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This study examines the complex linkages between employees' perceptions of HR systems and hospital performance. In particular, it explores the role of attitudinal and behavioural HR outcomes as potential mediating mechanisms of the HRM–performance link. Structural equation models using multi-informant (e.g. medical and non-medical staff, patients) and multi-source data from 167 acute hospital trusts in the English National Health Service reveal a positive relationship between employees' HR system perceptions and patient satisfaction. Moreover, results suggest that this relationship is mediated by employees' civility towards patients, that is, by the extent to which employees treat patients with courtesy, dignity and respect. This behavioural HR outcome, in turn, is negatively affected by employees' intention to leave, an essential attitudinal HR outcome that mediates the link between HR system perceptions and …