Association for Public Policy Analysis & Management

Being an essential component of democracy, citizen participation is an important tool for promoting active, informed, and empowered citizenry as well as responsive and accountable administration. It can also help advance the managerial and organizational goals, such as performance management and improvement. Much of the literature on citizen participation focuses on its determinants, types, characteristics and prevalence. Studies connecting citizen participation to the use of citizens’ feedback and, ultimately, to organizational performance are limited. To address this gap, this research examines the relationship between clients’ participation in governance and organizational performance. We study this relationship in the context of U.S. nursing homes. While this industry includes public, nonprofit, and for-profit organizations, its funding comes primarily from the federal Medicare and Medicaid programs. The latter necessitates higher levels of federal and state regulation and the expectation of providers’ accountability on care quality and residents’ health outcomes. To investigate this topic, we use a hybrid data that combines a survey of nursing home administrators’ managerial practices with a federal archival performance appraisal data that include a set of performance indicators – overall 5-star ratings and total number of health deficiencies – for each nursing facility in the U.S. Our empirical findings suggest that more intense levels of participation, such as the use of clients’ and families’ feedback in decision-making, are positively associated with performance: they increase the overall 5-star ratings and lower health deficiencies. In contrast, less intense client engagement efforts, such as merely communicating with client/family civic groups, are not significantly associated with performance. This study highlights the role of participation intensity, suggesting that public administrators should go beyond informing and listening to their stakeholders, but also take steps to use the obtained feedback in organizational decision-making. This research also suggests that citizen engagement, especially when it entails changes in administrators’ strategies, policies, and actions, may serve as an additional important accountability mechanism complementing the strong regulatory regime currently implemented by federal and state agencies.