and appreciated. This cannot be done without HR placing emphasis on managing their human capital.

The concept of organisational citizenship is important enough to discuss in some detail.[5, 6] Whereas a complete discussion is beyond the scope of this article, a brief one would be useful. It is commonly thought that if an employee is happy he/she will perform better. Yet repeated studies have shown little correlation between satisfaction and individual job performance. In order to understand this discrepancy we need to understand the difference between ‘in-role’ and ‘extra-role’ performance.

Let’s say that a nurse has to give three medications, one enema, two injections, and a bath to a patient. Whether or not the nurse is happy, once she gives the medication to the patient, the effect of the medication will be the same. This is in-role performance.

Extra-role performance, on the other hand, is entirely volitional and thus is strongly affected by how happy an employee is. For example, let’s say the same nurse is suddenly called away for an emergency and returns an hour later. When she returns, she is behind and needs help to catch up. A fellow nurse, who is satisfied and happy with the organization, will willingly lend a helping hand, thus making sure that the patient gets his medications on time because she cares about the organization’s reputation and the patient. On the other hand, a dissatisfied fellow nurse will simply shrug it off and let the original nurse come back and struggle to catch up. In the latter case, the patient gets bad service (i.e. gets his medications late), simply because the fellow nurse was unhappy. The key point here is that, although an individual case like this may not make a big difference, when you consider the fact that a medium sized hospital may have up to 4,000 employees, the collective impact of such acts of helping is tremendous.

These extra-role behaviours are defined as organisational citizenship behaviours (OCBs) and generally fall into two major categories: those that target either other individuals or the organisation, and those that are either promotive or protective in nature. These OCBs include behaviours such as helping, sportsmanship, innovation, and compliance

● Helping – is interpersonal / promotive and is defined as voluntarily giving ones time and effort to support coworkers;

● Sportsmanship – is interpersonal / protective and is defined as an act that reduces or prevents negative affective events;

● Innovation – is organisational / promotive and is defined as proactive and innovative behaviours to change/improve the way things are done;

● Compliance – is organisational / protective and is defined as support for established rules and regulations).

What has clearly been established is that ‘an organisation’s long-term viability and performance is critically dependent on the proactive behaviours of its members’. Why? Because no matter how brilliant senior administration might be, they can never foresee all potential contingencies, problems and environmental changes. Thus the intellectual and cooperative resources of the employees in innovation, in spontaneous cooperation, and in protective and creative behaviour are vital to organisational survival and effectiveness.

Happy or not

As stated above, there is a clear lack of correlation between satisfaction and individual job performance – thus an employee could be performing very well, but be unhappy or happy. So then, why should it make a difference if the employee is happy or not? The answer to this question is that OCBs, which are so crucial to a successful organisation, are directly correlated with employee happiness. Thus, ‘the link between satisfaction and individual performance is not as strong as the link between satisfaction and organisational performance – where satisfaction leads to OCBs, which in turn leads to stellar organisational performance’.

Chester Barnard (1886- 1961, noted business executive and pioneer of management theory and organisational studies)[7], put it eloquently when he said that organisations are cooperative systems and “rules, structures, policies, job descriptions, sanctions, incentives – they all play necessary roles in collaborative endeavours, but as derivatives of, not as substitutes for, the underlying disposition to cooperate.”

Such a disposition can be sustained only by a sense of the organisation as a microcosm of a just world. Occasional inequities can be tolerated if there is faith that the system works fairly over the long run, with self-correcting tendencies. When faith yields to a narrowly defined, quid pro quo contractual relationship, the disposition to cooperate ebbs.

As the link between satisfaction and organisational performance becomes clear, the task for HR professionals becomes clearer as their strategy can now be developed based on a data-proven theory of organisational citizenship.

Clearly, talent management is crucially and strategically important. As alluded to above, the work force in the GCC is transient in nature, usually has more of a focus on financial gain, and is exposed to many offers of employment in a neighbouring hospital or country, usually for more money. If a hospital has a rapid turnover of employees it is essentially impossible to build a culture and a sense of organisational citizenship.

Thus, managing these employees becomes essentially a make-or break hospital competency. Senior management should pay special attention to this issue. They can create all sorts of lofty plans for employee engagement, education, and so on, but if 20% of your employees leave every year, and the other 80% are dissatisfied and disengaged, it is essentially impossible to create a meaningful culture of organisational citizenship. Thus, instead of focusing on employees’ financial issues – compensation, benefits, vacations, and such things – HR needs to focus on increasing the value of human capital. This increase in value can initially be measured by such intangibles as employee engagement and organisational citizenship. As organisational citizenship takes hold, this eventually reflects in the bottom line as patients are increasingly satisfied and employees increasingly happy to work with cooperative, cordial and helpful peers.

Change of attitude

Such thinking requires a complete change of attitude and philosophy from both HR and senior management. A new kind of HR professional is needed in the hospitals in the GCC – one who not only understands talent management, but also the strategy and goal of the individual department and the organisation as a whole. For example, if there is a project to be undertaken, traditionally the question asked by senior management will be, “who has the appropriate skills for this task”, and that person will be assigned to the project. The new HR professional will ask the same question, but will also ask one other crucial question: “If we assign this person for this project how does that help this person’s development needs.”[8] This is an important question to ask and the answer should be clear and tangible. If there is no clear benefit for the individual employee under consideration for the project, he/she will quickly become a disengaged employee and will basically just do enough to get the job done. Such bare minimum effort by individual employees does not foster organisational citizenship and thus does not help create stellar organisations.

Hospitals in the GCC

So, how can hospitals in the GCC create an environment that promotes organisational performance? Each hospital is, of course, different and thus will need to emphasise different aspects of the optimal approach. Various considerations follow:

HR focus on human capital: It is vitally important that HR shift its focus to managing and developing human capital rather than concentrating on benefits, compensation, and so on. If necessary, the latter can be outsourced, but in any case need to be subjugated to the primary concern of managing and developing human capital. Such thinking and change in primary focus has to come from the top and proceed all the way through the ranks of HR. Appropriate changes in personnel may be required.

Culture: The new HR focus requires a different type of HR officer. This officer needs to understand the department he/she is recruiting for, its culture, its needs, and how its productivity fits into the institution’s greater goal. This also means that this officer needs to understand the financial statements generated by that particular department.

Micro HR officers: Each Department in the hospital (Surgery, Medicine, etc) should be assigned an HR officer. This officer should sit in the Department and not in the HR office. This officer should work closely with the Department Chair, go to relevant meetings, understand the microculture of the department, have a clear idea about the financial statements and goals of the department, and be familiar with the personalities of each member of that department. Such understanding of the department’s day-to-day workings is necessary in recruiting the right person. Additionally, this HR officer would be pivotal in helping the Department Chair decide how to keep the current employees engaged and how to help develop their individual skills in such a way that it contributes to organisational citizenship.

Financial disparity: It is vitally important that all financial inequities present within similarly qualified and experienced personnel within any given department be eliminated immediately. Any such inequities are a pointed source of discontentment and a significant barrier to the development of organisational citizenship.

Mission clarity: Both the department and the hospital should set their missions in clear and simple words. For example, one mission of the Department of Surgery could be “to improve the outcomes of our operations year after year to approach or exceed international benchmarks”. This will make the goal clear to all the members of the Department and, most importantly, enable it to be measured. The HR officer in turn will recruit people who demonstrate that they can help fulfil this goal. Of course, new recruits will also be people who will build organisational citizenship.

The HR officer’s compensation should be directly related to the achievement of the department’s goals, as should the compensation of all other members of the department. Traditional “measures of activity” for HR such as positions filled, training hours delivered, appraisals, and so on are nonsensical and are not aligned with the Department’s requirements or strategic goals.

If there aren’t enough HR personnel to help develop and manage human capital, then labour-intensive chores like benefits, payroll, salary surveys, vacations, etc can be outsourced. This way, HR officers can focus on attracting, motivating, and retaining superior employees.


Healthcare has traditionally been slow at assimilating innovations, e.g. information technology. Here is a chance for healthcare to ride the crest and be at the forefront of strategic management of hospitals. Organisations other than hospitals that demonstrate the best track records of attracting and retaining good performers are those with the most innovative talentmanagement programmes. These companies, by necessity and design, are ahead of the curve and there is no reason why hospitals cannot do the same. In fact, hospitals in the GCC are in dire need of such talent management because of the extraordinary environment that makes it difficult to attract and retain good performers. It is also vital that these performers contribute to organisational citizenship. If the above six steps are implemented some dramatic changes will be visible sooner than one might imagine. HR will abandon traditional programmes that have no demonstrable affect on organisational performance and will create ones that boost results. Perhaps the new HR department should have an “intelligence section” that identifies employees at other organisations and lures them away. In the end, as the goals of the department and the hospital are measurable (or should be if they are not), the HR officer, in conjunction with members of the department, can be held directly responsible for performance. Good performance should be rewarded (part of which should be financial and part non-financial[8]) and poor performance should be carefully scrutinised and both the HR officer and members of the department should be held equally accountable.

People are indeed the most valuable resource and it is time that hospitals started to manage their talent appropriately. What’s more, in due time, the positive effects will also reflect in the bottom line.

Abrar Khan, MD, MS, MPhil, FACS is Senior Consultant and Director, Transplantation and Hepatobiliary Surgery at Sheikh Khalifa Medical City-Cleveland Clinic Foundation (SKMC), Abu Dhabi. He is a multiorgan Transplant Surgeon and Immunologist and has successfully started, from the ground up, two multi-organ transplantation programmes – one in the United States and one in Abu Dhabi. He is the author of many clinical and basic immunology papers, and has been educated, trained and employed variously at University of California - Berkeley, McGill University, University of California - San Francisco, Harvard Medical School, Yale University - Graduate School of Immunobiology, University of Pittsburgh - Starzl Transplantation Institute, University of Vermont - School of Medicine, and Columbia University (NY). He came from the USA to Abu Dhabi in October 2007 to help start the Transplantation Programme at SKMC.


1. Berman, K. and J. Knight. Do HR Managers Have the Skills they Need. Harvard Business Review - Blogs 2009; Available from: managers-have-theskills.html

2. Breitfelder, M.D. and D.W. Dowling, Whe Did We Ever Go Into HR? Harvard Business Review, 2008(July ).

3. Kaufman, G., How To Fix HR. Harvard Business Review, 2006 (September).

4. Khan, A., Out with the old - in with the new. Middle East Health, 2009.

5. Moon, H., m. Van Dyne, and K. Wrobel, The circumplex model and the future of organizational behavior, in A Handbook on organizational citizenship behavior: A review of “good soldier” activity in organizations, D. Turnipseed, Editor. 2004, Nova Science Publications: New York.

6. Organ, D.W., The Subtle Significance of Job Satisfaction, in Psychological Dimensions of Organizational Behavior, B. Staw, Editor. 2004, Pearson-Prentice Hall: New Jersey.

7. Barnard, C., The Functions of the Executive. 1971, Boston, MA: Harvard University Press.

8. Gallo, A. Retaining Star Performers in Trying Times. Harvard Business Review - Blogs 2009; Available from: 09/12/retaining-starperformers-in-t.html

 Date of upload: 20th April 2010

                                               Copyright © 2010 All Rights Reserved.