University of Southern California Dissertations and Theses

Barriers to practice: primary care patient experience and quality health outcomes in the Veterans Health Administration

(USC Thesis Other)

Barriers to practice: primary care patient experience and quality health outcomes in the Veterans Health Administration

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Barriers to Practice: Primary Care Patient Experience and Quality Health Outcomes in
The Veterans Health Administration
by
Tiffany Christine Jennings
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2023

© Copyright by Tiffany Christine Jennings 2023
All Rights Reserved

The Committee for Tiffany Christine Jennings certifies the approval of this Dissertation

Jennifer Phillips
Frances Martinez Kellar
Helena Seli, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
Negative patient experience (PX) in primary care clinical settings can greatly diminish quality
health outcomes for patients (Alaloul et al., 2019; Doyle et al., 2013; Moreno et al., 2021; Price
et al., 2014). This qualitative study is supported by a conceptual framework informed by the
Burke-Litwin causal model of organizational change and performance (2018) and the Veterans
Health Administration (VHA) high-reliability organizational (HRO) framework (Vaezie, 2019).
Primary care providers (PCPs) at seven VHA level 1 sites of care were interviewed to learn
about their experiences and perceptions of executive leaders’ behaviors and organizational
culture and how these factors impact their PX efforts. Preliminary findings indicate numerous
operational, cultural, and executive leadership issues that PCPs feel limit their medical practice.
Participants exposed concerns about (a) executive leaders’ perceived lack of commitment to
leadership and HRO leadership behaviors (bi-directional communication, purposeful rounding,
and creating psychologically safe work environments); (b) poor or even harmful experiences
with organizational culture and the subsequent negative impacts on the culture of safety and
continuous process improvement; and (c) how those perceptions and experiences negatively
influence both individual and organizational performance in the participating VHA sites.
Recommendations to practice are discussed.
Keywords: patient experience, primary care, Veterans Health Administration, Veterans
Affairs, quality care, patient outcomes, executive leaders, HRO, organizational culture,
individual performance, organizational performance

v
Acknowledgements
My deepest appreciation goes to Helena Seli, Ph.D., my committee chair. I could not
have undertaken this journey without your guidance, flexibility, and startlingly prompt return
edits. I am also thankful to Jennifer Philips, D.L.S., and Frances Martinez Kellar, Ph.D., my
defense committee, for your gentle support and expertise. Additionally, this endeavor would not
have been possible without backing from The Beryl Institute – I am privileged to be a 2022
Patient Experience Scholar. I am also eternally grateful for my Indigenous culture and to Ogaxpa
(Quapaw), Osakiwung (Sac and Fox), and Myaamia (Miami) Nations.
I am grateful to the C19 OCL cohort, especially the “Thursday Strong” Crew! Thank you
for always being a group chat away, there for a sanity check, endless encouragement, and the
always-needed humorous reprieve. To my PX leaders, Martina and Mandy, your expertise,
grace, and leadership are inspiring – I hope to continue learning from you for years to come.
Hussain, thank you for your endless support and encouragement – you made me feel like my
research and dissertation were a shared journey. You graciously opened your professional
network and resources, and I graduated on time because of you! I also cannot express enough
appreciation to the research participants. Thank you for trusting me with your experiences and
anonymity. Lacey, the VA IRB was [mostly] painless because of your guidance – thank you!
And, to my chosen family, whether from school (which one?), Air Force, global travels,
or Bumble – “The blood of the covenant is thicker than the water of the womb.” Thank you to
the many mentors I’ve accumulated over the years – you saw my potential when I could not.
Sweetpea, Poppy, and Bunny – thank you for the endless snuggles and unconditional love. And,
of course, to my Grandad and Uncle Buzz – there are not enough earthly languages to express
the amount of shared love. I am me because of you.

vi
Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgments ........................................................................................................................... v
List of Tables ............................................................................................................................... viii
List of Figures ............................................................................................................................... iix
List of Abbreviations ..................................................................................................................... x
Chapter One: Introduction to the Problem of Practice .................................................................... 1
Background of the Problem ................................................................................................ 2
Importance of Study ............................................................................................................ 6
Purpose of the Study and Research Questions ................................................................. 14
Overview of Theoretical Framework and Methodology .................................................. 15
Definitions ........................................................................................................................ 16
Organization of the Dissertation ....................................................................................... 17
Chapter Two: Review of the Literature ........................................................................................ 18
History of Patient Experience ........................................................................................... 18
Veterans’ Health Administration and Patient Experience ................................................ 29
Healthcare Stakeholders’ Contributions to Patient Experience ........................................ 36
Theoretical Frameworks ................................................................................................... 41
Conceptual Framework ..................................................................................................... 49
Chapter Three: Methodology ........................................................................................................ 53
Research Questions .......................................................................................................... 54
Methodological Overview ................................................................................................ 54
The Researcher .................................................................................................................. 55
Data Source: Interviews and Focus Groups ...................................................................... 56
Approach to Qualitative Analysis .................................................................................... 58

vii
Credibility and Trustworthiness ....................................................................................... 59
Ethics ................................................................................................................................. 60
Chapter Four: Findings ................................................................................................................. 61
Interview and Focus Group Participants ......................................................................... 61
Findings for Research Question #1: Individual and Organizational Performance ........... 65
Findings for Research Question #2: Executive Leaders .................................................. 74
Findings for Research Question #3: Organizational Culture ............................................ 83
Summary of Findings ....................................................................................................... 84
Chapter Five: Discussion and Recommendations ......................................................................... 87
Discussion of Findings ..................................................................................................... 89
Recommendations for Practice ......................................................................................... 95
Limitations and Delimitations ........................................................................................... 99
Recommendations for Future Research .......................................................................... 100
Implications for Veteran Health Equity .......................................................................... 101
Conclusion ..................................................................................................................... 102
References ................................................................................................................................... 103
Appendix A: Relationships Between Patient-Centered Care, Patient Experience, and
Quality Healthcare Domains ....................................................................................................... 122
Appendix B: VA Patient Experience (PX) Framework and Domains ........................................ 123
Appendix C: CAHPS Clinician & Group Survey: Differences between the core items in
3.0, 3.1, and Visit 4.0 (beta) versions ......................................................................................... 124
Appendix D: SHEP Composites & Reporting Measures Reference Guide ................................ 126
Appendix E: Interview Protocol ................................................................................................. 128

viii
List of Tables
Table 1: Total Sums of Potential Costs by Priority Groups 12
Table 2: Estimated Baseline Reimbursement and Lost Reimbursement 13
for CITC (2023)
Table 3: A Brief Timeline of the Evolution of Patient Experience Surveys 18
in the United States
Table 4: Domains and Performance Questions on the Clinic and Group 25
Consumer Assessment of Healthcare Providers and Systems
Table 5: Target Demographics of Primary Care Provider Participants 62
Table 6: Overview of Primary Care Provider Participants 63
Appendix E: Interview Protocol 128

ix
List of Figures
Figure 1: Participating VHA Sites of Care Primary Care Trust Scores 35
Figure 2: The VHA HRO Framework 41
Figure 3: The Burke-Litwin Causal Model of Organizational Performance 43
and Change
Figure 4: Conceptual Framework 50
Appendix A: Relationships Between Patient-Centered Care, Patient 122
Experience, and Quality Healthcare Domains
Appendix B: VA PX Framework 123

x

List of Abbreviations

CG/CAHPS Clinic and Group Consumer Assessment of Healthcare Providers and
Systems
PX Patient Experience
PCC Patient-Centered Care
PCP Primary Care Provider
VA Department of Veterans Affairs
VHA Veterans Health Administration
SHEP Survey of Healthcare Experience of Patients

1

Chapter One: Introduction to the Problem of Practice
Negative patient experience (PX) is believed to have a deleterious impact on the quality
of health outcomes. The literature suggests that lower PX metrics are correlated with reduced
compliance with a provider’s treatment plan, reduced patient safety, higher overall health
systems usage, and diminished quality healthcare outcomes (Doyle et al., 2013; Price et al.,
2014). Although the research on PX assessments and ratings continues to evolve, the issue with
negative PX in healthcare systems, hospitals, and clinics is that it sullies high-quality outcomes.
The literature proposes that neglecting these concerns creates healthcare inequities throughout
entire populations through reduced patient compliance, lower quality outcomes, and decreased
quality of life (Alaloul et al., 2019; Moreno et al., 2021). Furthermore, with ever-increasing
choices afforded to patients, healthcare organizations’ success or failure is driven mainly by
patient experience (Richter & Muhlestein, 2017).
The Institute for Healthcare Improvement (IHI) developed the Triple Aim framework
used in U.S. healthcare systems. The elements of the Triple Aim include patient experience,
population health, and cost per capita. The U.S. healthcare system is the costliest on the planet;
therefore, aspiring to the Triple Aim is a lofty but much-needed goal to address healthcare
inequities (IHI, 2022). It is believed that organizations that succeed in reaching the Triple Aim
will see many benefits: pressure on publicly funded healthcare budgets will diminish, the burden
of illness on patients will decrease—because care coordination will increase, and populations
will be healthier overall (IHI, 2022).

2

Background of the Problem
Patient experience (PX) arose as a topic in the healthcare industry in the 1980s. At best,
the history of PX is contentious, as reflected in the literature in which many providers, clinicians,
and healthcare executives dispute definitions, how to measure it, and whether PX is relevant and
important. The Beryl Institute—industry experts in patient experience—ventured a working
definition of PX as “the sum of all interactions, shaped by an organization’s culture, that
influence patient perceptions across the continuum of care“ (The Beryl Institute, n.d.a; Wolf et
al., 2014).
In the early 2000s, the Center for Medicare and Medicaid Services (CMS) and the
Agency for Healthcare Research and Quality (AHRQ) launched an initiative to standardize
publicly reported PX metrics. Currently, PX metrics are quantitatively measured by several
surveys and cover a wide range of clinical care settings, including inpatient, ambulatory care,
mental health, hospice, home health, surgery, cancer, dental, home and community-based
services, emergency department, in-center hemodialysis, nursing homes, and outpatient and
ambulatory surgery (AHRQ, 2022b). Specifically, ambulatory care, also known as outpatient
care, is measured through the Clinic and Group Consumer Assessment of Healthcare Providers
and Systems (CG/CAHPS) survey in primary care and specialty care settings. The CG/CAHPS
asks patients questions about their experiences as they relate to their primary care group in the
domains of timeliness (appointments, care, and health-related information), provider
communication, coordination of patient care, the demeanor of office staff (helpfulness,
courteousness, and respect), and overall rating of the provider (AHRQ, 2022g).

3

What is Patient Experience?
The literature review quickly revealed the need for a shared definition of PX so that
industries and researchers can focus and align their efforts. To date, the literature leaves readers
with multiple definitions and varied beliefs about what constitutes PX. The Patient Experience
Journal (PXJ), published by The Beryl Institute, is the industry leader for peer-reviewed, open-
access content dedicated to growing PX evidence, innovation, and the international PX
conversation. The PXJ is arguably the most accurate and trusted source for peer-reviewed PX
literature. The two industry experts, The PXJ and the Agency for Healthcare Research and
Quality (AHRQ), agree that PX comprises patient-centered care (PCC) principles, spans the
continuum of care, considers what values are meaningful to the patient, family, and carers, and is
about more than just patient satisfaction (Cleary, 2016; QHRQ, 2022j; Wolf et al., 2014).
Patient- (or person-) centered care (PCC) defines the overarching principles of delivering quality
healthcare and a positive patient experience. The Picker Institute, a United Kingdom–based
international PX organization, defined PCC as an approach to care that recognizes people as
individuals, enables patients to participate in their healthcare journey, and addresses personal
needs through understanding and respect (The Picker Institute, 2022).
A 14-year literature synthesis published by Wolf et al. (2014) sought to provide a clear
definition of PX around which healthcare professionals and PX experts could rally. Wolf et al.
(2014) concluded the need for a standard definition and instead highlighted a significant
alignment around core themes. These core themes implicitly emphasize PCC concepts:
comprises the emotional and physically lived experience of the patient, includes personal
interactions with healthcare staff, spans the continuum of care (more than just one clinical
encounter), is driven by the organizational culture, and considers the importance of the patient-
4

provider relationship. Cleary (2016) reinforced the themes noted by Wolf et al. (2014),
specifically the emotional and physical needs of the patient delivered via a patient-centered
approach to care delivery. Given the lengthy discussion around PCC, clarity is needed on the
concept.
Patient-centered care (PCC) is a much older concept in the healthcare industry, dating
back several decades, with many authors crediting Dr. Avedis Donabedian’s seminal work from
1966 (Berwick & Fox, 2016; Cleary, 2016; Santana et al., 2017). While the concepts of PCC are
widespread, a consensus for a definition is just as evasive as a PX definition. Instead of
attempting to define PCC, as that is not the focus of the research, the concepts of PCC are
covered here. The PCC approach promotes the active engagement and enabling of patients by
providers to create shared decision-making between the patient and provider and is accomplished
by deliverers of healthcare services through the development of solid and effective
communication skills (Barry & Edgman-Levitan; 2012; Eklund et al., 2018; NEJM Catalyst,
2017; Reynolds, 2009; Smith & Topham, 2016).
The Beryl Institute’s definition of PX and the Picker Institute’s definition of person-
centered care include the principles required to deliver a positive patient experience. To address
negative PX, The Beryl Institute recommends that healthcare systems, hospitals, and clinics
implement initiatives that focus on eight guiding principles: (a) leadership commitment to
experience strategy; (b) formal experience definitions; (c) positive culture; (d) defined processes
for patient, family, and community partnerships; (e) frontline staff inclusivity for solution
development; (f) commitment to health equity; (g) wellness promotion; and (h) an understanding
of how all touchpoints across the continuum of care impacts the patient’s experience (The Beryl
Institute, n.d.a). Although PCC and PX share concepts, the two are conceptually distinct. Patient-
5

centered care is the approach to delivering quality care, and PX is one element of that care.
Despite absent and standard definitions for both PX and PCC, industry leaders agree that the
terms and concepts for PX differ distinctly from those of patient satisfaction.
Patient Experience versus Patient Satisfaction
Volumes of literature that incorrectly interchange PX and patient satisfaction are easily
found with a quick search in the University of Southern California’s online library, Google, and
Google Scholar platforms. The misuse and exchange of “patient experience” and “patient
satisfaction“ in the literature are likely due to nonpatient experience experts contributing to the
immense database of literature on the topic (Bull, 2021). While research into PX by non-experts
is important for a diverse perspective, language matters, and differentiating between distinct
concepts is crucial when considering how studies are approached. The Centers for Medicare and
Medicaid Services (2021a) and AHRQ (2022e) agree that patient satisfaction and patient
experience are not interchangeable concepts or terms. As the industry regulators in the United
States, both agencies briefly discuss the difference. Patient experience looks at specific
touchpoints of a patient’s care from their perspective, not whether they were satisfied with it.
Alternatively, patient satisfaction considers patient expectations for all encounters and whether
those expectations are met.
The distinction between experience and satisfaction is important for a few reasons. One
reason to clarify the difference is the pervasive myth that PX metrics are too subjective to make
informed business decisions. Therefore, metrics are often disputed (Doyle et al., 2013; Lord &
Gale, 2013; Sullivan, 2003). Patient experience surveys utilize mixed methods to gather patient
feedback about actual events during their visit or over a specific period (AHRQ, 2022d; CMS
2021a). Alternatively, patient satisfaction metrics are subjective because performance questions
6

assess the patients’ feelings regarding their unique healthcare expectations. Another reason to
distinguish the two topics is for more accurate methodological application and generalizability of
extant literature. If authors do not use a shared language, then consumers of the information are
unclear whether the literature applies to their area of study or professional considerations
(Godbold & Kame’enui, 2017). Last, when confusion between the terms “patient experience“
and “patient satisfaction“ is imported into the healthcare industry field of practice, organizations
may ineffectively and inefficiently channel resources to improve PX metrics.
An article in the New England Journal of Medicine (2018) discussed the challenges of
healthcare systems funneling unrelated resources that are believed to impact PX scores but do
not address PX performance questions directly. Two examples include valet parking and
customizable hospital gowns. While both offers may improve patient satisfaction, the
interventions do not address PX performance questions or the patient’s pain points with the
healthcare system. There are also concerns about providers approving medically unnecessary
treatments due to worrying about low PX scores if the provider disagrees with the clinical
appropriateness of what the patient is requesting. The confusion in the industry over what has a
meaningful impact on PX and quality health outcomes has led to a disconnect between
healthcare executives and clinical staff.
Importance of Study
Patient experience (PX) is a leading factor in quality health outcomes. The problem of
negative PX is critical to address because PX is not just about customer service or patient
satisfaction; it is a reporting requirement and a crucial component of quality healthcare (Hefner
et al., 2019). According to Congiusta et al. (2019), historically, PX studies predominantly
focused on inpatient settings and yielded inconsistent results—meaning there are disagreements
7

about how PX impacts patient health outcomes. The Institute of Medicine, in its seminal report
Crossing the Quality Chasm: A New Health System for the 21st Century (2001), defined quality
health outcomes as “safe, effective, patient-centered, timely, efficient, and equitable“ and are
assessed by a vast list of quantitative metrics.
For inpatient clinical care settings, Jha et al. (2008) showed that healthcare systems with
PX in the top quartile outperform all other systems concerning pneumonia, acute myocardial
infarction outcomes, and lower 30-day hospital readmission rates. Conversely, in hospice and
palliative care settings, Fenton et al. (2012) indicated that higher PX metrics are linked to higher
mortality, hospital admissions, and cost, indicating that too great a focus on PX may reduce some
aspects of quality healthcare. However, the patient populations of the Fenton et al. (2012) study
were in palliative and hospice care, which are inherently more costly and have increased
mortality rates.
Numerous studies in ambulatory care, also known as outpatient clinical care settings,
indicate recurring positive associations between PX, patient safety, and quality health outcomes
(Doyle et al., 2013). In a meta-analysis, Zolnierek and DiMatteo (2009) found greater patient
compliance with the treatment plan when quality patient-provider communication was delivered.
Preventive healthcare screening utilization also improved when patients were engaged, and
provider communication was delivered effectively (Carcaise-Edinboro & Bradley, 2008; Kaplan
et al., 1989; Sequist et al., 2008).
In a study with focus groups held with medical doctors (MDs), some participants argued
that because patients are not medically trained experts, they cannot possibly be expected to
report their experiences accurately (Manary et al., 2013). Aside from the unsubstantiated
presumptions made by the MDs about a patient’s educational experiences, the logical fallacies
8

presented in this argument are abundant. Patients do not require medical training to know when
they are treated with dignity and respect or when a negative experience occurs. Aside from the
fallacies, PCC’s core value is enabling patients with health literacy (Brega et al., 2019; DeWalt
& McNeill, 2013).
As evidence grew, the relationships between PX, PCC, and quality health outcomes
became more apparent and robust. Beginning in 2002, various organizations sought to
incentivize healthcare systems to improve the quality of care through the public reporting of PX
metrics (Christensen, 2017; Kash & McKahan, 2017; Siegrist, 2013; Standley, 2021). Shortly
after the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys were
developed, the requirement for public reporting of PX metrics was met in the United States in
2005 via the efforts of CMS, AHRQ, Office of Management and Budget, and finally, the Deficit
Reduction Act [of 2005]. Publicly reported PX metrics were expected to increase transparency
and drive greater accountability within the U.S. healthcare system for the quality of care
provided, which aligns with the Institute for Healthcare Improvement’s (IHI) Triple Aim goal.
Furthermore, now that healthcare consumers are offered greater choice in where to receive care,
patient-reported experience is one way for patients, families, and carers to decide where they
seek and receive healthcare services (Richter & Muhlestein, 2017).
Organizational Context and Mission
The Department of Veterans Affairs (VA) is led by the presidentially appointed secretary
and oversees three administrations with four missions. The mission of each administration is
considered a mission of the VA. The Veterans Benefits Administration’s (VBA) mission is to
provide benefits and services to veterans and their families “in a responsive, timely, and
compassionate manner in recognition of their service to the Nation“ (VA, 2022). The VBA
9

provides a wide range of benefits and services to veterans, including disability compensation,
insurance, education, and home loans—to name a few, and employs approximately 18,000 staff.
The National Cemetery Administration (NCA) ensures dignified burials for veterans and select
family members, maintains 155 cemeteries and 34 monuments, supports an additional 119 state
veteran cemeteries, and staffs around 1,800 employees. The NCA honors veterans and eligible
family members with a final resting place in national shrines and lasting tributes to
commemorate their service and sacrifice to the Nation (About VA, 2022). The Veterans Health
Administration (VHA) is the most extensive integrated healthcare system in the United States,
serving over nine million veterans annually, with approximately 371,000 employees, 171
hospitals, and 1,113 outpatient clinics across all 50 states and several U.S. territories with the
mission to provide exceptional healthcare. The fourth mission, in short, is to support the nation
during war, terrorism, natural disasters, and other emergencies (About VA, 2022). Understanding
the structure and vastness of the VA and the three underlying administrations is critical to
appreciating how the National Veterans Experience Office supports the VA and ultimately sets
the standard as the leader in federal government customer experience.
Current Organizational Response to the Problem
The Veterans Experience Office (VEO) was established in 2015 and is responsible to the
secretary of the VA and the three administrations by enabling the organization to provide the
highest quality customer experience (CX) across all services for veterans, their families, carers,
and survivors. Within the VA, PX is only measured for VHA due to the administration’s
emphasis on healthcare for veterans and is the principal focus for the problem of practice. The
VHA provides a full range of clinical services, including primary care, specialty care, mental
10

health (in and outpatient), inpatient care, and surgical care in various specialty areas. This study
will focus on VHA primary care clinical settings.
The VHA National Office of Primary Care gives veterans access to healthcare providers
who provide continuity of care, foundational patient and provider relationships, care
coordination, personalized health education, and preventive health measures (Veterans Health
Administration [VHA], 2022c). The patient aligned care team, also known as a PACT, is the
patient-centered medical home model used by the Veterans Health Administration in primary
care clinics and is a crucial step in establishing a veteran in the system. The PACT is the
foundation for transforming veteran care by providing patient-driven, proactive, personalized,
team-based care focused on wellness and disease prevention, resulting in improved veteran
experience and improved patient health outcomes. Primary care is the entry point into the VHA
for most patients. Suppose a veteran has a negative experience within VHA primary care. In that
case, there is a higher likelihood of the patient being referred to the VHA Care in the Community
(CITC) program, which leads to a loss of reimbursement for the organization (VHA, 2022a).
Cost of Patient Attrition
One of the direct costs associated with poor PX is patient attrition from the clinic,
provider, or healthcare system (Bucknum, 2021; Capko, 2021). Not only do patients leave the
practice, but they also share their negative experiences with their human networks via word of
mouth and may even provide negative feedback through an online review platform where the
potential audience is unlimited (Widmer et al., 2018; Wolf, 2018). When a patient is lost to a
practice group, all reimbursement amounts are adjusted downward or cease altogether. Within
the context of the VHA, the potential repercussions from negative patient experiences within the
primary care clinical setting mean the patients may, at a minimum, request an internal “change of
11

provider“ or, at most, request to transfer to the VHA CITC program. Additionally, veterans are
well-connected to their veteran peers. Word of a bad VHA experience with specific providers
spreads easily and quickly throughout the local veteran communities, perpetuating the
downstream consequences for the healthcare site and the patients. When a veteran is “lost to
care“ from VHA primary care, all potential referrals to specialty care clinics within the VHA are
also lost. The lost reimbursement per patient annually ranges from $1,023 for non-reliant patients
to $1.5 million for the most complex patients, according to Table 1.
The VHA has a complex reimbursement methodology. The Veterans Equitable Resource
Allocation (VERA) categorizes priority groups based on a veteran’s disability and income status.
Veterans with service-connected disabilities, meaning they incurred the disability while on active
duty, are assigned the highest priority (group 1). Veterans who earn a higher income and do not
have service-connected disabilities qualifying them for disability compensation are assigned to
the lowest priority group (group 8) (VHA, 2022a). The VERA model also accounts for varying
levels of healthcare complexity. There are three primary VERA care complexity groups that
encompass 11 price groups. The lowest complexity level is for non-reliant veterans in the VHA
healthcare system. Basic care comprises price groups 1.5–6, and complex care comprises price
groups 7–11. Table 1 presents a simplified cost breakdown to reflect the 2023 VHA VERA
patient classification hierarchy with advanced appropriation prices (VHA, 2022a).
12

Table 1
Total Sums of Potential Costs by Priority Groups

Complexity

Price group

Priority groups 1–5

Priority groups 6–8

Total

Non-Reliant 1 $563 $460 $1,023
Basic Care 1.5–6 $83,443 $75,248 $158,691

Complex Care

7–11

$767,318

$731,090

$1,498,408

Note. ([VHA, 2022a]. Veteran Equitable Resource Allocation 2023 Patient Classification
Hierarchy with Advance Appropriation Prices.)

As of 2022, 22% of the nine million veterans who receive healthcare through VHA
annually are referred to the private sector via the CITC program for various reasons. In its
current form, the program was initiated by President Obama via the Veterans Choice,
Accountability, and Transparency Act of 2014 (Rogers, 2014) and expanded via the Mission Act
of 2018 (Isakson, 2018), which means that roughly two million veterans are lost to the
community annually, and subsequent reimbursement decreases or ceases. While the CITC
program is helpful for veterans in that it ensures the utmost access to care for primary and
specialty care services, it can have negative repercussions for the veteran and the VHA system.
For veterans, when healthcare treatments are divided between multiple healthcare systems (e.g.,
private sector and VHA) without connected electronic records and with different standards of
care, care continuity and comprehensiveness are negatively impacted (Bucknum, 2021; Capko,
2021; Germack et al., 2022). Negative repercussions for VHA mean not only a loss of VERA
13

reimbursement dollars, but also that the organization pays the community providers for services
provided to veterans for CITC referrals.
Table 2 is based on care complexity and shows the maximum potential reimbursement
for nine million veterans and the estimated loss of reimbursement due to the current 22% (two
million) CITC patients. How many patients are lost annually to CITC due to negative patient
experiences is unknown. Therefore, the table reflects all veterans lost to CITC. The current
approach means a minimum reimbursement potential of 7.2 billion and a maximum of 13.5
trillion U.S. dollars.

14

Table 2
Estimated Baseline Reimbursement and Lost Reimbursement for CITC (2023)

Complexity

Maximum potential
reimbursement

22% loss to
reimbursement due
to attrition

Max potential
reimbursement after
CITC loss

Non-Reliant $9,207,000,000 $2,025,540,000 $7,181,460,000

Basic care $1,428,219,000,000 $314,208,180,000 $1,114,010,820,000
Complex care

$13,485,672,000,000

$2,966,847,840,000

$10,518,824,160,000

Note. (VHA [2022a]. Veteran Equitable Resource Allocation 2023 Patient Classification
Hierarchy with Advance Appropriation Prices.)

Purpose of the Study and Research Questions
Nationally, VHA PX metrics outperform all other healthcare agencies (private, academic,
rural, and other federally qualified healthcare systems) (Lawrence, 2023; Shekelle et al., 2023).
Nonetheless, the problem of practice explored in this study is the negative PX within VHA
primary care. The study aimed to learn from primary care providers (PCPs) about their beliefs
toward PX and their experiences and perceptions of executive leadership and organizational
culture. All participants are from the Veterans Health Administration (VHA) and practice
general medicine as PCPs in a level 1 tertiary care hospital. The following research questions are
addressed in the study:
1. What are PCPs’ needs to be successful with PX efforts within VHA?
2. How do PCPs’ perceptions of executive leaderships’ behaviors impact PX efforts within
VHA primary care?
15

3. Based on PCPs’ experiences, what role does organizational culture play in supporting
PCPs with PX efforts within the VHA?
Overview of Theoretical Framework and Methodology
Two theoretical models are applied to the study. First, the Burke-Litwin causal model of
organizational performance and change (2018) offers a lens through which to research the impact
of executive leadership, organizational culture, and individual and organizational performance
related to adverse patient experiences and poor-quality health outcomes. The second model is the
VHA high-reliability organization (HRO) pillars; leadership commitment, a culture of safety;
and continuous process improvement.
The first framework is the VHA high-reliability organization (HRO) model. The
framework was developed by VA thought leaders and is grounded in HRO theories (Veazie et
al., 2019). The foundational pillars of the framework are (executive) leadership commitment,
continuous process improvement, and a culture of safety. The pillars support the principles and
values of HROs and include (a) sensitivity to operations, (b) deference to expertise, (c)
preoccupation with failure, (d) reluctance to simplify, and (e) commitment to resilience. Given
that the framework is the established VHA model for HRO implementation efforts, it is the
guiding theoretical model used in the study. However, the VHA HRO framework does not lend
itself to individual or organizational outcomes. Therefore, a secondary theoretical framework
was also leveraged to assess individual and organizational performance.
The second framework draws from W. Warner Burke’s (2018) book Organizational
Change: Theory and Practice, which focuses on two organizational dimensions:
transformational and transactional factors. Specifically, the study considers three
transformational factors: executive leadership, organizational culture, and individual and
16

organizational performance. By leveraging this framework, a better understanding of the needs
of PCPs for PX initiatives can be gleaned. The framework also lends itself to understanding how
the transformational factors of executive leadership and organizational culture impact PCPs’
performance. Depending on the organizational culture and leadership, patient experience
initiatives are viewed as “what we do“ versus “just another thing we have to do.” Sites that
believe this is “what we do“ have few radical or organizational-wide, sweeping changes (Burke,
2018) in day-to-day business. However, sites that believe PX initiatives are an addition to their
daily work have more significant inherent organizational culture issues to address before
individuals and work units can focus on behavior changes to improve PX measures. The research
method for the study is qualitative, given that the research questions focus on PCPs’ perceptions
of executive leaders’ behaviors and the organizational culture. Interviews are an appropriate
qualitative strategy as they allow for face-to-face interactions, whether virtual or in-person, that
help forge a connection between me and the participants, which is important to ensuring credible
and trustworthy data are gathered (Creswell & Creswell, 2018).
Definitions
To properly understand the problem of practice, the following concepts must be clearly
defined:
• Executive leadership refers to any clinical or non-clinical executive, including the
director, assistant director, and chief of staff.
• Level 1 hospital refers to a trauma center, a tertiary care facility providing care for all
aspects of healthcare—from prevention to rehabilitation.
• Outcomes, in the context of this paper, refers to quality patient health outcomes.
17

• National program offices are VA or VHA departments with a national area of focus and
responsibility.
• Primary care provider (PCP) refers to a general medicine practitioner clinician, is the
primary provider responsible for care coordination, and refers patients to specialty care.
Organization of the Dissertation
The study consists of five chapters. Chapter 1 provides the reader with the macro-scale
context of the problem, the purpose and research questions guiding the study, the participants of
focus, the theoretical and methodological framework, and definitions. Chapter 2 examines the
scholarly literature on patient experience, quality health outcomes, executive leaders,
organizational culture, and how the aligning theoretical framework informs the study. Chapter 3
presents the study’s methodology, including data collection and analysis. The study’s findings
are reported in chapter 4. Chapter 5 provides opportunities for action.
18

Chapter Two: Review of the Literature
The following literature review examines relevant research and the theoretical and
conceptual frameworks that inform the study. The review of literature first attempts to outline a
shared understanding of patient experience (PX) and explains why PX is not the same as patient
satisfaction. The review also explores the history and measurement of PX in outpatient clinical
care settings, outcomes, and firmly established PX in the Department of Veterans Affairs (VA)
context. Last, the two theoretical frameworks are discussed in detail before the conceptual
framework is considered.
History of Patient Experience
Despite the current focus and increased efforts in healthcare surrounding patient
experience (PX), the patients’ experience has not always been considered. A few articles
reported the four-decade history of the topic (Christensen, 2017; Kash & McKahan, 2017;
Siegrist, 2013; Standley, 2021). The AHRQ (2020c; Khanna & Ginsberg, 2020) provided a
comprehensive timeline of the organization’s involvement with PX surveys, reporting, and
improvement efforts in the United States. A brief non-exhaustive U.S.-specific timeline is shown
in Table 3.

19

Table 3
A Brief Timeline of the Evolution of Patient Experience Surveys in the United States

Year

Agency / Organization

Significance

1985

Press Ganey

Created space for methodologically sound healthcare surveys design
and administration

1992 The Institute of Patient and
Family-Centered Care
Established four guiding principles for PCC: dignity and respect,
information sharing, participation, and collaboration

1995 Agency of Research and Quality
(AHRQ)
Created the Consumer Assessment of Healthcare Providers and
Systems (CAHPS) program

1999 AHRQ CAHPS program initiated research on a survey to assess PX for
medical groups and clinicians.

2001 Institute of Medicine Defined patient and family engagement as the delivery of respectful,
responsive, and individualized care

2002 Centers for Medicare and
Medicaid Services (CMS)
The first involvement of the United States Government. CMS and
AHRQ collaborated to standardize the Hospital (inpatient)
CAHPS (H/CAHPS).

2005 National Quality Forum Endorsed CMS and AHRQ’s work on H/CAHPS

2005 United States Government Enactment of the Deficit Reduction Act incentivized private and for-
profit hospitals to adopt H/CAHPS.

2005 United States Office of
Management and Budget
Approved national implementation of H/CAHPS for public reporting

2007 CMS All hospitals subjected to the Inpatient Prospective Payment System
are required to collect and submit H/CAHPS data to receive full
payments.

2007 AHRQ The Clinic and Group Survey (CG/CAHPS) is released and assesses
PX in outpatient clinical care settings.

2010 United States Government The Affordable Care Act further incentivized reimbursement for
reporting H/CAHPS

Note. Historical timeline for the evolution of patient experience surveys (AHRQ, 2020c;
Christensen, 2017; Kash & McKahan, 2017; Khanna & Ginsberg, 2020; Siegrist, 2013; Standley,
2021).
20

Although AHRQ (2020c, 2022f initiated conversations surrounding PX prior to 1995, the
launch of the CAHPS program signaled the advancement of scientific knowledge on the topic.
The CAHPS program sought to accomplish three goals. The program was designed to create
comparable and objective information from the patient’s perspective for care within health
systems on domains that are meaningful to patients, endorsed a better understanding of PX
across the continuum of care, and supported the development and distribution of surveys and the
results to improve quality care while helping patients make informed decisions about their care
(AHRQ, 2022e). The alignment of the CAHPS program goals to PCC concepts is clear. Before
the CAHPS program, there was industry-wide concern about the lack of standardized data from
patients’ perspectives. Without hearing directly from consumers of healthcare services, it is
difficult to know how well hospitals, healthcare systems, and clinics leveraged the patient-
centered care (PCC) behaviors of clinicians to drive quality care.
As the evidence grew relating PCC, PX, and outcomes, various organizations sought to
incentivize healthcare systems to improve the quality of care through public reporting beginning
in 2002 (Christensen, 2017; Kash & McKahan, 2017; Siegrist, 2013; Standley, 2021). The
requirement for public reporting of PX metrics was accomplished in the United States in 2005
via CMS, AHRQ, Office of Management and Budget efforts, and finally, the Deficit Reduction
Act [of 2005]. Publicly reporting PX metrics was expected to increase transparency and drive
greater accountability within the U.S. healthcare system for the quality of care provided.
Furthermore, with greater choice offered to consumers, patient-reported experiences are one way
for patients, family, and carers to decide where to seek and receive healthcare services (Richter
& Muhlestein, 2017).
21

The initial focus of the CAHPS program was on inpatient surveys. As the healthcare
industry shifted focus toward preventive care, AHRQ (2022f) began researching survey elements
for outpatient clinical care areas within medical groups and individual clinicians. In 2007, the
Clinic and Group Consumer Assessment of Healthcare Providers and Systems (CG/CAHPS)
survey was released for use in primary care clinical care settings. Greater detail about the survey
is outlined in subsequent sections of this paper. The literature is clear on the relationship between
patient experience and outcomes.
Why Patient Experience Matters: A Look at Quality Patient Health Outcomes
While previous sections of this study provide the foundation of patient experience (PX)
and patient-centered care (PCC), this section seeks to review the definition of quality healthcare.
Then, the associations among PX, PCC, and quality care are explained so that a better
understanding of how quality patient health outcomes, or simply outcomes, occur. A foundational
understanding from the literature of how care delivery impacts the patient experience and,
subsequently, the patient’s health outcomes is prudent. This study does not seek to correlate
specific patient outcomes with PX measures but instead seeks to highlight the relationship between
the concepts.
Donabedian’s “Evaluating the Quality of Medical Care“ (1966) not only considered a
PCC approach to quality healthcare delivery but also identified the crucial link between how
medical professionals deliver care to patients and their outcomes. Just as definitions for PX and
PCC are important, “quality care” and “quality health outcomes” must be defined. An abundance
of literature exists about quality care and agreed, nearly unanimously, that the Institute of
Medicine’s seminal report Crossing the Quality Chasm: A New Health System for the 21
st

Century (2001), defined quality as “the degree to which healthcare services for individuals and
22

populations increase the likelihood of desired health outcomes and are consistent with current
professional knowledge“ (p. 44). In layperson’s terms, patients get the proper diagnosis and
treatment to address their medical needs in a timely manner. Six domains of quality healthcare
are outlined and include safe, effective, patient-centered, timely, efficient, and equitable and are
assessed by a vast list of quantitative metrics.
The domains of quality healthcare are consistent across literature sources and stem from
the Institute of Medicine (2001), the Agency for Healthcare Quality and Research (2018), and
Donabedian’s (1966) work on the topic. Safe care addresses actual or possible bodily harm to
patients. Healthcare systems and professionals are expected to avoid injury to patients.
Effectiveness determines whether the delivered care is rooted in evidence-based, scientific
knowledge. Next, efficiency in healthcare means that the correct evidence-based treatment is
applied to the correct diagnosis. Ensuring patients receive an appropriate level of care is vital for
the patient’s health.
Additionally, the appropriate level of care manages under-, over-, and misuse of
resources, which addresses the “triple aim“ of the Institute of Healthcare Innovation (IHI).
Patient-Centered Care (PCC) has already been covered at length, but it means that care is
delivered with dignity and respect and that patients have shared decision-making (Bolger, 2012).
Timely care is delivered when the care is needed. Delays in care increase patient mortality and
increase health systems utilization by patients (Prentice & Pizer, 2007). When a diagnosis is
delayed, patients are sicker, require more extensive treatment, or present at emergency
departments, which means greater overall cost (Kraft et al., 2009; Surrey et al., 2020). Last,
equitable care conveys the need to deliver equal quality healthcare across all demographics,
locations, socioeconomic statuses, clinical conditions, and preferences of patients. Of note, all
23

quality of care domains are relevant across entire healthcare systems and, more generally, the
U.S. healthcare industry, not just individual patients. The Healthcare Effectiveness and Data
Information Set (HEDIS) is used for ambulatory care quality patient health outcomes.
The Center for Medicare and Medicaid Services (CMS) and the National Committee for
Quality Assurance (NCQA) developed the HEDIS for patients who require a special needs plan
for their healthcare conditions. The HEDIS includes more than 90 measures across six domains
of clinical care: care efficacy, access to care, experience, utilization, health plan descriptive
information, and clinical measures collected via electronic health record systems (NCQA,
2022b). Measures range from preventive care, such as annual screenings and immunizations, to
emergency care, disease management, behavioral health, medication use, and various life stages
like prenatal, postpartum, or end-of-life. Measurements of outcomes are necessary for healthcare
systems’ accountability for quality care delivery (Larson et al., 2019). The figure in Appendix A
was created to visually represent the shared relationships between quality care, patient-centered
care, and patient experience.
The literature has indicated strong associations between patients’ experiences and HEDIS
measures, both positively and negatively. Primarily, research data demonstrated a positive
correlation between positive patient experiences and overall quality patient outcomes. There are
direct and indirect paths to quality outcomes. Direct paths to patient outcomes from a positive
experience include survival, remission or cure of the condition, vitality, emotional well-being,
improved ability to care for themselves, pain management, and reduced suffering (Street et al.,
2009). Indirect paths of patient experience drivers for outcomes occur as either secondary or
tertiary effects (Hibbard & Greene, 2013; LaVela & Gallan, 2014; Street et al., 2003; Stewart,
1995; Stewart et al., 2000; Zill et al., 2014). Providers who effectively communicate and deliver
24

care to patients improve the patient’s comprehension of the information, increase trust, and share
decision-making, which leads the patients to adhere to the plan of care and thus to better self-
care and positively affects patient outcomes (LaVela & Gallan, 2014; Street et al., 2009). As it is
known in the healthcare industry, this therapeutic relationship requires the provider to connect
with the patient and be respectful, empathetic, and compassionate (Chaitoff et al., 2017; Torpie,
2014). Shared decision-making between provider and patient can be a product of patient
engagement—also known in the literature as patient empowerment or activation (Hibbard &
Greene, 2013; Street et al., 2009). When a patient is an active participant in their care, they are
more likely to have a positive experience and improved outcomes (Hibbard & Greene, 2013;
Street et al., 2003; Stewart et al., 2000; Stewart, 1995; Zill et al., 2014). While the literature links
PX directly to outcomes, a broader lens is applied here as outcomes are generally a secondary or
tertiary result of quality care.
Examining the CG/CAHPS
This study does not directly assess or leverage PX data, but it is important to understand
the tools used to gather feedback from patients within a primary care (PC) clinical setting. The
Clinic and Group Consumer Assessment of Healthcare Providers and Systems (CG/CAHPS)
Surveys are designed to do just that. There are currently three versions of the survey and four
supplemental questionnaires. The Clinic and Group Survey 3.0 asks patients about their
experiences with a specific provider or clinical group over the last 6 months. The Clinic and
Group Survey 3.1 is the same as the 3.0 version plus an expanded focus to include in-person,
phone, or virtual telehealth visits. Last, the newest CG/CAHPS is the Visit Survey 4.0 (beta),
which specifically asks the patient about their experience at their most recent outpatient visit,
whether in-person, by phone, or through virtual telehealth. The 6-month reference period in
25

surveys 3.0 and 3.1 allows for data capture when considering multiple care encounters with the
same provider or within the same practice group. The 4.0 version was specifically developed in
response to the drastic and rapid increase in telephone and virtual telehealth visits due to the
onset of the COVID-19 pandemic (AHRQ, 2017a). The survey is still in a testing phase, hence
the “beta“ designation, and is not currently considered an approved CAHPS survey (AHRQ,
2017a, b, c). Of note, there are also children’s versions of the surveys, but this study only
considers the adult patient population.
Appendix C from AHRQ (CAHPS Clinician & Group Survey: Differences between the
core items in 3.0, 3.1, and Visit 4.0 [beta] versions, n.d.) outlines the three primary CG/CAHPS
survey domains, performance questions, and variations among the three CG/CAHPS Surveys.
Although the three primary care surveys vary slightly due to the intended purpose, the domains
include timely access to care, provider communication, coordination of care, office staff
behaviors, and overall provider rating. Table 4 lists the domains and performance questions as a
reference to the CG/CAHPS 3.0 because it is the Veteran’s Health Administration outpatient PX
survey model.

26

Table 4
Domains and Performance Questions on the Clinic and Group Consumer Assessment of
Healthcare Providers and Systems
Domain Performance Question

Timely access to
care

The patient got an appointment for urgent care as soon as needed
The patient got an appointment for non-urgent care as soon as needed
The patient got answers to medical questions the same day they contacted
the provider’s office

Provider
communication

The provider explained things in a way that was easy to understand
The provider listened carefully to the patient
Provider showed respect for what the patient had to say
The provider spent enough time with the patient

Care coordination
Provider knew important information about the patient’s medical history

Someone from the provider’s office followed up with the patient to give
the results of blood tests, X-rays, or other tests
Someone from the provider’s office talked about all prescription
medications being taken

Office staff

The clerks and receptionists were helpful
Clerks and receptionists were courteous and respectful

Overall provider
rating

Rating of provider

Note. CAHPS Clinician and Group Survey 3.0 Measures. (2022).

Supplemental Items for the Clinic and Group Surveys
The four supplemental questionnaires include patient narratives, the patient-centered
medical home (PCMH) item set, health literacy, and health information technology. The patient
narrative survey asks patients open-ended questions to solicit qualitative information about their
27

experiences. Respondent answers can offer helpful information for healthcare systems, clinics,
and providers (Schlesinger et al., 2019). The insights gleaned from patient narratives capture
experiences that may not otherwise be provided via close-ended questions from one of the
CG/CAHPS surveys. However, patients are also able to provide positive or negative feedback
and identify areas of opportunity for improvement.
The supplemental PCMH item set is a series of six questions that can be added to local-
level CG/CAHPS surveys. The PCMH item set is intended for use when the healthcare system is
designed to support the patient care situations outlined in the supplemental survey (AHRQ,
2021c). The supplementary questions are meant to learn about the patient’s experience with the
team of caregivers that supports the PC provider in the same office. The PCMH item set
questions are designed to be embedded into the CG/CAHPS in specific sequences as
supplemental follow-on questions from the CG/CAHPS survey. The PCMH item set appears in
Attachment X.
Next, the Health Literacy Supplemental Questionnaire enquires about the effort providers
make to promote health literacy for the patient. Health literacy is defined as the patient’s ability
level to find, comprehend, and leverage health information to make informed decisions for
themselves (Brega et al., 2019; DeWalt & McNeill, 2013). As previously discussed, enabling
patients to participate actively in their healthcare through shared decision-making is a core
concept of patient-centered care, which drives the patient experience. The supplemental
questionnaire addresses communication about self-management of disease and related
conditions, communication about medications, communication about diagnostic tests and the
results, and communication about medical forms, and further investigates communication with
providers (AHRQ, 2021a).
28

The final supplemental questionnaire, the Health Information Technology Item Set,
accounts for the growing technological advancements that support healthcare systems, clinics,
and providers in care delivery. Patients can communicate in various ways with their healthcare
system, the clinic, or the clinical team. Virtual telehealth visits skyrocketed at the onset of the
recent pandemic, but there are also telephone, text, and secure messaging interactions, all of
which depend on the advancement and capabilities of the healthcare system (AHRQ, 2022i;
Saher & Anjum, 2021). As helpful as technology can be, the distancing from human connection
and patient safety is an actual occurrence (Alotaibi & Federico, 2017; Chua et al., 2019). The
Health Information Item Set was developed to measure whether providers continue to ground
their care delivery behaviors in PCC concepts when interacting with patients electronically
(AHRQ, 2022i; Rozenblum & Bates, 2013).
Leveraging Results from CG/CAHPS
An oft-repeated phrase across many industries is “data rich and information poor.” Peters
and Waterman Jr. (1983) stated that the healthcare industry is no different. The phrase articulates
the vastness of available data in organizations, married with the inability of those organizations
to use the data effectively and meaningfully to be competitive. Now that healthcare systems have
an abundance of PX metrics at their disposal, it is time that the data be turned into usable
information to improve patients’ experiences.
The AHRQ provides resources for healthcare systems to assess and improve PX survey
results. One such resource, “Preparing Data from CAHPS Surveys for Analysis“ (AHRQ,
2017b), is an evidence-based tool to help healthcare professionals through data collection,
analysis and the incorporation of feedback into process improvement initiatives within healthcare
systems. Given that the survey is designed to address specific touchpoints in the patient’s
29

healthcare journey, the results are easier to interpret and best for data-informed business
decisions.
Veterans’ Health Administration and Patient Experience
Healthcare systems, including the Veterans Health Administration (VHA), are highly
reliable organizations, or HROs. The term HRO applies to any industry that involves great risk in
highly complex and rapidly changing environments, yet few errors occur (Christianson et al.,
2011; Serou et al., 2021). In the 1990s, the VHA National Office of Patient Safety introduced the
HRO concept. However, it was not until 2019 that a concerted effort was made with 18 VHA
pilot sites to intentionally implement HRO pillars and principles (VHA, 2020).
As of 2015, nine million veterans are served annually from the 1,298 VHA healthcare
facilities strategically placed across the United States, several U.S. territories, and the Philippines
(Selected Veterans Health Administration Characteristics: FY2002 to FY2015, 2017). The same
report shows 95.2 million outpatient visits (across all clinical care outpatient settings) and 699.1
(in thousands) inpatient admissions in the same timeframe. The report, Average Expenditures Per
Patient by Healthcare Priority Group: FY2000 to FY2018 from VHA (2018), estimated the cost
associated with the healthcare encounters listed above and is reported as just under $828 million
annually. The amount does not factor in costs and associated encounters for veterans who, for
whatever reason, leverage care outside of the VHA through the Care in the Community (CITC)
program. The amount also does not account for the infrastructure, equipment, supplies,
personnel, or other operational costs.
Of the approximately 371,000 VHA employees, there are an estimated 32,368 medical
doctors (MDs) across all care areas and 80,000 nurses—including registered nurses (RNs),
licensed practical/vocational nurses (LP/VNs), nursing assistants (NAs), and advanced practice
30

nurses (APNs), which includes nurse practitioners (NPs) (VHA, 2016). The VHA is the largest
healthcare system contributing to the academic advancement of healthcare professionals.
Academic affiliations include 1,800 academic institutions, more than 90% of all United States
allopathic schools, and 85% of osteopathic institutes, with over 7,000 clinical training programs
(VHA, 2016). Through the affiliations, clinician trainees in over 40 healthcare disciplines total
120,000 trainees annually (VHA, 2016). The VHA is also one of the largest contributors to
medical, healthcare systems, organizational, and other research efforts, including three Nobel
prizes, seven Lasker awards, and other national and international awards (VHA, 2016). Several
influential factors led to the creation the Veterans Experience Office (VEO) in 2015. However,
the notorious access issue uncovered in Phoenix, Arizona, in 2013 and the subsequent Office of
Inspector General report in 2015 were essential to the organizational transformation efforts that
began the same year.
Customer experience (CX) was determined as a primary expectation during the
transformation, and the Veterans Experience Office (VEO) drives customer experience change
across all three VA administrations. However, this study only addresses PX through the VHA.
The vision of VEO is “to leverage CX data, tools, technology, and engagement to enable the VA
to be the leading CX organization in Government, so Service members, Veterans, their families,
caregivers, and survivors choose VA“ (Veterans Experience Office [VEO], 2022). The VEO
mission is to support the
VA as the Secretary of Veterans Affairs’ CX insight engine and [sic.] a shared service to
partner with, support, and enable [the three] VA Administrations and Staff Offices to
provide the highest quality CX in the delivery of care, benefits, and memorial services to
31

Service members, Veterans, their families, caregivers, and survivors. (Veterans
Experience Office, 2022)
In accordance with 38 CFR § 0.603 (Code of Federal Regulations, 2019), the VA measures CX
guiding principles based on ease, effectiveness, and emotion.
The alignment of quality healthcare delivery domains, patient-centered care domains, and
the guiding principles for CX in the VA are clear. Ease represents VHA’s commitment to
making timely access to healthcare services for veterans smooth and easy. Efficacy means
veterans receive quality healthcare aligned to the delivery of evidence-based care and meets
veteran expectations. Finally, emotion means the delivery of quality healthcare in a way that
leaves the patient, family, and carer feeling respected, honored, and valued (Veterans Experience
Office, 2022). The principles are established to build trust with veterans, which is crucial for PX
and outcomes. The combination of these factors impacts the veteran’s overall trust in VHA. The
guiding principles apply to all employees and clinical care settings. As such, VEO partners with
other national program offices to improve the patient experience.
It is essential to showcase the successes of the VHA. As the organizational focus of the
study, it is prudent to note that VHA outperforms the private sector in all categories of patient
experience and performs better than or equal to non-VHA healthcare in the areas of quality,
safety, access, cost, and efficiency (Lawrence, 2023; Shekelle et al., 2023). In a systematic
review of nonsurgical patient health outcomes, 85% of the peer-reviewed articles found that
VHA patients have better or equal quality patient health outcomes than non-VHA healthcare
(Shekelle et al., 2023).

32

Department of Veterans Affairs and the PX Framework
To better understand the Department of Veterans Affairs (VA) and how the patient
experience (PX) directorate delivers solutions and services, it is essential to understand how the
VA defines PX and the PX framework developed by VEO. Within the VA, PX is defined as “the
sum of all interactions, shaped but the organization’s culture, that influences Veterans’ and their
families’ perceptions along their healthcare journey“ (Veterans Experience Office, 2022). The
PX framework has seven domains centered around veteran experience and employee experience:
culture, leadership, patient communication, environment, measurement and improvement,
employee engagement, and voice of the veteran. (Appendix B presents the VA PX framework.)
Culture, within the context of the PX framework, means that veterans, families, and
employees are motivated by kindness, collaboration, innovation, transparency, and
accountability. Leadership as a domain means that leaders are visible, engaged, and set the tone
for the patient experience. Leaders also empower and build an organizational culture committed
to patient experience. When patient communications are consistent, use plain language, and
invite patient engagement, veterans know what to expect throughout their healthcare journey. A
welcoming and supportive healing environment is clean, safe, and mitigates anxiety for veterans
and employees. The domain of measurement and improvement means that the organization
leverages meaningful, contextually relevant, and real-time metrics to understand how to improve
the patient experience. Engaged employees feel passionate about serving veterans, are committed
and accountable to each other and the organization, and feel empowered by leadership. Last, by
incorporating the voice of the veteran, VHA organizations proactively collect and use veteran
feedback to make decisions and solve system problems that truly matter to veterans, families,
and carers.
33

Veterans’ Health Administration National Office of Primary Care
The VHA National Office of Primary Care gives Veterans access to healthcare providers
committed to continuity of care, foundational patient-provider relationships, care coordination,
personalized health education, and preventive health measures (VHA, 2022c). The Office of
Primary Care oversees the implementation of the patient-centered medical home (PCMH) model
through the Patient Aligned Care Team, also known as a PACT. The PACT approach to
delivering primary care within the VHA is the backbone of transforming veterans’ care by
providing team-based, patient-led, proactive, personalized, team-based care focused on wellness
and disease prevention, resulting in improved veteran experience and patient health outcomes.
When considering a team-based approach to healthcare delivery, the patient is part of the
team. Involving the patient drives patient engagement, and the array of experts on the team
means a more holistic approach to care rather than simply treating symptoms of conditions.
While each VHA healthcare facility varies, the core healthcare disciplines included in the PACT
model are the primary care provider (PCP), RN, and medical support assistant. Depending on the
complexity, size, staffing levels, and patient needs, additional disciplines may be added to the
PACT. Examples include pharmacists, social workers, dieticians, and mental health practitioners.
The team-based approach leads to supportive patient-staff relationships, increased trust, more
open communication, and improved cooperation across all involved parties (VHA, 2022c; VHA,
2022d). Also, by partnering, the patient receives “whole-person care,” which is vital to long-term
health and wellness (VHA, 2022c).
Furthermore, the patients’ PACT is their access to all other clinical specialties, internal
and external to the VHA, which may be required to diagnose and treat patients’ conditions.
Established processes within the VHA related to PACTs and specialty care are for the PACT
34

PCP to partner first with the patient for all medical and health-related concerns. Once the PCP
determines whether the patient’s condition requires the support of a medical specialist—such as
podiatry or gastroenterology—a consult, or referral, is placed in the integrated electronic health
record (EHR). This approach allows for the oversight of all patient conditions by the PACT,
which means improved care coordination. Last, the PACT accomplishes care coordination since
each team member performs within the license of their uniquely specialized roles. These
essential functions of a PACT make it a crucial clinical care setting to establish a veteran in the
VHA healthcare system.
Measuring Patient Experience in Veterans Health Administration Primary Care Settings
Many healthcare systems, including the VHA, contract with external vendors to develop,
disseminate, and measure PX metrics that include outpatient clinical care areas such as specialty
care, mental health, and primary care. The AHRQ allows organizations to add domains and
questions to PX surveys, but healthcare systems cannot remove any existing CG/CAHPS survey
domains or questions. The VHA leverages the Survey of Healthcare Experience of Patients
(SHEP) and includes outpatient metrics to gain comprehensive insight into patient care.
Given the support a PACT model of care delivery provides to the patient, the patient-
centered medical home (PCMH) SHEP survey is used to assess the patient’s experiences related
to the functions and situations in a primary care setting. The PCMH SHEP survey includes all
aspects of the CG/CAHPS 3.0, 3.1, and many aspects of the four supplemental questionnaires
previously discussed. (Appendix D showcases the Inpatient, PCMH, and Specialty Care SHEP
surveys in detail. Domains for PCMH include access to routine care, access to urgent care, care
coordination, provider communication, office staff behaviors, comprehensiveness of care, patient
self-management support, shared decisions for medications, and overall rating of the provider. It
35

is imperative to understand how the clinical teams are assessed. Sharing data reflecting
individual performance measures can drive improvements (Kotter, 2012; Shein, 2010; Lee et al.,
2016).
VHA Primary Care Trust Scores
Although the data focus of the study is not directly tied to VHA PX scores, it is
worthwhile to visualize the current trust scores of the participant sites of care. Patient trust in
their provider is a leading indicator of the overall patient experience (Stephens et al., 2020).
Providers who spend time building trust with patients report an increased likelihood of patient
engagement, improved adherence to the plan of care, and higher self-reported health ratings
(Birkhauer et al., 2020; Ozawa & Sripad, 2013; Shea et al., 2008; Stephens et al., 2020). Figure 1
shows the primary care trust scores from the seven VHA sites of care for the fiscal year 2023,
quarters 1–3 as well as comparisons to the national VHA benchmark for the same period. Five of
the seven primary care trust scores fall below the national VHA benchmark of 88%.

36

Figure 1
Participating VHA Sites of Care Primary Care Trust Scores

Note: (Veterans Health Administration. 2023. Primary Care Trust Scores (Unpublished raw
data). Veterans Signals.

Healthcare Stakeholders’ Contributions to Patient Experience
There are several stakeholders in healthcare systems to consider. The patient, families,
and carers are the customers who receive services from the organization. Additionally, frontline
employees, or those who engage directly with customers, are the foundation of any healthcare
system. Without frontline employees, the system could not exist. Frontline employees are
predominantly clinical, but nonclinical employees are included in this category. Last,
administrative employees comprise the remainder of a healthcare system’s roster. Like frontline
employees, administrators are clinical and non-clinical and range from individual contributors
37

(nonsupervisory) to executive leadership. This study concerns executive leaders and frontline
primary care providers (PCPs).
Healthcare Executive Leaders’ Contributions to Patient Experience
The clinical team is discussed at length in this study due to its focus on direct patient
engagement; however, executive leaders, especially the chief executive officer (CEO) and chief
medical officer (CMOs), are key figures in a healthcare organization and drive targeted change
for PX initiatives. There are other influential C-suite leaders in healthcare organizations, such as
the nurse executive. However, the CEO and CMO constitute the executive leader focus of the
study, given their influence within the organization and with the participant group. Schein (2010)
discussed how executive leaders (ELs) entrench their values, beliefs, and assumptions into
organizational culture. Specific behaviors drive organizational culture. Behaviors include what
ELs routinely pay attention to, measure, reactions to crises, resource allocation, how award and
recognition programs function, intentional role modeling and coaching, and how leaders recruit,
select, promote, and dismiss employees.
Chief executive officers comprise the bulk of the literature when considering
organizational culture, mission and vision, and organizational change due to their role, visibility,
and position. In considering PX, the literature highlights characteristics and behaviors of CEOs
that research has identified as positive drivers for patient experience. Largely though, the C-
suite’s influence on the organization is focused on organizational culture and the healthcare
delivery system rather than how frontline staff delivers positive patient experiences.
Galstian et al. (2018) and Silvera and Clark (2021) determined that women executives are
more strongly and significantly associated with higher PX metrics specific to interpersonal
interactions with providers. It is suggested that female CEOs lead with greater collaboration,
38

transparency, and compassion, inspiring other leaders to engage in their roles as managers and
supervisors (Galstian et al., 2018). The same study also determined that CEOs with longer
tenures in their roles were strongly and positively associated with higher PX metrics. Chief
executive officers with longer tenures are believed to have increased awareness and
understanding of stakeholders’ environments and needs, which promotes a supportive culture
that leads to better patient experience. Lee et al. (2016) looked at an extensive university
healthcare system within the United States and found similar findings to those reported by Shein
(2010). Input about the effects of robust award and recognition programs and data transparency
were highlighted by Lee et al. (2016). As part of a PX initiative rolled out in 2008, Lee et al.
(2016) explained how the CEO’s involvement during the initiative through quarterly recognition
of the highest performing and most improved clinical care units for PX metrics led to a positive
culture shift for patient-centeredness. The CEO hand-delivered the awards to the clinical units,
signaling to all staff what is important to leadership.
Furthermore, the CEO’s decision to publicly share PX metrics drove culture change
around care delivery. The healthcare system reported a shift toward more patient-centered care
over 8 years. Hefner et al. (2019) established a positive relationship between PX, patient
outcomes, and CEOs’ performance expectations. When organizational performance measures for
ELs align with the Institute of Medicine’s definition of quality care, the healthcare system
supported better overall organizational and quality patient health outcomes. The study also
identified the need to incorporate those same organizational performance measures in all
individual performance plans to see an increase in the same metrics. The CEO is the primary
driver of organizational culture in any industry. Healthcare systems are unique in that leadership
and supervision of highly specialized clinical staff are required throughout the leadership chain
39

to ensure quality care delivery. As such, the CMO is equally important in the healthcare industry,
although there is less literature about the indirect or direct impacts of CMOs on patient
experience.
The study by Veronesi et al. (2015) showcases an abundance of existing literature
supporting clinical leadership involvement in healthcare systems. Specifically, CMOs are
mentioned as the most influential clinical leaders for PCPs. Given the shared medical knowledge
between the CMO and PCPs, CMOs are trusted senders of communication throughout the
organization. Jeroen et al. (2016) furthered the conversation and found that high levels of support
from CMOs to frontline providers were positively associated with provider engagement. Both
studies indicated overall organizational performance improvement in quality care delivery
domains and PX measures. Finally, Burke (2018) and Caldwell et al. (2008) found that clinical
leaders are essential in any healthcare organization’s change efforts, regardless of the end goal.
However, patients do not, or rarely, engage with healthcare system C-suite leaders. Therefore,
the provider in the patient-provider relationship must be examined.
Primary Care Providers’ Contributions to Patient Experience
Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys inquire
about the continuum of care, but the PCP is one of the primary stakeholders in healthcare
systems. In this study’s context, PCPs consist of licensed independent practitioners and include
three license types: MDs, nurse practitioners (NPs), and doctors of osteopathy (DOs). From the
license types, the MDs perform the worst with PX measures.
Nurse practitioners (NPs) consistently outperform MDs in all areas of the delivery of
quality, patient-centered care. Nurse practitioners’ patients have fewer hospitalizations and
readmissions, fewer emergency department visits, better patient experiences, and greater patient
40

satisfaction compared to MDs (Kinnersley et al., 2000; American Association of Nurse
Practitioners [AANP] [2020]). Because of the literature, the study included NPs as a valuable
data resource. Alternatively, DOs are trained to treat patients’ physical, psychological, spiritual,
and emotional needs (Misra, 2021). The principles are codified in all DO training programs and
intend to address intellectual pathways to diagnosis, considerations of treatments, and whole-
person approaches when considering patient experience. The literature is sparse on Dos’ impacts
on PX measures.
A case study led by Caldwell et al. (2008) determined that organizational change within
healthcare systems is successful when the behavior change of the MD is the focal point of the
change initiative. The same study determined that the central outcome measure for the study was
improved patient experience metrics. A growing body of evidence supports MD engagement as
the primary driver of PX measures. Farrington et al. (2016), Fox (2017), Jha et al. (2008), Oppel
and Mohr (2020), and Roberts et al. (2014) all emphasized the vital role MDs play in
interpersonal patient-provider relationships. Furthermore, MDs’ ability to effectively
communicate with patients, families, and carers is well documented in the literature as a primary
driver for PX measures and patient outcomes (Fox, 2017). Oppel and Moher (2020), through the
“pay-it-forward“ theoretical model, determined that providers who engage civilly during patient
interactions had a correlating effect on PX variables. Specifically, when the workplace culture
was team-oriented, providers were more civil to their patients. However, this is a notable
difference in findings when comparing group-level PX scores and individual MD PX scores.
Roberts et al. (2014) examined ranges of PX scores within clinical group settings and
with the individual MDs in those clinical group settings. They determined that higher group-level
PX scores on communication were positively associated with individual provider communication
41

PX scores. However, when the clinical group’s PX scores for communication were low, the
individual providers’ PX scores were mixed. Roberts et al. (2014) proposed that the
inconsistency in provider communication was an indicator of poorly defined group processes that
negatively impacted PX measures and the quality of care delivered. Farrington et al. (2016)
reinforced the point through provider interviews where participants consistently expressed that
organizational PX scores are not helpful at the individual provider level when considering how
MDs communicate and deliver care.
Theoretical Frameworks
This study applies two theoretical models. First, the Burke-Litwin causal model of
organizational performance and change (2018) offers a lens to research the impact of executive
leadership, organizational culture, and individual and organizational performance related to
adverse patient experiences and poor-quality health outcomes. The second model is the VHA
High-Reliability Organization (HRO) pillars; leadership commitment, a culture of safety, and
continuous process improvement.
VHA High-Reliability Organization Framework
Within the VHA, high-reliability organization (HRO) pillars include leadership
commitment to zero harm, a positive safety culture, and leadership support and engagement with
all employees in a culture of continuous process improvement (VHA, 2020). Figure 2 represents
the foundational VHA HRO pillars. The five principles that align with the HRO pillars are (a)
sensitivity to operations, (b) preoccupation with failure, (c) reluctance to simplify, (d)
commitment to resilience, and (e) deference to expertise (Veazie et al., 2019).

42

Figure 2
The VHA HRO Framework

Note: Adapted from M. R. Chassin, & J. M. Loeb (2013). High-reliability health care: Getting
there from here. Milbank Quarterly, 91(3), 459–490.

Although the principles from the VHA HRO framework are not included as part of the
conceptual framework for this study, the principles were used as a priori codes during the data
analysis process and are reviewed here. Sensitivity to operations means all employees have a
heightened awareness of the current state of relevant systems and processes within their work
areas and a systems perspective on how their processes fit into the larger whole. Preoccupation
with failure infers that all employees view relevant systems and processes through a lens of
43

opportunities for improvement rather than evidence of success. When employees accept that
their work is complex and the potential to fail is imminent, they are reluctant to simplify
processes. Given the high complexity of healthcare systems, errors and mistakes are inevitable.
Therefore, employees, supervisors, and leaders must commit to resilience; that is, to learn from
and rebound from those mistakes. Last, deference to expertise means employees are valued
based on specialization, education, and training rather than according to seniority. Deference to
expertise in healthcare also means that clinicians are permitted to practice medicine at the top of
their license and that tasks are divided according to clinicians’ responsibility based on who is
best suited to perform the task.
Burke and Litwin Framework: Causal Model of Organizational Performance and Change
The Burke-Litwin causal model of organizational performance and change (2010) was
the theoretical framework for the study. The model evolved from organizational climate
literature in the 1960s and 70s and was fully formed through application in practice. The model
has three main parameters: inputs, throughputs, and outputs. The theoretical entry point for all
organizational performance and change is through input received via the external environment,
while the output comes from individual and organizational performance. The remaining
dimensions of the model are throughputs, presented in Figure 3. Within the model, there are both
transformational and transactional factors, which are explained in detail in this section. Burke-
Litwin highlighted how changes to one dimension in the open systems principal style model
ultimately impact all other dimensions. Finally, it is important to understand Burke’s research on
revolutionary versus evolutionary change to effectively apply the framework to the study.
Revolutionary change is viewed as a shock to the organization’s system—the change is drastic
44

and occurs so that the organization will never be the same. Alternatively, evolutionary change
consists of small, additive changes that change the system over a long period (Burke, 2018).

Figure 3
The Burke-Litwin Causal Model of Organizational Performance and Change

Note: W. W. Burke & G. H. Litwin (1992). A causal model of organizational performance and
change. Journal of Management, 18(3), 523–545.

45

Transformational Factors
The transformational factors comprise the top third of Figure 3 and include the external
environment, mission and strategy, leadership, organizational culture, and individual and
organizational performance. Transformational factors are named as such because changes to any
of these categories mean significant changes to employee behaviors and, when successful, to
revolutionary change (Burke, 2018). First, the external environment receives inputs for the
system. Influences on the external environment include customers, competition, regulatory
agencies, local and global economics, government, and technology. However, due to the nature
of open systems and the continuous feedback loop, inputs are also received from individual and
organizational performance outputs. An example is that how an individual performs (output)
could impact customer experiences, establishing customer expectations as input from the
external environment.
As transformational factors, mission and strategy define an organization’s what and how.
An organization’s mission establishes what it does for a community—irrespective of community
size—and the goals of the organization. The strategy supports the mission by explaining how the
organization expects to meet the mission. Strategies can change over time to meet the
organizational goals and objectives, whereas the mission rarely changes. Mission and strategy
are considered transformational factors in the Burke-Litwin model because they drive the
structure of the entire organizational system (Burke, 2018).
Within the model, leadership focuses on executive leaders. Executive leadership is about
change, vision, and influence. Burke (2018) defined leadership as those who do not rely on
command and control but act as role models within the organization and facilitate opportunities
for professional development by serving their followers. There is a reciprocal relationship
46

between the external environment and leadership, meaning that the external environment
influences executives personally, often translating into a vision for the organization—which is
not to say non-executives are incapable of being leaders—it only serves as an important
distinction based on who drives the organizational vision.
Next, organizational culture accounts for the values, beliefs, and feel of the
organization’s people. Every organization has both explicit and implicit cultural norms. Explicit
norms are clear because they are outlined in directives, handbooks, employee guides, and
standard operating procedures. Implicit norms, on the other hand, are more informal and are
rarely discussed. An example may be where executives sit in board meetings or who contribute
first to discussions. The last transformational factor, individual and organizational performance,
is an output of the open system. Individual performance is commonly measured via productivity.
Organizational performance then assesses the quality of goods and services provided, profit
margins, and customer experience, to name a few. In healthcare, most organizational
performance measures are established by regulatory agencies to ensure quality care is delivered
to patients.
Together, the transformational factors have reciprocal relationships. Burke (2019) noted
that the external environment can influence executives (leadership), which forms their vision and
plays a direct role in the strategic approach to accomplish the mission. Factor placement within
the model is important. Leadership is intentionally placed between mission and strategy and
organizational culture on the model because the mission and strategy created by the executives
are often derived from the culture, either explicitly or implicitly (Burke, 2018).

47

Transactional Factors
The remaining dimensions of the model are transactional factors consisting of the daily
operations of an organization. The categories include structure, systems, management practices,
work unit climate, individual needs and values, task requirements and individual skills, abilities,
and motivation. Evolutionary change occurs within this section of the model because, according
to Burke (2018), most changes are approached via continuous process improvement and happen
over extended periods.
Structure is easily defined as the functional categories of the organization—or, rather, the
departments. The organization’s structure is readily visualized via organizational charts, which
indicate reporting structures, functional areas within departments, and, in a broader context,
communication channels. The organizational chart can also identify operational units and special
programs (Burke, 2018). Management practices play a major role in an organization and are
generally transactional due to the relationship between managers (or supervisors) and their
followers (subordinates), which is typically interdependent. Burke (2018) considered managers
transactional on the premise that they prefer to maintain the status quo and because, typically, the
managers carry out the vision, mission, and strategy set forth by executive leadership.
Additionally, managers have less of a unified front compared to executives. Therefore,
these differences in vision and behaviors impact work unit climate differently (Burke, 2018).
Next, systems look at the policies and procedures of an organization. Although not shown in
Figure 3, there are subdimensions within the systems category. Examples include establishing
organizational goals, resource allocation, budget development, and employee reward and
recognition programs (Burke, 2018).
48

The work unit climate can be considered the microculture of a work unit or team. Climate
is rooted in team members’ perceptions of several factors, including manager efficacy,
performance expectations, recognition, shared decision-making, intrapersonal support from the
team, and team efficacy. Burke and Litwin (1992) reinforced that climate is the psychological
state of the employees in the unit, which organizational factors can impact. The following two
dimensions—, task requirements and individual skills and abilities and individual needs and
values, are closely connected. The former is addressed by hiring the right people for the right
positions by aligning employees’ skills and abilities with the positions’ roles and responsibilities.
The factors, individual needs and values considers whether the job aligns with the employee’s
needs and values. The two dimensions flank the motivation dimension because skills and
abilities and needs and values significantly influence employee motivation (Burke, 2018). The
final dimension of the Burke-Litwin causal model for organizational performance and change is
motivation. Motivation exists in all humans, albeit to varying degrees, and is mutable over time.
For organizations to achieve employee motivation, organizational and performance goals must
meet the needs of employees. Therefore, aligning skills, abilities, needs, and values is imperative
for employee motivation.
Transactional factors, like transformational factors, are reciprocal. Of note, individual and
organizational performance is both a transformational and transactional factor. In the context of
transactions, motivation directly impacts performance, positively and negatively. Additionally,
subcategories of the system’s dimension strongly influence performance, with the three most
important subcategories of human resource (HR) functions, information technology (IT)
functions, and the organization’s reward and recognition programs (Burke, 2018; Huselid et al.,
1997). The work unit climate, motivation, and individual performance will suffer if HR cannot
49

recruit, hire, onboard, and retain sufficient staffing levels. Similar negative output is seen when
IT functions and reward and recognition programs are lacking.
Applying the Burke-Litwin Model to Healthcare and Government Organizations
Since the 1950s, most organizational development, change, and performance research
looked at for-profit companies (Burke, 2018). As such, Burke dedicated an entire chapter to
governmental and healthcare organizations. For-profit organizations tend to be driven by
competition, which is led by the organizational strategy. Alternatively, governments and
healthcare systems tend to be mission-focused. Government agencies serve the citizens of a
country, whereas healthcare systems should be obligated to patient care. However, for-profit,
private healthcare systems fall into the trap of strategy-led operations, as seen in “Patient
Satisfaction Surveys“ (2018).
Burke (2018) contended that healthcare systems are controlled by the clinicians’ oath to
do no harm to patients and the need for financial survivability within the industry, often in
conflict in the private sector. However, as a governmental healthcare system, the VHA is
mission-driven and not beholden to profit. Burke’s assessment of governmental organizational
change is applied to the VHA for this section. At the federal level of government, one of the
biggest challenges when considering the application of the Burke-Litwin model is presidential,
congressional, senate, and cabinet member election cycles and turnover. Frequent change in
high-level stakeholders can create disjointed and competing priorities that make it difficult, albeit
not impossible, to drive change in federal government agencies (Burke, 2018).
Conceptual Framework
The purpose of a conceptual framework is to provide the reader with a lens through
which to look at the problem of practice, which allows readers to better understand the
50

conceptual theory developed from the literature, prior studies, and experience (Maxwell, 2013;
Merriam & Tisdell, 2016). Within the context of the Burke-Litwin causal model, a few
transformational factors are highlighted as the focus of the conceptual framework. Executive
leadership, organizational culture, and individual and organizational performance are all
considered transformational factors, as noted in Figure 4. These factors were selected due to their
alignment with and support for the VHA HRO framework pillars.
Two factors from the Burke-Litwin model, external environment and mission and
strategy, were excluded from the conceptual framework, although it is recognized that the factors
still exist. Within the context of the VHA and for the sake of the conceptual framework, the
external environment is driven mainly by laws and acts set forth by the president of the United
States, the House of Congress, and the Senate. For most of the external environmental pressures
seen within a federal government entity, especially the second-largest U.S. government
administration (VA), one can assume that the political climate within the country guides high-
level business decisions for the organization. Through this lens, there is limited control by an
individual VHA healthcare system and the external environment. One caveat is that Burke
(2018) specifically mentioned customer experience as a driving external environmental factor.
Despite this and the focus of the study on patient experience, it is redundant to include the
external environmental factor in the conceptual framework. I assume that all VHA sites have
opportunities to improve the patient experience. Due to the lack of control over inputs to the
external environment and an understood need to improve the patient experience throughout the
organization, the external environment is omnipresent.
Next, the mission and strategy within the VHA are well-defined and considered
immutable for the conceptual framework. Although strategy may vary slightly from one VHA
51

organization to the next, each VHA director has the same executive performance plan and
therefore have the same overarching annual goals. Due to the immutability and similar executive
goals, the mission and strategy factor is removed from the conceptual framework.
The conceptual framework used executive leadership and organizational culture as
crucial transformational factors because of individual and organizational performance
reciprocity. As mentioned, the executive performance plan is similar across all VHA healthcare
systems and is the foundation for all other employees’ performance plans. While each position
within an organization requires varying degrees of knowledge, skills, and abilities to perform
assigned roles and responsibilities, all performance plans align with the same performance
elements. Therefore, individual and organizational performance is directly connected to
executive leadership. Executive leadership styles and visions vary drastically and act as a leading
factor for individual and organizational performance and organizational culture. This study
implements a reinforcing feedback loop with the three transformational factors from Burke-
Litwin and the three pillars from the VHA HRO model.

52

Figure 4
Conceptual Framework

Leadership buy-in and support led to adopting behavior changes at the frontline staff
level (Burke, 2018; Shein, 2010). However, literature on adopting behavior changes focused on
PX initiatives and the perception of leadership support and organizational culture by PCPs does
not exist. Additionally, the private and nonprofit healthcare sector is financially incentivized to
pay attention to and care about PX efforts. There is no such incentive within the VHA; however,
pay-for-performance is not always effective, so it is imperative to learn what PCPs need from
organizational culture and executive leadership to engage with PX initiatives.

Executive Leadership /
Leadership Commitment
Organizational
Culture / CPI
PCP
(Individual
Performance)
Culture of Safety
Organizational
Performance
(as an output from PCPs’
collective individual
performance)
53

Chapter Three: Methodology
The problem of practice is negative PX in the VHA. The study sought to understand
whether or how executive leaders’ behaviors and the organizational culture impact primary care
provider (PCPs) efforts with patient experience (PX) initiatives. The purpose of the study is to
explore the beliefs, experiences, and perceptions of PCPs when supporting PX efforts. All
participants are from the VHA and practice general medicine in a level 1 tertiary care hospital.
The overarching goal was to learn from PCPs about their beliefs toward PX and their
experiences and perceptions of executive leadership and organizational culture to understand
frontline provider needs when supporting PX initiatives.
Little to no knowledge exists on PCPs’ beliefs about PX and their need to support such
efforts through the lens of their experiences and perceptions with executive leaders and
organizational culture. All findings from this study will contribute to existing PX literature but
share new insights as well. The findings may also be leveraged internally to the Department of
Veterans Affairs, Veterans Experience Office and inform the solutions and services delivered to
VHA to improve PX measures and help transform organizational cultures. As applicable,
findings and recommendations will also be shared with the Office of Primary Care and all other
national VHA program offices.
The research questions are grounded in the conceptual framework, which supports the
HRO pillars of leadership commitment, undergirding a culture of continuous process
improvement, and a culture of safety. The section begins by restating the study’s research
questions, describes the methodological approach for data collection and analysis, and addresses
the study’s limitations.

54

Research Questions
1. What are PCPs’ needs to be successful with PX efforts within VHA?
2. How do PCPs’ perceptions of executive leaderships’ behaviors impact PX efforts within
VHA Primary Care?
3. Based on PCPs’ experiences, what role does organizational culture play in supporting
PCPs with PX efforts within the VHA?
Methodological Overview
The qualitative study utilized narrative inquiry via semistructured interviews and focus
groups to gather data and answer the research questions. The methodological approach was
selected because narrative inquiry allows for learning about the participants’ beliefs, perceptions,
and experiences universally and with greater context than other qualitative, quantitative, or
mixed-methods approaches. The questions and participants’ responses focused on their
perceptions of executive leaders’ behaviors, the organizational culture within the VHA system
where the PCPs deliver care, and the PCPs’ needs to succeed with PX efforts. Semistructured
interviews and focus groups are appropriate qualitative strategies because they allow for dynamic
virtual or in-person interactions, which can help build rapport with the participants and collect
robust data. Interviews and focus groups are best held in-person due to the participant cohort’s
low email utilization rates, but virtual Zoom interviews are also possible. The PCPs were
employed at seven VHA sites of care that are level 1 tertiary care trauma facilities. Recruitment
was based on PCPs’ availability and availability to participate. Participant involvement was
strictly voluntary, meaning that supervisors or leadership could not sign participants up for the
study. Options for after-hours interviews were offered to ensure patient care was uninterrupted.

55

The Researcher
Tiffany C. Jennings is a 6-year Operation Iraqi Freedom disabled female combat veteran,
and a consumer of the services provided by the VA. Therefore, as a patient of the VHA system,
I have a vested interest in the patient care and experiences the organization delivers.
Additionally, I am a 15-year employee of the U.S. federal government and was an Experience
Field Consultant for the VA in the Veterans Experience Office (VEO) with experience and
expertise in large healthcare systems at the time the research began. As a VA employee, I
routinely hear from PCPs regarding their beliefs about patient experiences. Statements such as,
“Why am I here [in PX training]? I don’t have anything to do with patient experience,“ “Why
should I listen to you? You’re not an MD,” and “Why should I care about patient experience?
I’m just here to diagnose and treat patients“ are frequently voiced. These three statements
motivated me to seek understanding within the PCP participant group and to remove barriers for
PCPs to deliver a consistent and positive patient experience.
Additionally, although I am in a non-supervisory position and perform as an individual
contributor within VEO, I am mindful of how field employees perceive national program offices
and the employees within these offices. Generally, national program offices are considered
overseeing authorities. However, VEO is unique in delivering solutions and services to the field.
The VEO teams work to build and maintain relationships with all field members, exhibit
collaborative behaviors, and function as supportive resources. There is no real authority from
VEO to the field, although there is perceived authority. The lack of real authority creates
inequities in how PX initiatives are implemented and adopted across VHA sites. Perceived
authority can negatively impact how the participants welcome me (Ridgeway et al., 2022).
56

I am a “white-appearing“ Indigenous Person (Quapaw, Sac and Fox, and Miami Nations).
Because of the outward appearance presented, I am astutely aware of the potential placement, by
the participants, to an authoritative position from the perspectives of those from other non-
Caucasian races, nationalities, and cultures. However, my heritage and cultural background
means that I view the world through an intersectional lens with a minority perspective. The
minority aspects of my identity allow for greater awareness of disparities and inequities and
make for a more sensitive and respectful approach at work, in school, and in social settings.
Data Source: Interviews and Focus Groups
Two data sources were used for the study: narrative inquiry using semistructured
interviews and focus groups. As a qualitative study design, narrative inquiry allowed me to hear
firsthand stories from participants. Merriam and Tisdale (2016) stated, “Stories are how we make
sense of our experiences, how we communicate with each other, and through which we
understand the world around us“ (pp. 33–34). By allowing the participants to share, greater
insight was gleaned about their needs related to executive leadership, organizational culture, and
individual and organizational performance.
Data were gathered via semistructured interviews and focus groups with 14 participants
from seven VHA sites of care. The inductive approach to interviews and focus groups is well
suited to seeking a greater understanding of participants’ beliefs, perceptions, and experiences
(Merriam & Tisdale, 2016) and for generating large amounts of data with a relatively small
sample (Creswell & Creswell, 2018). When properly designed, interview questions solicit
responses that reflect the individual perspectives of the participant group. Interview responses
were examined for shared experiences and themes within the PCP cohort to add a much greater
understanding of their needs to the existing literature.
57

Participants
A sample of 14 participants from a finite population was selected from one of seven
VHA sites of care. The sites were selected based on the complexity level (level 1, tertiary care)
and existing professional relationships held by me with someone in the organization but not
connected to the primary care clinical setting or any of the PCP participants. All of the
participants were non-supervisory and functioned as frontline primary care providers.
Instrumentation
The protocol leveraged a semistructured format of open-ended questions. The interview
questions were categorized into themes that explored the conceptual framework factors of
executive leadership, organizational culture, individual and organizational performance (Burke,
2018) and leadership commitment, continuous process improvement, and a culture of safety
(Veazie et al., 2019). Appendix E presents the interview protocol, consisting of 12 prompts with
related probes. Each question was designed to solicit informative responses from participants.
Semistructured interviews and focus groups allowed protocol to act as a guide rather than a rigid
set of predetermined questions. Protocol that acts as a guide creates greater flexibility for myself,
which aids in the conversational exploration of each unique interviewee (Merriam & Tisdale,
2016).
Data Collection Procedures
Participants were contacted via email, which provided general research information. I
developed a direct scheduling tool for ease of volunteer sign-up by PCPs. Expectations were set
before each interview and included consent, an introduction to the study, time for clarifying
questions, and an opportunity to ensure the interviewee was in a quiet location. An Information
Sheet for Exempt Studies customized for the study was provided to participants. Logistics for
58

consideration included PCP availability—the participants’ primary responsibility is patient care.
Therefore, meeting times were offered after business hours. Meetings were conducted virtually
via Zoom and in-person. I used a third-party application with secure cloud storage for in-person
meetings to record and capture participant responses. Both audio and video recordings were
captured and were utilized only with the expressed permission of the participants. Once
recordings are no longer needed, the recordings are destroyed.
The timeline for data collection began when the first volunteer participant agreed to
engage, which occurred after both the University and VHA Internal Review Boards (IRB)
approved the study. Data collection ended when the last participant was interviewed. The
anticipated time for data collection was 2 to 3 months. It is imperative to note that the VA, VHA,
or VEO do not support my travel costs for the study. I was responsible for all travel costs
associated with data collection.
Approach to Qualitative Analysis
In qualitative research, data analysis begins during data collection. Participant responses
are assessed in real-time so a preliminary determination about the quality of the protocol can be
made and adjusted if needed (Merriam & Tisdale, 2016). The raw data include audio and video
recordings, which must be transcribed. Transcription allows for responses to be reduced and
categorized into question-level responses to help isolate themes. A coding system was
constructed to aid analysis and recall as categories and themes emerged. The coding process
comprises multiple techniques, which include textual-thematic relationships, repetition, shared
experiences across all participants, missing data, or natural shifts in conversation and topic.
Initial a priori codes were identified and applied to the participant transcripts using
qualitative analysis software. Codes focused on transformational factors from the Burke-Litwin
59

framework (Burke, 2018) and the VHA high-reliability organization (HRO) pillars of leadership
commitment, continuous process improvement, and a culture of safety (Veazie et al., 2019).
However, a priori codes were expanded to include patient care aspects, patient and employee
experience, positive and negative sentiments, and high-reliability organizational principles. Next,
identified quotations from a priori coding were assessed for co-occurrences using axial coding.
The embedded artificial intelligence (AI) coding feature in the analysis software helped to
identify additional quotations and codes not previously identified. The AI codes were analyzed
for duplications and similarities, then streamlined with a priori codes. Finally, smart codes were
strategically created based on the theoretical framework from key subcodes. Smart codes are
explained in detail in each respective section. Together, the themes informed a response to the
research questions. Case-by-case comparisons were made from the coded themes (Gibbs, 2018).
This approach to analysis was selected due to the intentional application to the conceptual
framework by applying the participants’ lived experiences (Mazzucca et al., 2019). Preliminary
findings were obtained and easily organized by comparing the participant question responses and
transcripts.
Credibility and Trustworthiness
Merriam and Tisdale (2016) explained credibility and trustworthiness in terms of validity
and reliability. The importance of credible and trustworthy research is paramount in qualitative
studies. Rigorously conducted research is necessary for trustworthy findings. Credibility and
trustworthiness began by delimiting the participant group. Participants were limited to level 1
tertiary care trauma sites and were primary care providers (PCPs). By delimiting the hospital
complexity and the clinical care setting in this way, the results are more easily generalized
regardless of geographical location.
60

The interview questions were designed to solicit rich and descriptive responses from
participants, providing rich and descriptive data. The follow-up questions supported the
interview questions by further probing the participants’ responses to glean additional
descriptions and insight. Once transcripts were generated from recorded interviews, transcription
review helped thematically group participant responses to perform data triangulation.
Triangulation occurred across participant responses, research questions, and the conceptual
framework.
Additionally, I leveraged interview transcription verification to validate respondent
responses. Interview transcription verification provided the transcribed interview back to the
interviewee, which helped ensure the participant and researcher’s accurate interpretation of the
data (Merriam & Tisdale, 2016). Response saturation was expected with the selected number of
participants.
Ethics
First and foremost, participants were not contacted, and data were not collected before
IRB approval. Additional ethical considerations regarding confidentiality included sanitizing all
identifying information of the participant, such as the specific VHA site of care where the
participants work, names, and clinic names. Permission to record was obtained at the start of
each interview, prior to interview protocol use. Transcripts were provided to participants, which
allowed them to confirm or clarify the intentionality of their responses. I forwent participant
compensation and incentives to avoid potential federal government ethical violations.
The research primarily serves the interest of the VHA due to the potential for leveraging
the findings. The ultimate beneficiary of the study is the veteran. It is the veterans who are
impacted by change, organizational culture, and how facilities support and deliver PX initiatives.
61

There is little to no harm involved, and the confidentiality of participants and participating VHA
sites of care is imperative.

62

Chapter Four: Findings
The study examined how the transformational factors, executive leadership and
organizational culture impact primary care providers’ (PCPs) experiences, beliefs, and
perceptions with support for individual and organizational performance to be successful in the
delivery of patient experience (PX) efforts within the Veteran Health Administration (VHA)
primary care clinical settings. This chapter examines the research findings through the lens of the
conceptual framework. Aggregated participant responses are aligned to the research questions
and presented within the context of the model’s transformational factors of (a) individual and
organizational performance, (b) executive leadership, and (c) organizational culture. Findings are
then summarized in the conclusion section of the chapter.
Interview and Focus Group Participants
Limited demographics were collected from the participants via rapport-building
questions. Table 5 presents demographics to help readers learn about participants. Demographics
include the PCPs’ license type, length of employment with the VHA, gender, type of
participation (interview or focus group), and region of the United States (U.S.). Table 6 offers an
overview of the participants’ reason(s) for joining and the reason(s) for continued employment
with VHA.

63

Table 5
Target Demographics of Primary Care Provider Participants
Participant License type
Length of
employment
Gender
Participation
type
Region of
United States

P1

MD

20

F

INT

South Central
P2 NP 4 F INT Southwest
P3 NP 15 F INT South Central
P4 MD 19 F INT Northeast
P5 MD 24 M FG Northeast
P6 MD 19 M FG Northeast
P7 NP 16 F FG South Central
P8 DO 29 M FG South Central
P9 NP 15 F INT Southwest
P10 MD 15 M FG South Central
P11 MD 6 M FG South Central
P12 MD 3 F FG South Central
P13 MD 22 F FG South Central
P14

MD

10

F

FG

South Central

64

Table 6
Overview of Primary Care Provider Participants
Participant Reason(s) for joining VHA
Reason(s) for continued employment
with VHA

P1

Benefits; work-life balance

Not staying; notified supervisor of
retirement
P2 Wanted to try something new Fellow employees; veterans
P3 Benefits; connection to veterans Benefits; work-life balance
P4 Benefit; work/life balance Benefits; work-life balance
P5 Work-life balance; no “on call” Work-life balance
P6 Work-life balance; no “on call” Work-life balance
P7 The mission to care for veterans
Extreme compassion for veterans; a
desire to “give back”
P8
Vietnam War ended before university
graduation—wanted to serve
Work-life balance; desire to “give
back”
P9
The mission to care for veterans; has
veteran family members
Fellow employees; veterans
P10 Benefits; work-life balance Does not know anymore
P11 Benefits; work-life balance Does not know anymore
P12
Married to a veteran; has veteran
family members
Connection to veterans; desire to “give
back”
P13 Work-life balance; schedule Work-life balance
P14

Work-life balance; mission to care
for veterans

Connection to veterans; work-life
balance

Primary Care Providers from seven VHA sites of care participated from across the United
States. The VHA sites of care were in the U.S. Northeast, north and south central, and
Southwest. All sites of care were level-1, tertiary care healthcare systems. Five one-on-one
interviews and three multiparticipant focus groups were held with 14 participants. The
participants were comprised of nine medical doctors (MDs), four nurse practitioners (NPs), and
one doctor of osteopathy (DO). Nine participants identified as female and five as male. Although
65

there is a difference in how each provider type practices medicine, perceptions, experiences, and
beliefs were shared across all participants regarding executive leadership, organizational culture,
and individual and organizational performance. Of importance, I was unable to ask all interview
questions to all participants from one focus group. The five participants from the large focus
group arrived at the session with what I perceived as agitation and frustration. I sensed that the
PCPs had their own agendas in mind. All questions were answered, although not always within
the context of the targeted interview questions.
Length of employment ranged from 3 to 29 years, and the average number of years
employed by VHA was 15.5. Most PCPs (57%) cited factors aligned with work-life balance as a
reason they began employment with VHA; examples included schedules, schedule flexibility, no
evening or weekend coverage required, annual time off, and the ability to spend time with
children. Five (36%) participants mentioned federal employee benefits as a primary reason they
joined the VHA. Half of the PCPs mentioned work-life balance as the primary reason to continue
VHA employment. Notably, three (21%) participants indicated that they were so frustrated with
the system that they had recently initiated retirement or were unclear about their reasons and
motivations for continued employment with VHA. Additionally, I noted that most participants
(71%) spoke English as a secondary language—important information for readers reviewing
direct quotations from transcripts presented here as findings.
Findings for Research Question #1: Individual and Organizational Performance
The first research question focused on what PCPs need to be successful in their PX
efforts, which directly aligned to the theoretical framework’s transformational factor, individual
and organizational performance. Targeted interview questions sought to assess the participants’
understanding of PX, how PX applies to their role, their beliefs about the importance of PX, and
66

finally, what they need to be successful in PX initiatives. The first question aimed to assess the
PCP’s baseline knowledge of PX and to provide the context for responses to all remaining
questions. The PCPs were then asked how PX applied to their roles. Next, I asked the PCPs
about their beliefs toward PX and whether they felt it was important. Finally, I asked the PCPs
what they needed to be successful in PX efforts. The PCPs were clear and direct with their needs.
Several opportunities for improvement were highlighted.
PCPs’ Definition of PX
The definition of PX includes elements of individual and organizational performance and
organizational culture. A smart code was developed from the a priori codes. Individual and
organizational performance, organizational culture, and patient experience (positive or negative)
codes were collocated, and 300 quotations were identified. Of these, 208 quotations had negative
sentiments associated with the subcodes, and only 36 were positive. When asked to share their
definition of PX, only one participant (7%) came close to comprehensively understanding what
constituted PX. Participant P1 referenced the doctor-patient relationship, comfortability and
trust, and active listening by the PCP as contributing elements to define PX.
All PCPs understood that the patient’s experience is more than solely the clinical
encounter with the provider. The patients’ experience occurs across the continuum of care and at
multiple touchpoints along the patients’ healthcare journey. Several PCPs believed that PX is
defined as “delivering quality care,” while the DO defined PX through his own lens and
experience with the patients rather than as what the patient experiences within the healthcare
system and during their appointments with PCPs. Inference suggests that individual and
organizational performance and organizational culture in the VHA sites of care are not
supportive of PCPs delivering consistent and positive patient experiences.
67

PCPs’ Understanding of How PX Applies to Their Role
The next interview question explored the PCPs’ beliefs regarding how PX applied to their
roles. All NPs and one MD effectively communicated how PX applied to their roles as PCPs.
Several participants touched on one or two PX guiding principles, but none was as thorough as
Participant P2’s detailed example. Participant P2, an NP from the Southwest United States,
discussed her typical patient encounter and how PX applied. She explained the importance of eye
contact during the initial greeting and how facing the patient when completing the appointment’s
history portion helps her connect with the veteran. Participant P2 shared:
I pull the table over to me so that I can face myself towards the patient cause I don’t like
my back to them. I just feel like that’s rude, so I will face them, and I put my computer
there so that I can glance up as I’m talking to them so that hopefully they feel like it’s a
conversation.
Participant P2 continued by explaining how she placed personal patient notes in the electronic
health record (EHR), which she would read during the patient’s next appointment. This was part
of her approach to connecting with veterans. She also performed this task with important clinical
procedure dates as personal reminders for each patient. Participant P2 summarized her holistic
approach to patient appointments: “[It is] Not just fixing whatever is going on today, but [I] try
to keep you [the patient] healthy. My goal is not just fixing that, but wellness as much as I can.
That’s how I feel like my role is in their patient experience.”
The participant’s account of how she managed her patient workload and the patient’s
experiences during appointments showed a clear understanding of PX in her role as a PCP.
Participant P2 highlighted ease, emotion, and efficacy—the VA’s PX guiding principles—as the
68

core tenets of her practice, albeit not in those words. Six of the nine (66%) MDs described the
application of PX to their role in managing patient expectations or explaining the healthcare
systems to the patient. Next PCPs were asked about their beliefs about PX and its importance.
PCPs’ Beliefs about the Importance of PX
All participants believed PX is important, although very few gave responses that reflected
a deeper understanding of why. Participant P8 reflected:
The patient is not just a disease entity that’s walked into your office. It’s a human being
with a problem, whatever that problem may be. And so, for the patient to know that they
have a doctor that’s connecting with them, listening to them, trying to understand them,
bringing them into the discussion of a two-way discussion, a patient-centered care
approach, it’s important because I don’t want to be treated like I’m just a disease entity
that came into the office.
Participant P5 elaborated on the importance of building patient trust so that patients are
more likely to engage in their healthcare and adhere to the plan of care. He stated, “If you don’t
get that [trust], he [the patient] may not follow my instructions.” However, it was Participant P9
who communicated how PX is important for both the patient and the organization:
I think the importance is that they [the patient] know that we are helping them achieve
hey understand the plan. I think sometimes people walk away their goals and that t
But we have to balance that with all these questions . . . t heard ’ feeling like they weren
that we need to ask the patient.
P9 offered the first glimpse into challenges within the systems that do not support PCPs
in delivering a consistent and positive patient experience. The “questions” she referred to are
called clinical reminders. Participant P9 elaborated on how patients become frustrated and
69

annoyed if the PCP asks a lot of questions from the EHR reminders or if the PCP must ask the
patient the same questions repeatedly over multiple visits. When PCPs cannot complete clinical
reminders, P9 reported, they are “dinged,” meaning, “We hear about it if we didn’t complete all
these reminders, and they just take a lot of time to do.” In an exacerbated tone, P9 finished her
thought with, “I really want to help them [the patient] with what they came in to see me for.”
The above example portrayed the frustration of PCPs and their perceived inability to
deliver quality care meaningfully while connecting with the patient. The clinical reminders
mentioned by P9 are one element of a recurring theme from all participants. The theme of
administrative burden was significant in the findings and is pertinent to the discussion on
individual and organizational performance. As challenges continued to emerge, it was important
to learn what PCPs felt they needed to succeed with PX efforts.
PCPs’ Needs to be Successful with PX Efforts
As the interviews progressed, the participants were increasingly forthcoming in the
openness and directness of their replies. I sought to understand what PCPs need to be successful
with PX efforts. Many systems challenges were presented. All PCPs expressed concern about
systems that do not allow for the practice of medicine at the top of their license and scope. The
theme, administrative burden, was recurring and comprised multiple elements. The first element,
clinical reminders, was at the top of the list of administrative burdens, while consults, orders, and
CITC workload were also top hindrances.
Clinical Reminders as Administrative Burdens to PCPs
The importance of clinical reminders is explained in the VA Clinicians’ Guide on
Clinical Reminders (VHA, 2006). Clinical reminders assist clinicians, including registered
nurses (RNs), licensed practical/vocational nurses (LP/VN), and all provider license types, such
70

as MDs, DOs, and NPs, to deliver quality care. The problem with clinical reminders, from the
perspective of all PCPs, is that more reminders are added, but few to none are ever removed,
which increases the administrative burden. Administrative burdens can negatively impact PX
because it takes time from the patients’ appointments and the reason the patient scheduled an
appointment to see the provider, as P9 previously expressed. Another frustration all participants
shared is the inability to remove specific reminders for specific patients once the clinical team
has determined that the reminder is no longer necessary. She shared her thoughts on how
veterans who, year after year, refuse the influenza vaccine. Participant P9 stated, “We know
them. They refuse every year, multiple times a year. They aren’t going to take it. Why can’t we
remove the reminder? And that is just one example.”
Three PCPs (21%) mentioned the national Clinical Reminder Workgroup recently formed
in the VA (2022) at the national level to correct many of the issues highlighted here about
clinical reminders. However, all three participants shared that senior leaders at the national level
attempt to empower VHA sites of care to manage their clinical reminder cleanup, yet, at the local
level, executive leaders state that national leadership would make the decisions. According to the
participants, the perceived lack of clarity, accountability, and ownership for decision-making
places the PCPs and the patient in the middle, which leads to poorer patient experiences, reduced
quality care, and worse health outcomes.
Consults as Administrative Burdens to PCPs
Administrative and clinical consults are addressed in numerous Department of Veterans
Affairs directives (VHA, 2016, 2022). For example, a clinical consult is when the PCP
recognizes that clinical diagnosis and treatment must be performed by a specialty provider (e.g.,
oncologist, cardiologist, or gastroenterologist) because it is outside the PCPs’ scope of practice
71

or outside their scope of license. According to participants, consults, also known as referrals,
contribute to the administrative burden of PCPs. Specifically, travel consults were a focal point
of concern for several PCPs. Ten participants (71%) expressed deep frustration and sometimes
anger, with the responsibility of the patient travel consult falling to the PCP instead of
administrative personnel. Due to the considerable ambulatory and mobility issues in the VHA
patient population, transportation services are a provided benefit. The request for travel is
initiated by a travel consult in the EHR. Participant P5 detailed how administrative burden
directly limits PCPs from working at the top of their license:
It [travel consult] used to be done by the social worker, or some non-medical person in
the past. One of the explanations [it was transferred to PCPs] is workload [of other
departments]. I know that other departments are also working hard, but it makes no sense
for me, that kind of a job transferred to the physician. It’s literally a clerical job.
The challenge presented in this scenario means that the PCPs are denied the ability to
work to the top of their license, which means lower quality care, poorer PX, and poorer health
outcomes. Participant P9 stated, “ my NPI [national provider identifier] time and re using ’ They
efforts of going to medical school to do an administrative task that someone else could do.”
Ultimately, participants believe it is the veteran who is negatively impacted.
Orders as Administrative Burdens to PCPs
Several participants mentioned orders as an administrative burden. Per various
Department of Veterans Affairs directives (2015, 2022), orders are necessary for those seeking
ancillary and support services within a healthcare system. Examples of order types include
requests for new equipment from Prosthetics Service, laboratory tests, or wound ostomy
supplies. PCPs can also receive orders from other clinicians in the healthcare system.
72

Specifically, orders are mentioned in the context of poor workflow development. Participant P2
gave an example. When the PCP orders a medical device for a patient (e.g., knee brace), the
order is sent internally to Prosthetics Service, and the order is fulfilled, which the prosthetics
employee annotates in the patient EHR. Fulfilling the order generates an alert back to the
ordering PCP. No further action is required by the PCP, but there is no way to know what the
alert is for unless the PCP opens and reads every alert by entering each patient’s EHR before
they can clear the alert from the system. Participant P2 shared, “I don’t care if they [Prosthetics
Service] filled it [the order]. I don’t need to know that. I need to be able to trust that they are
doing their job.”
Further examples of the administrative burden from orders were expressed as workload
redistribution to PCPs from other employees. Participant P7 detailed how nursing employees are
not permitted to report negative diagnostic test results to patients, despite being the normal
standard of care and within the registered nurses’ (RNs) scope of practice. The participants
perceived that executive leadership does not allow nursing employees to perform this task. The
PCPs did not understand or accept the justification for the workload transfer. Multiple PCPs
explained that the usual standard of care indicated that an RN license permits them to
communicate clinical decisions made by an individual with a higher-level license (e.g., NP, MD,
or DO). Participant P7 made a logical argument for reversing the workload assignments because
the radiologist, in his example, had already made the clinical decision. Therefore, the RN is only
communicating the negative results to the patient on behalf of the PCP. Again, sentiments
regarding the patient’s quality of care and negative employee psychological safety were cited,
“That doesn’t serve the patient, and that makes the provider leave.”
73

I inquired whether participants were aware of an approved VA document disseminated in
2017 regarding scopes of practice parameters for all clinical and administrative VA job types that
require direct patient contact. The specific document clearly communicates which professional
tasks could be performed and by whom. The tasks were aligned based on the minimum level of
education, training, credentialing, and privileges required to complete the task. None of the
participants was aware of the document. Through this lens, it is easy to see how PCPs feel they
are denied the ability to work at the top of their license within the participating VHA sites of
care. All experiences shared by PCPs related to working at the top of their license went against
the guidance found in the 2017 document.
Care in the Community (CITC) as Administrative Burdens to PCPs
Care in the community (CITC) administrative burdens are of significant concern to the
PCPs due to the delay in care for patients and the lower quality of care delivered in the private
sector due to regulation and standard variances. Care in the community is a catchall term for any
mechanism permitting the veteran to be seen outside the VHA for care. Veterans have been able
to receive CITC in various capacities for several decades, yet it was the Veterans Access,
Choice, and Accountability Act of 2014 and the Mission Act of 2019 that expanded Veteran
access to CITC. Many directives and policies outline veteran eligibility for CITC. Regardless of
eligibility, all participants agreed there are benefits to CITC for patients—yet also voiced
concerns. Participant P8 explained, “I have found that farming patients out for community care
has become a real disaster because community care doctors do it differently than VA doctors.”
Worries included lower quality of care, delayed care due to lack of access in the community and
untimely patient record return to VHA, and unnecessary, costly diagnostic tests and treatment
plans.
74

Participants did not view CITC as inherently negative. The challenge is that PCPs feel
they spend an inordinate amount of time tracking down patient records despite expansions to all
CITC departments throughout VHA sites of care between 2019 and 2021. Participants P10–14
perceived that CITC administrative burden was directly tied to poor internal processes.
Participant P11 cited differences in personal experiences between the VA and the private sector:
“ versus private . . . the VA clinical work that comes down to physicians in - s a lot of non ’ There
The PCPs repeatedly stated ” clinical stuff. - practice. They have people that take care of the non
but all the administrative burdens required by the ” seeing patients is not that difficult, “ that
load. Participants in the focus group expressed frustration PCPs created an unreasonable work
with the record return process from the community to the VA. Lost records cause duplicate
orders and prolong delays in care for the patient. P11 continued:
[No one] tells us a patient didn’t go for the appointment, or we scheduled it, but we don’t
know what happened to the test. Now we have to track, did the patient actually make that
appointment or did they not? Where are the tests? Until we don’t [sic] get the reports, the
imaging, we cannot consult a specialist. So, we have to track and run after our nurses.
[They] have to run after the written report and pictures, have it scanned. So, we have to
do all those things, and it all adds up.
The VHA site of care for Participants 7, 8, and 10–14 all mentioned the lack of
radiological services for patients. According to participants, the issue was raised through
management to executive leadership. However, a replacement computed tomography (CT) scan
or magnetic resonance imaging (MRI) machine had not been moved to the site of care, despite
sufficient space and existing serviceable equipment sitting unused at the local VHA. As such,
PCPs are forced to send patients to CITC, but the community organizations do not return patient
75

records to the VHA within the allotted 6-month window, delaying patient care and negatively
impacting patient experience. Participants felt that laws, policies, and amendments to acts do not
aid the VA in delivering quality care to veterans. Specifically, the VHA is required to pay the
community care invoices within a specific timeframe, regardless of whether the patient records
have been returned. Participant P13 stated:
Who does that? Who pays the bill before you receive goods and services? It’s dumb, and
I’d bet millions of dollars are wasted just from duplicate orders because we never got the
records back. And millions more from them [the community] placing unnecessary tests or
treating our patients with third-line treatment plans. It’s a terrible quality of care out there
in the private sector.
More than any other concern mentioned, removing the excessive administrative burdens
from clinical reminders, consults, orders, and CITC workload were the leading needs identified
by participants to consistently deliver a positive patient experience. However, half of the
participants attributed the inability to work at the top of their license and scope to the lack of
executive leadership support from the chief medical officer (CMO) and the chief executive
officer (CEO). Participant P7 explained that she did not perceive executive leaders as providing
support for the administrative burdens shared by the PCPs. She stated, “They are not helping in
that aspect . . . if I want to follow all the rules with all those notifications, my time with the
patient, to just put the stethoscope on the patient and examine them, would be like two minutes.”
Findings for Research Question #2: Executive Leaders
The second research question concerned PCP perceptions of how executive leadership
behaviors impact PX efforts within VHA primary care. The inquiry considered specific
behaviors of executive leaders. Questions focused on communication, purposeful rounding, and
76

creating a psychologically safe environment. Themes emerged and were considered under the
umbrella pillars of HROs, leadership commitment, continuous process improvement, and
supporting a culture of safety.
Interview questions for this section of findings were grounded in the conceptual
framework and presented through the lens of the three pillars of highly reliable organizations
(HROs); leadership commitment, continuous process improvement, and creating a culture of
safety. The transcripts were reviewed for HRO pillars and the five HRO principles: (a)
commitment to resilience, (b) deference to expertise, (c) preoccupation with failure, (d)
reluctance to simplify, and (e) sensitivity to operations. Participants were asked about the
specific behaviors of the ELs. The behaviors included communication, creating psychologically
safe environments, and purposeful rounding. These behaviors are included in the leadership
commitment section to support the expected behaviors of the executive leaders.
High-Reliability Pillar: Leadership Commitment
A smart code was created from the subcodes; executive leadership, employee experience,
HRO: leadership commitment, and HRO: sensitivity to operations. From this, there were 81
quotations—one had a positive intonation and 72 were negative. The one positive quotation
came from Participant P1, who proposed a solution for the current ELs based on previous
experiences with ELs at a different VHA site of care. The prevailing sentiment from all
participants is that they felt unsupported, particularly by the CMO.
The primary complaint from participants for ELs was the CMO’s apparent lack of
interest in making decisions that are best for primary care providers (PCPs) and the operations
within a primary care clinical setting. When asked about their experiences with the CEO and
CMO, all participants interjected their appreciation for management but felt that ELs did not
77

make decisions that deferred to the expertise of PCPs or were sensitive to operations within
primary care. Participant P8 expressed concern about the local CMO being a clinical specialist in
an area in which that CMO would never have exposure or an understanding of primary care
clinic workflow and operations. His example highlighted the lack of deference to expertise
throughout the CMO chain of command in that VHA site of care. Participants were particularly
concerned about how the administrative burden negatively impacted their ability to work to the
top of their license, which related to the consistent and positive delivery of PX and quality health
outcomes. Participants shared their mostly negative experiences and perceptions of the CEO and
CMO of the sites.
Perceptions of Communication Behaviors from Executive Leaders
The study participants shared perceptions and experiences regarding the ELs’
communication, or lack thereof. Participants also raised additional elements of systemic
communication challenges that negatively impact PX. The primary examples are the centralized
call center model used in VHA and other departments not answering internal or external calls.
Although related to communication, the findings better align with the HRO pillar of continuous
process improvement (CPI) and will be discussed in the correlating section.
A smart code was created from the subcodes (executive leadership, communication,
employee experience, and HRO: leadership commitment), which generated 110 quotations. Of
these quotations, 95 were negative and 13 were positive. The participants’ positive replies were
predominantly focused on approaches observed by previous leaders or offered solutions for the
perceived lack of communication. All PCPs reported that their only communication with ELs
was unidirectional via employee town halls and emails, with participants being passive receivers.
Participant P8 shared:
78

Isn’t it sad that executives don’t come up here and say, “Doctors, what is it that you
need? Tell us what you need to provide better patient care.” Nobody in 29 years, I’m
telling you, nobody’s ever come up here with that approach.
Most participants (86%) desired to communicate meaningfully with ELs—which meant an
opportunity to be heard by ELs with the expectation that the PCPs’ communication was taken
seriously for CPI efforts to provide a higher level of quality care and to improve the patient
experience.
Purposeful Rounding by Executive Leaders
When asked if the CEO and CMO performed purposeful rounding, 100% of participants
reported that ELs rarely to never purposefully round in their respective primary care clinical
areas. Participants from the South Central locations indicated that purposeful rounding only
occurs when the ELs are new to their roles. Some PCPs (36%) indicated knowing of the CEO
and CMO rounding but experienced ELs as not being sensitive to operations. Although
participants did not use the term “sensitive to operations,” their examples focused on ELs
rounding in their clinics with patients. If PCPs are in the clinic when ELs purposefully round,
they cannot engage with ELs as intended. When sensitivity to operations is not a consideration,
PCPs reported feeling slighted or that they do not matter because they are not given an
opportunity to communicate with ELs directly. Participant P1 shared, “They’re walking by,
waving, and saying hi. That’s it.”
Executive Leaders’ Behaviors to Create Psychologically Safe Environments
Seventy-one (71) quotations from a newly created smart code were found for ELs’ efforts
to create psychologically safe environments; of these, 65 were negative, and only five were
positive. Similar to the communication findings, participants’ positive replies focused on
approaches observed by previous leaders or offered solutions to correct the current state.
79

Participants were asked, “To what degree do you feel ELs act in a way to create a
psychologically safe environment?” and “How does that impact your efforts for PX?” None of
the participants (0%) reported fear of retaliation from ELs. However, all participants (100%)
reported the lack of follow-through from ELs to correct reported issues as the top reason they do
not feel psychologically safe. Participant P11 stated, “People have given up. People just come,
work, and go home. Nothing people says, nobody listens. It’s like talking to a wall.” Sentiments
expressed across all participants suggested that employees feel psychologically safe with
management. Participants shared concerns and topics for improvement of the systems with them.
Nevertheless, all participants maintained that the final responsibility of systems issues fell to
executive leaders.
Participants reflected and shared their experiences about ELs’ lack of follow-through.
Participant P7 shared:
Well, they tell us they care, but we know that isn’t 100% effective [sic.] . . . but where is
it? I think it causes a lot of mental duress in our day-to-day activities . . . There’s a
multitude of things that interfere with patient care.
Participant P8 added: “
How do you think that affects us? Psychiatrically or mentally? It kind of stews up some
anger in us. It’s like, are you kidding me? You give me this (expletive) [administrative
burden]. Well, then you come up here and do them. You get off your (expletive), big
CMO, and you take care of them [clinical reminders].
The distress and anger were also palpable in other interviews and focus groups. Furthering the
discussion, participants shared examples of how they perceive other departments are prioritized
over primary care clinical operations. Largely, participants from the South-Central sites of care
80

felt the CMOs did not advocate for primary care clinical operations. Specifically, ELs over
administrative and nursing departments were perceived as better advocates for their departments
than the CMO for primary care. Participant P10 reflected on how he believed ELs other than the
CEO and CMO are better advocates and gave an example of actions permitted by other
departments that negatively impact PX and patient care. “There is [sic] a couple of departments,
and everybody knows, if you put [in] a consult, [a] denial will come.” He continued on about
how these actions cause delays in care, poor PX, and lower quality care. Participant P12
persisted, “We are actually kind of in a competition with all the other departments. We don’t
work together. Nursing, they do their own thing.” Participant P13 added details on how one
presumably small task takes the PCPs hours or days to complete. He continued by describing
how he routinely placed the same consult in multiple departments for one patient hoping that one
would approve one of the consults. The other PCPs in the focus group all nodded or mumbled
sentiments of agreement as he spoke. However, P13 did not feel that he accomplishes everything
he needs to daily. “[I] just did this one little thing, and because it took so much time, headspace,
energy, it drains you, and in the end, the patients are suffering.”
The majority (79%) of PCPs believed that the patient experience and quality of care are
negatively impacted by poor psychological safety within the organizations and employee
populations. The contributing behaviors of ELs to the HRO pillar, leadership commitment, and
the three behaviors of communication, purposeful rounding, and creating psychologically safe
environments are summarized as less than optimal. In addition to leadership commitment,
executive leaders must support an environment conducive to continuous process improvement
(CPI).

81

High-Reliability Pillar: Continuous Process Improvement
Continuous process improvement (CPI) represents the second of three pillars for HROs.
The findings from the interview and focus group transcripts for CPI built on previous topics,
such as administrative burdens and perceived lack of executive leadership support. A new smart
code was created from subcodes (executive leadership, employee experience, HRO: CPI, HRO:
commitment to resilience, HRO: reluctance to simplify, and HRO: preoccupation with failure).
Two themes arose from the coded transcripts.
The first theme was previously mentioned as systemic issues within the organizations
identified by PCPs as directly contributing to negative patient experiences outside their control.
Specifically, participants mentioned the centralized call center model used in VHA and how
other departments do not answer calls, including lines within the healthcare systems that are
considered “must answer” lines (e.g., the emergency department and inpatient nursing stations).
Half of the participants (50%) referenced these two issues. Participant P4 shared their concerns
about the centralized call centers, “I’m spending all my time trying to make sure that my patients
are doing well, but I just don’t understand how somebody cannot fix that phone system and, in
the end, it’s sad that the patient ends up suffering.”
Five participants (36%) commented how they and the patients have difficulties reaching
specific VHA employees when called directly, bypassing the centralized call center. Participant
P8 elaborated on other departments not answering their phones:
One of the big problems with communication, nobody answers the phone. Patients
complain, “I call; nobody answers the phone.” I said, “Don’t feel bad. I have the same
problem.” I could call the executive office, and it’ll ring off the wall.
82

The second theme that arose from the findings on CPI was the perceived lack of clarity,
accountability, and ownership of problems within the organization. Over half of the participants
(57%) noted that ELs blame the lack of CPI on ownership at the highest levels of the
organization. Nevertheless, a few PCPs (22%) gave examples of how they sought to understand
the organizational systems better by attempting to communicate issues to the highest levels.
When the PCPs escalated their concerns, national leaders instructed that the decisions were the
responsibility of the local leadership. Participant P1 vocalized that she often hears “no,” without
any explanation from ELs. Alternatively, if an explanation is provided, it is “wishy-washy.” The
PCPs perceived that the lack of local-level accountability and ownership by ELs negatively
impacted PX efforts for PCPs because fundamental issues were not corrected. Participant P2
articulated her perception of local ELs’ lack of accountability and ownership:
It’s not that the leadership doesn’t know what the problems are. It seems to me . . . that
they really are just impotent. They don’t have the power to make these changes here at
this level. It has to be at a much higher level. The only real power they have is punitive. I
mean, they just don’t have [it], and in some ways, that makes it a little bit better because
then I don’t blame them [local ELs] as much. Right? So, then what’s the point of talking
about it?
Of note, a few participants (43%) expressed their understanding of the size and
complexity of the VHA. They felt that the size of the VHA impacted what CPI efforts are
addressed, locally and nationally. However, ELs’ perceived lack of support for CPI in the
participant organizations is a broader issue that impacts the third HRO pillar, creating a culture
of safety.

83

High-Reliability Pillar: Culture of Safety
The final pillar of HROs is the ELs’ support for a culture of safety. A new smart code
was developed and included the subcodes executive leadership, employee experience, and HRO:
culture of safety. Seventy-seven (77) quotations were found, 67 were negative, and three were
positive. The positive quotations were aspects the participants liked about previous executive
leaders or were offered as solutions. One quotation from Participant P1 was especially poignant
and directly aligned with a culture of safety, “He’s probably the best leader we’ve had since I
started working at the VA, and one of the things he used to say is that we should work to the
level of our degrees.” Much was shared about the PCPs’ inability to work to the top of their
licenses.
Arguably, the PCPs’ previously shared concerns related to individual and organizational
performance, EL support, and ELs’ behaviors are some of the factors that encourage a culture of
safety. Participant P12 gave an example of how he felt he cannot collaborate, communicate, and
coordinate easily with other departments:
Doctor says, “Please, can you rearrange the schedule [to see a patient]?” No, you have to
okay that with your director, and then your director has to talk to my director, and then
they can tell me. What sense is that?
Sentiments were the same across all sites of care. Primary care providers (PCPs) do not believe
they are empowered to collaborate, communicate effectively, or coordinate with other
departments to deliver the best quality care and a consistently positive patient experience.
Findings for Research Question #3: Organizational Culture
The final research question considered the PCPs’ experiences with their organizational
culture and how that impacted their ability to support PX efforts within the VHA. Largely, PCPs
84

felt their experiences at the seven VHA sites of care were less than optimal and did not support a
consistently positive patient experience. Similar to other research questions, the organizational
culture at all seven sites of care was reported to be less than optimal.
Organizational culture is the final transformational factor from the conceptual framework
explored in the study. A smart code was created from the subcodes of organizational culture and
employee experience. Two hundred and twelve (212) quotations were coded, 180 being negative
and only 29 positives.
Organizational Culture and a Culture of Safety
Participant responses on organizational culture aligned with several subcodes during data
analysis. Specifically, the subcode, HRO: culture of safety, was co-coded for 134 quotations
from the transcripts. From the 134 quotations, 128 were expressed negatively by participants and
only six were expressed as positive sentiments. The theme suggests that PCPs do not perceive
the organizational cultures of their respective sites of care as supporting or aligning with
expectations for ELs to create a culture of safety; or, participants perceived the alignment was
poor.
As organizational interview questions continued, most of the PCPs (86%) felt they had
belabored negative sentiments about ELs and transitioned the conversations to management
when organizational culture topics were discussed. An example of such remarks came from
Participant P1 when I asked her about CEO and CMO contributions. She directly stated, “I do
not want to talk about them. Sorry.” However, management and immediate supervisors are
different factors in the theoretical framework and are not reported in detail.
A few PCPs (21%) expressed sentiments about their primary aligned care team (PACT)
members. Participant P1 stated, “I think the people that I work with in my pod . . . are very
85

dedicated to the patients.” However, at this micro level, a pod is considered part of the work unit
climate factor within the theoretical framework (Burke, 2018), which is not covered by the study.
Twelve (12) of the 14 interview questions were related to organizational culture. Therefore, the
findings from themes aligned to executive leadership and individual and organizational
performance also apply to organizational culture. This means that the three HRO pillars and the
EL behaviors (communication, creating a psychologically safe environment, and purposeful
rounding) also contribute to the findings for organizational culture.
PCPs’ Solutions for Successful Patient Experience
I provided the PCPs multiple opportunities to share possible solutions to the challenges
they identified in their organizations that prevent them from providing a consistently positive
patient experience. Several solutions were discussed, although approaches to how exactly
processes should be corrected were not mentioned: (a) Bi-directional communication with
executive leaders, (b) Ability to work at the top of their license, (c) Follow-through and
correction of systemic issues, (c1) Reduction of administrative burden, (c2) Correct phone
systems, (d) More flexible schedules, (d1) Additional official administrative time, (d2) Ability to
schedule complex patients for more than 30 minutes.
Participant P2 shared, “I wish we had more control at the local level to make changes that
affected our day-to-day,” and “[We have] got to standardize a little bit more. I think that would
be helpful.” The PCPs agreed that greater local-level control and standardization of routine
processes would help them create an organizational culture that supports safety. Participant P5
shared a similar sentiment, “I don’t expect the senior executive office to come and listen to me
say I need things. It’s completely micro-management. It’s going to kill their time. Rather, I want
them to give more powers to my immediate supervisor.”
86

Summary of Findings
To group the findings easily, interview questions were cross-walked with the conceptual
framework. This was done. From here, all interview questions and participant responses were
aligned and presented through the lens of the study research questions.
The first research question focused on what PCPs need to be successful in PX efforts,
which directly aligned with the theoretical framework’s transformational factor, individual and
organizational performance. The PCPs were clear and direct with their needs. Several
opportunities for improvement were highlighted. Reducing administrative burdens was the top
hindrance to PCPs’ PX efforts. They reported that being straddled with clerical tasks and poorly
formed systems processes contributed to their psychological distress, increased their desire to
leave VHA employment, and limited their ability to deliver consistently positive patient
experiences. Participants also highlighted bi-directional communication with ELs, and I noticed
undertones from participants that correcting this issue would yield other changes. Regardless of
license type, participants reported feeling unsupported and constrained by the culture, systems,
and processes, and expressed frustration about their perceived inability to work to the top of their
license. More than any other concern, PCPs indicated not working to the top of their license was
the number one negative impact on delivering quality care to veterans. Last, PCPs suggested
more flexible schedules that include additional official administrative time. Currently, PCPs are
given 8 hours per week to complete administrative tasks. However, the administrative burdens
mentioned in the findings are outside of the scope of a PCP, which means that an employee with
a lower-level license can perform said tasks. The final topic related to schedule flexibility is
scheduling patients more easily, which means greater accountability and ownership at the PCP
level.
87

The second research question looked at the PCPs’ perceptions of executive leaders’
behaviors and how they impact the adoption of PX efforts within VHA primary care clinical
settings. Specific behaviors, communication, purposeful rounding, and creating a
psychologically safe environment emerged and were considered under the pillars of HROs,
leadership commitment, continuous process improvement, and supporting a culture of safety.
Although not all PCPs expressed negative sentiments toward executive leaders, findings from all
seven VHA sites of care (100%) showcased that PCPs perceive a lack of local EL support to
deliver consistently positive patient experiences. The PCPs clearly and effectively communicated
their dissatisfaction with bi-directional EL communication, EL visibility, and how ELs,
specifically the CMOs, do not foster psychologically safe environments. Not only did
participants believe the ELs’ actions contributed to worse patient experiences (100%), but also
most (93%) believed their behaviors negatively impacted the quality of care provided to
veterans.
The third research question considered the PCPs’ experiences with organizational culture
in their sites of care and how those impacted their PX efforts. Largely, PCPs felt their
experiences at the seven VHA sites of care were less than optimal and did not support a
consistently positive patient experience. Similar to research question number one, the
organizational culture at all seven sites of care was reported to be less than optimal.
Primary care providers shared experiences of organizational cultures that do not support
delivering consistently positive patient experiences. The experiences included examples of how
PCPs believe ELs did not support an organization rooted in continuous process improvement
(CPI), the actions required for a culture of safety, and the absence of communication,
collaboration, and coordination across departments. Most of the organizational culture themes
88

(85%) contained negative sentiments from participants. Participants did not believe the
organization’s culture supported their delivery of consistently positive patient experiences.

89

Chapter Five: Discussion and Recommendations
Chapter 5 first explores the study findings with more context to the organization. Then,
practice recommendations provide evidence-based solutions for the findings through the lens of
the conceptual framework, which is rooted in the Burke-Litwin causal model for organizational
performance and change (2018) and the Veterans Health Administration (VHA) high-reliability
organization (HRO) framework (2019). Transformational factors of executive leadership,
organizational culture, and individual and organizational performance from Burke (2018)
overlay the HRO pillars of leadership commitment, continuous process improvement, and a
culture of safety (Veazie et al., 2019), as noted in Figure 4.
Discussion of Findings
The depth and breadth of insight gleaned from participants was robust. The findings
strengthen and support ongoing VHA improvement initiatives around the research question
topics. A discussion of the findings is presented here with additional resources and context for
reference.
Individual and Organizational Performance
Individual and organizational performance was the first transformational factor explored
via the first research question. Based on the conceptual framework, Figure 4, executive leaders
and organizational culture affect individual and organizational performance and the subsequent
metrics. Individual performance is commonly measured via productivity. However, patient
experience (PX) metrics are now also part of most PCPs’ performance plans and therefore are
measurable expectations of their performance (Department of Veterans Affairs, 2015).
Individual performance is extrapolated to organizational performance at the macro
systems level. If all individual performance outputs are aggregated and monitored at the systems
90

level, then organizational performance becomes the new conceptual framework output.
Organizational performance assesses the quality of goods and services provided, profit margins,
and customer experience, to name a few (Burke, 2018). In healthcare, most organizational
performance measures are established by regulatory agencies to ensure quality care is delivered
to patients (AHRQ, 2022f; CMS, 2021). As the healthcare industry continues to shift from
volume-based performance to quality and experience-based performance, PX measures are
increasingly monitored industry-wide (CMS, 2022; Hefner et al., 2019; Kash & McKahan,
2017). The VHA monitors PX metrics at all levels of the organization.
The importance of PX is grounded in the benefits for the patient. Participants mentioned
several benefits for the patient, which include comprehensiveness, continuity, patient
engagement or activation, patient literacy, quality of care, and patient health outcomes. As
participants reported, when the PCP can provide continuity, comprehensiveness, and quality
care, the patient is more likely to be engaged, understand their diagnosis and treatment plan,
adhere to the plan of care, and, ultimately, have better health outcomes. Findings indicate that
PCPs do not understand what PX is, how it is defined, and the supporting theoretical concepts.
This lack of comprehension is a problem because without a foundational understanding, PCPs
cannot work toward a common goal if they do not understand the target performance and
expectations.
Next, 100% of participants believed that administrative burdens kept them from
consistently providing quality care and positive patient experiences to veterans. Administrative
burdens important to the participant group included orders, clinical reminders, consults, and
CITC workload. Rao et al. (2016) found that PCPs had more administrative burdens than their
medical specialist counterparts. In addition to poor-quality care and PX delivery, administrative
91

burdens lead to more significant burnout, higher job dissatisfaction, and fewer patients receiving
healthcare due to the physician’s inability to maintain the expected workload.
Primary care providers (PCPs) were concerned with four administrative burdens: orders,
consults, clinical reminders, and CITC workload. Per various Department of Veterans Affairs
directives (Department of Veterans Affairs, 2015; VHA, 2022), orders are necessary to engage
with ancillary and support services within a healthcare system. Examples of order types include
requests for new equipment from prosthetics service, laboratory tests, or wound ostomy supplies.
PCPs can also receive orders from other clinicians in the healthcare system.
The concern with orders from PCPs is with the process and workflow design.
Specifically, order return notifications are frustrating to PCPs, yet some order return notifications
are necessary. Orders and order return notifications are received in electronic health records
(EHRs). The challenge, according to the participants, is that orders and order return notifications
look identical until the item is opened. Clinicians, including PCPs, cannot easily clear the
notifications because of their inability to preview the notification.
Next, the importance of clinical reminders is explained in the VA Clinicians’ Guide on
Clinical Reminders (2006). Clinical reminders assist clinicians, including registered nurses
(RNs), licensed practical/vocational nurses (LP/VN), and all provider license types, such as MD,
DO, and NP, to deliver quality care. Examples of reminders include preventive health and
chronic disease management and helping ensure prompt diagnosis and treatment. Reminders
enable the clinician’s ability to choose the best treatment plans effectively and efficiently and
improve EHR documentation for improved continuity of care. The branching logic in some
reminders directs providers to the most clinically appropriate decision pathways without
92

undermining the PCPs’ education, training, and clinical decision-making capabilities. Clinicians
then place relevant orders and consults based on the reminder pathway.
Administrative and clinical consults are addressed in numerous Department of Veterans
Affairs (2015; VHA 2022) directives. For example, a clinical consult is when the PCP recognizes
that clinical diagnosis and treatment must be performed by a specialty provider (e.g., oncologist,
cardiologist, or gastroenterologist) because it is outside the PCPs’ scope of practice or outside of
their scope of license. Examples of administrative consults include patient transportation,
smoking cessation classes, and Qigong. The purpose of the consults, regardless of type, is to
connect the patient to additional resources for quality, holistic care. Typically, the consult type
determines which clinician or administrator should enter the consult into the EHR. Clinical
consults to specialists are determined and entered by the PCP, while an RN can enter a consult
for a patient to nutrition classes. Some consults are strictly administrative and can be entered by
anyone with access to the EHR, such as a social worker, dietician, or medical support assistant.
Last, care in the community (CITC) is a catchall term for any mechanism permitting the
veteran to be seen outside the VHA for care. Veterans have been able to receive CITC in various
capacities for several decades, yet it was the Veterans Access, Choice, and Accountability Act of
2014 and the Mission Act of 2019 that expanded Veteran access to CITC. The participants
understood why CITC services are necessary, especially for rural areas. However, the PCPs felt
their administrative burden had increased significantly since the Mission Act of 2019, despite
each VHA site of care ramping up new CITC departments with administrative staff to assist with
the workload that has now shifted to PCPs. Timely care is delivered when the care is needed.
Delays in care increase both patient mortality and health systems utilization by patients (Prentice
& Pizer, 2007). When a diagnosis is delayed, patients are sicker, require more extensive
93

treatment, or present at emergency departments, which means greater overall cost (Kraft et al.,
2009; Surrey et al., 2020).
Leadership Commitment via Executive Leaders
Interview questions for this section of findings were grounded in the conceptual
framework and are presented through the lens of the three pillars of highly reliable organizations
(HROs): leadership commitment, continuous process improvement, and creating a culture of
safety. The behaviors included communication, creating psychologically safe environments, and
purposeful rounding. The chief executive officer (CEO) and chief medical officer (CMO) are key
figures in healthcare organizations and drive targeted change for PX initiatives with
administrative and clinical professionals. The CEO and CMO comprise executive leaders (ELs)
for the study.
A core activity for ELs of HROs is purposeful rounding. In 2019, senior VA leaders
established the expectations for all ELs in the VHA to purposefully round throughout all areas of
their organizations. In addition to increased visibility, leading by example, and accessibility, the
intention of purposeful rounding is for ELs to communicate bi-directionally with employees
throughout the organization (VHA, 2020; Veazie et al., 2019). Purposeful rounding is different
from previous or concurrently existing rounding efforts. Environment of care rounding is an
example of a different type of rounding performed by interdisciplinary teams to find
infrastructure, privacy, safety, and operational issues. Participant P1 indicated that environment
of care rounding is perceived as an inspection and not an opportunity to communicate with ELs.
All participants stated the ELs rarely to never purposefully round, which participants felt directly
related to the lack of bi-directional communication and poor psychological safety at each VHA
site of care by the PCPs.
94

Communication occurs as written, read, heard, or spoken (O’Boyle & Klyukanov, 2023),
and is internal or external, formal or informal, and ideally occurs tri-directionally in
organizations: vertically (top to bottom and bottom to top) and laterally (Lewis, 2019). The
importance of transparent and effective communication from ELs remains the top expectation
from employees across many industries (Men et al., 2020). Most participants (86%) reported
wanting to engage with ELs, but it was equally important that participants also felt heard so that
actions were taken when they provided recommendations. Finally, ELs are expected to embody
behaviors that contribute to creating and sustaining psychologically safe work environments.
Participants associated ELs’ lack of purposeful rounding and bi-directional communication with
perceived poor psychological safety. Edmondson (1999) defined psychological safety as the
perceived ability of employees to speak up or report errors without retaliation and with the
expectation that issues will be corrected once voiced.
Organizational Culture and a Culture of Safety
The findings revealed less than optimal organizational cultures and cultures of safety
within the seven VHA sites of care, based on PCPs reporting that they cannot practice medicine
to the top of their licenses. Working to the top of one’s license means that the clinician can
practice to the full extent of their education, training, and experience (Spiro, 2017). Additionally,
the clinician’s time should not be spent performing tasks that someone with a different
education, training, and experiences could effectively perform. Practicing at the top of a license
leads to greater financial reimbursement for the organization, more clinician experience, and
improved patient outcomes and experiences.
Organizational culture is defined as the way employees behave in the workplace, the way
in which norms and values are communicated, and the implicit and explicit rules followed by all
95

employees (Burke, 2018). All participants felt that neither ELs nor their organizational cultures
supported delivering quality care and consistently positive patient experiences. They saw their
inability to practice to the top of their license as primarily due to administrative burdens, but
participants also reported feeling a lack of support from ELs for all primary care operations.
Participants reported concerns about the CMOs not having experience in primary care clinical
settings or understanding primary care clinic operations, highlighting the lack of deference to
expertise. Supporting a culture of safety means employees are encouraged and have the capacity
to collaborate, communicate, and coordinate with each other to improve patient outcomes and
sustain healthy work environments (Veazie et al., 2019).
Recommendations for Practice
Three organizational-level recommendations are presented here. The opportunity for
collaboration and implementation will depend on project ownership. Recommendations are made
for other responsible national program offices external to the Veterans Experience Office (VEO).
The first recommendation targets leadership commitment from executive leaders and addresses
their behaviors surrounding purposeful rounding, communication, and creating psychologically
safe environments. The second recommendation addresses the individual performance of
primary care providers (PCPs)—given the existing administrative burdens and considers
solutions through continuous process improvement (CPI). The final recommendation focuses on
organizational culture by addressing the PCPs’ concerns regarding barriers to practice in creating
a culture of safety.

96

Recommendation for Practice 1: Reduce Administrative Burden via Continuous Process
Improvement
The VHA formally began its continuous process improvement (CPI) journey in 1999 by
first enabling all employees to directly support organizational transformation through the pursuit
of “zero harm” and a deeply rooted culture of improvement, sustainment, and patient safety
(VHA Directive 1026.01, 2019). The PCPs felt they had repeatedly requested an easement from
administrative burdens, but little to nothing had been addressed. As such, there is an opportunity,
VHA-wide, to develop interdisciplinary teams to address the issues via an evidence-based
approach.
Melnyk (2016) and the advancing research and clinical practice through close
collaboration (ARCC) model have suggested that all employees, especially clinical staff, must
implement an evidence-based practice solution over 12 months. Projects should focus on patient
quality of care, safety, and outcomes to qualify. Schwarz et al. (1999) suggested assigning an
interdisciplinary team to address the root cause of the issues. Diverse, interdisciplinary teams
leverage their expertise, skills, experience, and perspectives to identify sustainable solutions. As
the United States’ largest integrated healthcare system, the VHA has a size and complexity that
means that CPI teams are almost always appropriate. Processes in large complex systems rarely
involve one discipline. Therefore, all disciplines impacted by a process must be involved in any
projects related to the process.
Diverse, interdisciplinary teams are needed at each VHA site of care to reduce
administrative burden. Representatives are necessary from all primary aligned care team (PACT)
disciplines (PCPs, RNs, LP/VNs, medical support assistants (MSAs), social workers,
pharmacists, and registered dieticians), health informatics, business operations, clinical education
97

and learning, and nursing education. A holistic approach to reviewing each area of concern for
administrative burden is necessary to removing barriers to practice for PCPs. Considering the
participants’ perceived lack of clarity regarding accountability and responsibility for
administrative burdens, a dual approach is recommended. National Program Office oversight is
necessary, but each VHA site of care is responsible for the CPI efforts and administrative burden
correction to meet the needs of local VHAs. Many National Program Offices have reputations
for isolating their work and maintaining staunch silos. I have observed this firsthand as an
experience field consultant who consults across all VHA sites and experienced it routinely in my
daily work. It is an antiquated approach for such a large organization. Therefore,
interdisciplinary teams must also be initiated at the highest levels of the organization.
Addressing administrative burdens will allow PCPs to spend more time connecting with
the patient, which leads to increased trust between the patient and provider. When trust increases,
so do care comprehensiveness, patient literacy and engagement, quality of care and outcomes,
and patient experience (Birkhauer et al., 2020; Ozawa & Sripad, 2013; Shea et al., 2008;
Stephens et al., 2020). Additionally, reducing administrative burdens for PCPs removes one issue
they feel currently places barriers to practice.
Recommendation for Practice 2: Leadership Commitment Via Executive Leadership HRO
Behaviors
Frankel et al. (2017) have maintained that ELs are crucial to the organizational adoption
of HRO principles and values that create a system of safety. Given that ELs were not the focus of
the study, I recommend using a strategic tool developed by the joint commission (TJC). The
HRO leadership maturity assessment is an HRO implementation strategy from TJC and
determines the current state and capacity for EL’s HRO behavior adoption (Chassin & Loeb,
98

2013). Once the current state and capacity for change are identified, a gap analysis is necessary
to aid in isolating thematic barriers for executive leaders.
Historically, VHA ELs self-report HRO activities and implementation status updates.
However, from my experience in various VA and VHA roles, I have observed firsthand how data
collection for self-reported assessments can easily succumb to human error and inaccurate
representation of realities. Examples include incorrect interpretation of assessment questions,
overly subjective reporting, or masking of organizational challenges due to large samples and
aggregated data. Internal HRO consultants from the Office of Healthcare Transformation are
suggested to facilitate the maturity assessment at all 171 VHA sites of care. Using consultants is
a supported approach to implementation by Aboumatar et al. (2017). Evidence indicates
sustainable implementation of HRO principles and values when consultants are leveraged due to
workload easement for the permanent employees at the specific VHA site of care.
Recommendation 3: Creating a Culture of Safety via an Internal “Barriers to Practice”
Audit
Given that the study did not seek to learn about definitive roles, responsibilities, and
processes, an audit to review currently established scopes of practice for all PCP license types
and the objective work performed at the individual level is necessary. The audit is recommended
prior to the implementation of solutions. Once audit findings are finalized, interdisciplinary
organizational solutions and standardization of systems are necessary to ensure sustainment. An
interdisciplinary approach at the national level with oversight by the Office of Primary Care is
recommended.
Once audit findings are determined, all involved disciplines must agree to the roles and
responsibilities expected of each license type to ensure efficiency and efficacy. Melnyk (2016)
99

encouraged using the advancing research and clinical practice through close collaboration
(ARCC) model to aid in implementing evidence-based clinical practices when creating a culture
of safety. Given the current findings and examples of PCPs not working to the top of their
license, it is likely that individual contributors to the PACT must adjust their existing workflows.
Roles and responsibilities will be shifted to varying degrees, and therefore, the literature supports
the use of simulation labs for interdisciplinary teams to practice behaviors and tasks (Riley,
2010).
Limitations and Delimitations
The qualitative methodology used in the study was designed to solicit narratives from
PCPs about their beliefs, experiences, and perceptions as they relate to patient experience,
executive leadership, organizational culture, and individual and organizational performance
through the lens of HRO pillars. As in any study, limitations and delimitations exist. Examples of
research limitations include design constraints and factors outside of mine or the participant’s
control, whereas delimitations refer to the boundaries I established on the study to improve
validity and reliability (Merriam & Tisdale, 2016).
One anticipated limitation was the lack of engagement by the participant group. Primary
care providers (PCPs) do not routinely check emails in their work environment, given that they
spend the entirety of their workday interacting with patients. Shifts are long and often extend
beyond regular duty hours due to the lack of administrative time allotted for PCPs to take clinical
notes, complete orders, manage consults, order and follow-up diagnostic tests and prescriptions,
and other administrative burdens.
The study was initially delimited to explore the experiences of only MD PCPs who
deliver general medical care in a primary care clinical setting. Nurse practitioners (NPs)
100

consistently outperform their MD peers in all areas of care quality and experience (AANP,
2020). Nurse practitioners’ patients have fewer hospitalizations and hospital readmissions, fewer
emergency department visits, better patient experiences, and greater patient satisfaction
compared to MDs (AANP, 2022; Kinnersley et al., 2000). Osteopathic physicians (DOs)
typically perform the same or slightly worse than MDs for patient outcomes (Miyawaki et al.,
2023). Additionally, there are far fewer DOs in the healthcare industry (Association of American
Medical Colleges, 2023), so it was unlikely that I would encounter DO participants. Therefore, it
seemed reasonable to isolate MDs. However, I quickly realized the importance of learning from
NPs. How is it that they deliver care in the same inefficient healthcare systems, but their patients
have uniquely different and better outcomes and experiences?
Recommendations for Future Research
Factors for consideration in future research include the initial study’s research limitations,
exploring specific aspects from the initial study’s findings, and alternate theoretical frameworks.
The initial aim of the research was limited to a small percentage of VHA sites of care and used
only qualitative data. The limitations were necessary for an appropriately designed study, yet the
limitations are now presented here as opportunities.
Limitations of the initial study that should be considered for further research include
leveraging mixed methods and expanding the number of participating sites. Improved specificity
of future findings and recommendations are seen from incorporating mixed methods and
application to future studies would benefit (Maxwell, 2013; Merriam & Tisdell, 2016).
Specifically, quantitative PX and healthcare effectiveness data and information set (HEDIS)
measurements for quality patient health outcomes should be leveraged. Potential metrics include
the following HEDIS topics: (a) prevention and screening; (b) respiratory, cardiovascular, and
101

diabetes conditions; (c) behavioral health; (d) medication management and care coordination; (e)
overuse/appropriateness of use; (f) access; (g) hospitalization for potentially preventable
conditions; and (h) emergency department utilization. Including additional VHA sites of care in
future studies enables generalizability and application to the broader healthcare industry.
A substantial area of consideration to build on the findings from the initial study includes
executive leaders (ELs) as the primary participant focus. As a VHA health systems expert who
works with executives, managers, and individual contributors at all levels of the VA, I routinely
observe and hear discrepancies between the actions and behaviors of ELs and the perception of
those behaviors by frontline staff. Studying the disconnect can lead to recommendations for
practice targeted at executive leaders.
Before considering alternate frameworks, assessing the existing theoretical frameworks
used in the initial study is reasonable. Specifically, only three transformational factors were
initially included from the Burke-Litwin causal model for organizational change and
performance (2018). It is possible to design a similar study by leveraging different combinations
of transformational factors or looking through the lens of transactional factors. Alternate
frameworks were considered for the initial study. One example is the Bronfenbrenner ecological
systems theory (Bronfenbrenner, 2000), which considers the multiple levels within
organizational systems: micro-, meso-, exo-, macro-, and chronosystems.
Implications for Veteran Health Equity
Many factors affect health equity. Often the terms health equity and social determinants
of health are used interchangeably (Bogard et al., 2017). However, social determinants of health
are only one element of health equity. Examples of social determinants of health include race,
102

income, and rural or urban residence. While these are important considerations for veteran health
equity, that is not the focus of the initial study.
The three broad categories impacting health equity in the United States are (a) access, (b)
quality, and (c) affordability. Not surprisingly, these categories are addressed by the Institute for
Healthcare Improvement (IHI) triple aim. This study only explored quality, leaving out access
and affordability.
Patient experience and healthcare systems’ inefficiencies are direct, secondary, and
tertiary influences on quality health outcomes, as discussed in chapter 2. This study did not
attempt to frame health inequities specifically. Therefore, it is a future research consideration.
However, inference of the findings in context of the literature implies that the lack of
engaged ELs and healthy organizational cultures that support cultures of safety and continuous
process improvement for individual and organizational performance means that the seven
participating VHA sites contribute to the health inequities of the patients in their catchment
areas. Comparing and identifying outliers in patient outcome metrics across regions and specific
VHA sites of care is simple. The intention is not to punish VHA sites with lower PX and quality
outcome measures but rather to learn best practices for reducing inequities in care delivery so
that all veterans, regardless of geographical residence, have access to equitable healthcare
through the lens of patient experience.
Conclusion
Yes, the Veterans Health Administration outperforms non-VHA healthcare in all 10
categories of patient experience (Lawrence, 2023; Shekelle et al., 2023), and in 85% of the peer-
reviewed articles, VHA also excels in quality, safety, cost, efficiency, and access for nonsurgical
healthcare (Shekelle et al., 2023). However, vigilance and action are necessary to remain the best
103

and to improve individual and organizational performance within primary care clinical settings.
Ultimately, veterans suffer from inefficiencies, real or perceived, within the Veterans Health
Administration. The literature is clear on the relationship between the delivery of quality care,
patient experience, and quality health outcomes. The study sought to elucidate the participants’
perceptions, beliefs, and experiences about executive leaders and organizational culture to better
understand what PCPs need to consistently deliver positive patient experiences. The study
combined two theoretical frameworks, the Burke-Litwin causal model for organizational change
and performance (2018) and the Veterans Health Administration high-reliability organization
(HRO) framework.
By adopting the three recommendations, the VHA can support PCPs in delivering quality
care and consistently positive patient experiences. The goal is to maximize the efficiency and
efficacy of the systems so that the right care is provided at the right time to the right patient and
without the patients’ exposure to how the system works. The trust scores found in Figure 1
provide baseline data from one data source to effectively measure the successful implementation
of the recommendations.
When executive leaders exhibit HRO behaviors, PCPs feel supported, heard, and that
their voices matter. Only 4% of the 171 VHA sites of care were included in the study, but the
total number of employees potentially impacted is approximately 31,500, and the veteran impact
is over 700,000 service members. However, if the VHA seeks to reduce inequities in care
delivery, improve the patient experience, and ensure patients have the best possible health
outcomes, then attention to the findings and recommendations is prudent.

104

References
Agency for Healthcare Research and Quality (AHRQ). (n.d.). CAHPS clinician & group survey:
Differences between the core items in 3.0, 3.1, and Visit 4.0 (beta) versions.
https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/cg-
comparison-3-4.pdf
Agency for Healthcare Research and Quality (AHRQ). (2015). CAHPS clinician & group adult
survey 3.0. https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-
guidance/cg/cg-cahps-4-beta.zip
Agency for Healthcare Research and Quality (AHRQ). (2017a). Patient experience measures
from the CAHPS clinician & group survey.
Agency for Healthcare Research and Quality (AHRQ). (2017b). Preparing data from CAHPS
surveys for analysis. https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-
guidance/helpful-resources/analysis/preparing-data-for-analysis.pdf
Agency for Healthcare Research and Quality (AHRQ). (2017c). The CAHPS ambulatory care
improvement guide. https://www.ahrq.gov/cahps/quality-improvement/improvement-
guide/improvement-guide.html
Agency for Healthcare Research and Quality (AHRQ). (2022a). CAHPS: Assessing healthcare
quality from the patient’s perspective. https://www.ahrq.gov/sites/default/files/wysiwyg/
cahps/about-cahps/cahps-program-brief.pdf
Agency for Healthcare Research and Quality (AHRQ). (2020a, February). The CAHPS
ambulatory care improvement guide: Practical strategies for improving patient
experience. https://www.ahrq.gov/cahps/quality-improvement/improvement-
guide/improvement-guide.html
105

Agency for Healthcare Research and Quality (AHRQ). (2020b, June). Understanding quality
measurement. https://www.ahrq.gov/patient-safety/quality-
resources/tools/chtoolbx/understand/index.html
Agency for Healthcare Research and Quality (AHRQ). (2020c, October). Celebrating 25 years
of CAHPS | agency for healthcare research and quality.
https://www.ahrq.gov/cahps/about-cahps/25timeline.html
Agency for Healthcare Research and Quality (AHRQ). (2021a, September). CAHPS health
literacy item sets. https://www.ahrq.gov/cahps/surveys-guidance/item-
sets/literacy/index.html
Agency for Healthcare Research and Quality (AHRQ). (2021b, October). CAHPS patient
narrative item sets. https://www.ahrq.gov/cahps/surveys-guidance/item-
sets/elicitation/index.html
Agency for Healthcare Research and Quality (AHRQ). (2021c, November). CAHPS patient-
centered medical home (PCMH) item set. https://www.ahrq.gov/cahps/surveys-
guidance/item-sets/PCMH/index.html
Agency for Healthcare Research and Quality (AHRQ). (2022b, May). CAHPS patient experience
surveys and guidance. https://www.ahrq.gov/cahps/surveys-guidance/index.html
Agency for Healthcare Research and Quality (AHRQ). (2022c, May). CAHPS supplemental
items. https://www.ahrq.gov/cahps/item-sets/index.html
Agency for Healthcare Research and Quality (AHRQ). (2022d, May). Development of the
CAHPS clinician & group survey. https://www.ahrq.gov/cahps/surveys-
guidance/cg/about/Develop-CG-Surveys.html
106

Agency for Healthcare Research and Quality (AHRQ). (2022e, May). The CAHPS program.
https://www.ahrq.gov/cahps/about-cahps/cahps-program/index.html
Agency for Healthcare Research and Quality (AHRQ).. (2022f, July). About CAHPS.
https://www.ahrq.gov/cahps/about-cahps/index.html
Agency for Healthcare Research and Quality (AHRQ). (2022g, July). CAHPS clinician & group
survey. https://www.ahrq.gov/cahps/surveys-guidance/cg/index.html
Agency for Healthcare Research and Quality (2022h, July). CAHPS clinician and group survey
3.0 measures. https://www.ahrq.gov/cahps/surveys-guidance/cg/about/survey-
measures.html
Agency for Healthcare Research and Quality (AHRQ). (2022i, July). CAHPS health information
technology item set. https://www.ahrq.gov/cahps/surveys-guidance/item-
sets/HIT/index.html
Agency for Healthcare Research and Quality (AHRQ). (2022j, August). What is patient
experience? https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html
Alaloul, F., Myers, J., Masterson, K. M., DiCicco, J., Collins, M. P., Hogan, F., Roesler, L., &
Logsdon, M. C. (2019). Patient experience factors and health-related quality of life in
hospitalized individuals. Oncology Nursing Forum, 46(2), 238–247.
https://doi.org/10.1188/19.ONF.238-247
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient
safety. Saudi Medical Journal, 38(12), 1173–1180.
https://doi.org/10.15537/smj.2017.12.20631
107

American Association of Nurse Practitioners (AANP). (2020). Quality of nurse practitioner
practice. https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-
of-nurse-practitioner-practice
Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—The pinnacle of patient-
centered care _ enhanced reader.pdf. New England Journal of Medicine, 366(9), 780–
781.
Berwick, D., & Fox, D. M. (2016). “Evaluating the Quality of Medical Care”: Donabedian’s
classic article 50 years later: “Evaluating the Quality of Medical Care.” The Milbank
Quarterly, 94(2), 237–241. https://doi.org/10.1111/1468-0009.12189
The Beryl Institute. (n.d.a). About the Beryl Institute—The Beryl Institute—Improving the patient
experience. https://www.theberylinstitute.org/page/About
The Beryl Institute. (n.d.b). Guiding principles—The Beryl Institute—Improving the patient
experience. https://www.theberylinstitute.org/page/GuidingPrinciples
Bogard, K., Murry, V. M., & Alexander, C. M. (2017). Perspectives on health equity and social
determinants of health. National Academy of Medicine.
Bolger, G. (2012). Safeguarding quality in health care: What does it mean? British Journal of
Nursing, 21(5), S36–S37.
Brega, A., Hamer, M. K., Albright, K., Brach, C., Saliba, D., Abbey, D., & Gritz, M. (2019).
Health literacy research and practice.pdf. Health Literacy Research and Practice, 3(2),
e127–e146.
Bronfenbrenner, U. (2000). Ecological systems theory. Encyclopedia of Psychology, 3, 129–133.
https://doi.org/10.1037/10518-046
108

Bucknum, A. (2021, June 16). The patient experience & the cost of patient loss.
https://www.synctimes.com/blog/the-patient-experience-the-cost-of-patient-loss
Bull, C. (2021). Patient satisfaction and patient experience are not interchangeable concepts.
International Journal for Quality in Health Care, 33(1), mzab023.
https://doi.org/10.1093/intqhc/mzab023
Burke, W. W. (2018). Organization change theory & practice (5th ed.). Sage.
Burke, W. W., & Litwin, G. H. (1992). A causal model of organizational performance and
change.pdf. Journal of Management, 18(3), 523–545.
Caldwell, D. F., Chatman, J., Iii, C. A. O., Ormiston, M., & Lapiz, M. (2008). Implementing
strategic change in a health care system: The importance of leadership and change
readiness. Health Care Manage Review, 33(2), 124–133.
Capko, J. (2021, March 3). Unhappy patients are costly. American Association for Physician
Leadership - Inspiring change. Together. https://www.physicianleaders.org
Carcaise-Edinboro, P., & Bradley, C. J. (2008). Influence of patient-provider communication on
colorectal cancer screening.pdf. Medical Care, 46(7), 738–745.
Centers for Medicare and Medicaid Services (CMS). (2021a, December 1). HCAHPS: Patients’
perspectives of care survey | CMS. https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS
Centers for Medicare and Medicaid Services (CMS). (2021b, December 1). Healthcare
effectiveness data and information set (HEDIS) | CMS.
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS
Chaitoff, A., Sun, B., Windover, A., Bokar, D., Featherall, J., Rothberg, M. B., & Misra-Hebert,
A. D. (2017). Associations between physician empathy, physician characteristics, and
109

standardized measures of patient experience. Academic Medicine, 92(10), 1464–1471.
https://doi.org/10.1097/ACM.0000000000001671
Christensen, T. (2017). Rebalancing the patient experience: 20 years of a pendulum swing.
Patient Experience Journal, 4(3), 6–8. https://doi.org/10.35680/2372-0247.1257
Christianson, M. K., Sutcliffe, K. M., Miller, M. A., & Iwashyna, T. J. (2011). Becoming a high
reliability organization. Critical Care, 15(6), 314. https://doi.org/10.1186/cc10360
Chua, I. S., Jackson, V., & Kamdar, M. (2020). Webside manner during the COVID-19
pandemic: Maintaining human connection during virtual visits. Journal of Palliative
Medicine, 23(11), 1507–1509. https://doi.org/10.1089/jpm.2020.0298
Cleary, P. D. (2016). Evolving concepts of patient-centered care and the assessment of patient
care experiences–optimism and opposition. Journal of Health Politics, Policy and Law,
41(4), 675–696. https://doi.org/10.1215/03616878-3620881
Code of Federal Regulations. (2019, May 20). 38 CFR 0.603—Customer experience principles.
Code of Federal Regulations. https://www.ecfr.gov/current/title-38/chapter-I/part-
0/subpart-A/section-0.603
Congiusta, S., Solomon, P., Conigliaro, J., O’Gara-Shubinsky, R., Kohn, N., & Nash, I. S.
(2018). Clinical quality and patient experience in the adult ambulatory setting.pdf.
American Journal of Medical Quality, 34(1), 87–91.
https://doi.org/doi.org/10.1177/1062860618777878
Creswell, J. W., & Creswell, J. D. (2018). Research design qualitative, quantitative, and mixed
method approaches (5th ed.). Sage.
Department of Veterans Affairs. (2015). VA Directive 5013.
https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=209&FType=2
110

DeWalt, D. A., & McNeill, J. (2013). Integrating health literacy with health care performance
measurement. NAM Perspectives, 3(7). https://doi.org/10.31478/201307f
Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank Quarterly, 44(3 pt.
2), 166–203.
Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness. BMJ Open, 3(1), e001570.
https://doi.org/10.1136/bmjopen-2012-001570
Eklund, J. H., Holmström, I. K., Kumlin, T., Kaminsky, E., Skoglund, K., Höglander, J.,
Sundler, A. J., Condén, E., & Meranius, M. S. (2018). “Same same or different.” A
review of reviews of person-centered and patient-centered care. Patient Education and
Counseling, 102(1), 3–11. https://doi.org/10.1016/j.pec.2018.08.029
Farrington, C., Burt, J., Boiko, O., Campbell, J., & Roland, M. (2016). Doctors engagements
with patient experience surveys in primary and secondary. Health Expectations, 20(3),
385–394. https://doi.org/10.1111/hex.12465
Fenton, J. J., Jerant, A. F., Bertakis, K. D., & Franks, P. (2012). The cost of satisfaction a
national study of patient satisfaction, health care utilization, expenditures, and mortality.
Journal of American Medical Association, 172(5), 405–411.
Fox, S. (2017). Patient experience: Why it is important to providers. Frontiers of Health Services
Management, 33(3), 42–48. https://doi.org/10.1097/HAP.0000000000000004
Frankel, A, Haraden C, Federico F, & Lenoci-Edwards J. (2017). A framework for safe, reliable,
and effective care. White Paper. Institute for Healthcare Improvement and Safe &
Reliable Healthcare.
111

Galstian, C., Hearld, L., O’Connor, S. J., & Borkowski, N. (2018). The relationship of hospital
CEO characteristics to patient experience scores. Journal of Healthcare Management,
63(1), 50–61. https://doi.org/10.1097/JHM-D-16-00020
Germack, H. D., Leung, L., Zhao, X., Zhang, H., & Martsolf, G. R. (2022). Association of team-
based care and continuity of care with hospitalizations for veterans with comorbid mental
and physical health conditions. Journal of General Internal Medicine, 37(1), 40–48.
https://doi.org/10.1007/s11606-021-06884-5
Godbold, J. M., & Kame’enui, E. J. (2017). An ode to clarity in communicating the written word
on research. The Elementary School Journal, 117(3), 340–344.
Hefner, J. L., McAlearney, A. S., Spatafora, N., & Moffatt-Bruce, S. D. (2019). Beyond patient
satisfaction—optimizing the patient experience. Advances in Health Care Management,
18, 255–261. https://doi.org/10.1108/S1474-823120190000018010
Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation—better
health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2), 207–
214. https://doi.org/10.1377/hlthaff.2012.1061
Huselid, M. A. (1997). Technical and strategic human resource management effectiveness as
determinants of firm performance. Academy of Management Journal, 40(1), 171–188.
Institute for Healthcare Improvement. (2022). The IHI Triple Aim | IHI - Institute for Healthcare
Improvement. https://www.ihi.org:443/Engage/Initiatives/TripleAim/Pages/default.aspx
Institute of Medicine. (2018, November). Six domains of health care quality.
https://www.ahrq.gov/talkingquality/measures/six-domains.html
Institute of Medicine, et al. (2001). Crossing the quality chasm a new health system for the 21st
century. Committee on Quality of Health Care in America Institute of Medicine.
112

Isakson, J. (2018, June 6). Text - S.2372 - 115th Congress (2017-2018): VA Mission Act of 2018
(2017/2018) [Legislation]. http://www.congress.gov/
Jeroen, T., Canfyn, S., Lieven, A., & Paul, G. (2016). Physician–hospital exchanges and extra-
role behaviour of physicians: The moderating role of the chief medical officer.
International Journal of Healthcare Management, 9(4), 225–235.
https://doi.org/10.1179/2047971915Y.0000000022
Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients’ perception of hospital care
in the United States. New England Journal of Medicine, 359, 1921–1931.
Kaplan, S. H., Greenfield, S., & Ware, J. E. (1989). Assessing the effects of physician-patient
interactions on the outcomes of chronic disease. Medical Care, 27(3), S110–S127.
Kash, B., & McKahan, M. (2017). The evolution of measuring patient satisfaction. 1(1), 4.
Khanna, G., & Ginsberg, C. (2020, October 7). CAHPS®: 25 years of putting the patient first.
https://www.ahrq.gov/news/blog/ahrqviews/cahps-25yrs.html
Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard, L., Turton, P., Stainthorpe, A.,
Fraser, A., Butler, C. C., & Rogers, C. (2000). Randomised controlled trial of nurse
practitioner versus general practitioner care for patients requesting “same day”
consultations in primary care. BMJ, 320, 1043–1048.
https://doi.org/10.1136/bmj.320.7241.1043
Kotter, J. (2012). Leading change. Harvard Business Review Press.
Kraft, A. D., Quimbo, S. A., Solon, O., Shimkhada, R., Florentino, J., & Peabody, J. (2009). The
health and cost impact of care delay and the experimental impact of insurance on delays–
evidence from a developing country. National Institute of Health, 155(2), 281–285.
https://doi.org/10.1016/j.jpeds.2009.02.035
113

Larson, E., Sharma, J., Bohren, M. A., & Tunçalp, Ö. (2019). When the patient is the expert:
Measuring patient experience and satisfaction with care. Bulletin of the World Health
Organization, 97(8), 563–569. https://doi.org/10.2471/BLT.18.225201
LaVela, S. L., & Gallan, A. (2014). Evaluation and measurement of patient experience (SSRN
Scholarly Paper No. 2643249). https://papers.ssrn.com/abstract=2643249
Lawrence, Q. (2023, June 14). VA hospitals are outperforming private hospitals, Medicare
survey shows. NPR. https://www.npr.org/2023/06/14/1181827077/va-hospitals-health-
care
Lee, V. S., Miller, T., Daniels, C., Paine, M., Gresh, B., & Betz, A. L. (2016). Creating the
exceptional patient experience in one academic health system. Academic Medicine, 91(3),
338–344. https://doi.org/10.1097/ACM.0000000000001007
Lord, L., & Gale, N. (2013). Subjective experience or objective process- understanding the gap
between values and practice for involving patients in designing patient-centred care.
Journal of Health Organization and Management, 28(6), 714–730.
https://doi.org/10.1108/JHOM-08-2013-0160
Manary, M. P., Boulding, W., Staelin, R., & Glickman, S. W. (2013). The patient experience and
health outcomes. New England Journal of Medicine, 368(3), 201–203.
https://doi.org/10.1056/NEJMp1211775
Maxwell, J. (2013). Qualitative research design: An interactive approach (3rd ed.). Sage.
Men, L. R., Chen, Z. F., & Ji, Y. G. (2021). Cultivating relationships with startup employees:
The role of entrepreneurs’ leadership communication. Management Communication
Quarterly, 35(4), 518–545. https://doi.org/10.1177/08933189211017918
114

Merriam, S. B., & Tisdale, E. J. (2016). Qualitative research: A guide to design and
implementation (4th ed.). Jossey-Bass.
Misra, S. (2021). Osteopathic principles and practice: Essential training for the primary care
physician of today and tomorrow. Family Medicine, 53(7), 544–547.
https://doi.org/10.22454/FamMed.2021.123494
Moreno, M. R., Sherrets, B., Roberts, D. J., & Azar, K. (2021). Health equity and quantifying the
patient experience: A case study. Patient Experience Journal, 8(2), 94–99.
https://doi.org/10.35680/2372-0247.1621
National Committee for Quality Assurance (NCQA). (2022a). HEDIS. NCQA.
https://www.ncqa.org/hedis/
National Committee for Quality Assurance (NCQA). (2022b). HEDIS measures and technical
resources. NCQA. https://www.ncqa.org/hedis/measures/
NEJM Catalyst. (2017, January 1). What is patient-centered care?
https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559
New England Journal of Medicine. (2018, January 1). Patient satisfaction surveys. New England
Journal of Medicine. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0288
Oppel, E.-M., & Mohr, D. C. (2020). “Paying it forward”- The link between providers’ civility
climate, civility toward patients and patient experience outcomes. Health Care
Management Review, 45(2), 141–150. https://doi.org/10.1097/HMR.0000000000000209
Peters, T. J., & Waterman Jr., R. H. (1982). In search of excellence: Lessons from America’s best
run companies. Harper Business.
The Picker Institute. (2022). The Picker principles of person-centred care. Picker.
https://picker.org/who-we-are/the-picker-principles-of-person-centred-care/
115

Prentice, J. C., & Pizer, S. D. (2007). Delayed access to health care and mortality. Health
Research and Educational Trust, 42(2), 644–662. https://doi.org/10.1111/j.1475-
6773.2006.00626.x
Price, R. A., Elliott, M. N., Zaslavsky, A. M., Hays, R. D., Lehrman, W. G., Rybowski, L.,
Edgman-Levitan, S., & Cleary, P. D. (2014). Examining the role of patient experience
surveys in measuring health care quality. Medical Care Research and Review, 71(5),
522–554. https://doi.org/10.1177/1077558714541480
Reynolds, A. (2009). Patient-centered care. Radiology Technology, 81(2), 133–147.
Richter, J. P., & Muhlestein, D. B. (2017). Patient experience and hospital profitability—Is there
a link? Health Care Management Review, 42(3), 247–257.
https://doi.org/10.1097/HMR.0000000000000105
Ridgeway, C. L., Korn, R. M., & Williams, J. C. (2022). Documenting the routine burden of
devalued difference in the professional workplace. Gender & Society, 36(5), 627–651.
https://doi.org/10.1177/08912432221111168
Roberts, M. J., Campbell, J. L., Abel, G. A., Davey, A. F., Elmore, N. L., Maramba, I., Carter,
M., Elliott, M. N., Roland, M. O., & Burt, J. A. (2014). Understanding high and low
patient experience scores in primary care: Analysis of patients’ survey data for general
practices and individual doctors. BMJ, 349. https://doi.org/10.1136/bmj.g6034
Rogers, H. (2014, August 7). H.R.3230 - 113th Congress (2013-2014): Veterans Access, Choice,
and Accountability Act of 2014 (2013/2014) [Legislation]. http://www.congress.gov/
Rozenblum, R., & Bates, D. W. (2013). Patient-centred healthcare, social media and the internet:
The perfect storm? BMJ Quality & Safety, 22(3), 183–186.
https://doi.org/10.1136/bmjqs-2012-001744
116

Saher, R., & Anjum, M. (2021). Role of technology in COVID-19 pandemic. Researches and
applications of artificial intelligence to mitigate pandemics (pp. 109–138). Elsevier.
http://dx.doi.org/10.1016/B978-0-323-90959-4.00005-5
Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2017). How to
practice person-centred care: A conceptual framework. Health Expectations, 21, 429–
440. https://doi.org/10.1111/hex.12640
Schlesinger, M. J., Rybowski, L., Shaller, D., Martino, S., Parler, A. M., Grob, R., Finucane, M.,
& Cerully, J. (2019). Americans’ growing exposure to clinician quality information:
Insights and implications. Health Affairs, 38(3), 374–382.
https://doi.org/10.1377/hlthaff.2018.05006
Sequist, T. D., Schneider, E. C., Anastario, M., Odigie, E. G., Marshall, R., Rogers, W. H., &
Safran, D. G. (2008). Quality monitoring of physicians: Linking patients’ experiences of
care to clinical quality and outcomes. Society of General Internal Medicine, 23(11),
1784–1790. https://doi.org/10.1007/s11606-008-0760-4
Serou, N., Sahota, L. M., Husband, A. K., Forrest, S. P., Slight, R. D., & Slight, S. P. (2021).
Learning from safety incidents in high-reliability organizations: A systematic review of
learning tools that could be adapted and used in healthcare. International Journal for
Quality in Health Care, 33(1), mzab046. https://doi.org/10.1093/intqhc/mzab046
Shein, E. H. (2010). Organizational Culture and Leadership (5th ed.). Wiley.
Shekelle, P., Maggard-Gibbons, M., Blegen, M., Apaydin, E., Paige, N., Ko, J., Ulloa, J.,
Salzman, G., Begashaw, M., Girgis, M. D., & Larkin, J. (2023). VA versus non-VA
quality of care: A systematic review. Veterans Health Administration Health Services
Research Service.
117

Siegrist Jr., R. S. (2013). History of medicine patient satisfaction: History, myths, and
misperceptions. American Medical Association Journal of Ethics, 15(11), 982–987.
Silvera, G. A., & Clark, J. R. (2021). Women at the helm: Chief executive officer gender and
patient experience in the hospital industry. Health Care Management Review, 46(3), 206–
216. https://doi.org/10.1097/HMR.0000000000000252
Smith, K., & Topham, C. (2016). Patient-centered care. Journal of Medical Imaging and
Radiation Sciences, 47, 373–375. https://doi.org/10.1016/j.jmir.2016.10.004
Spiro, A. (2017). Challenging paradigms practising at the top of Your Licence. Health
Management, 17(3).
Standley, C. (2021, July 30). The history of patient experience | Purple.
https://purple.ai/blogs/the-history-of-patient-experience/
Stephens, J., Lambalot, H., & Ramiah, K. (2020). Patient trust: A guide for essential hospitals.
Essentials Hospitals Institute.
Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: A
review. Canadian Medical Association Journal, 152(9), 1423–1433.
Stewart, M., Belle Brown, J., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W., &
Jordan, J. (2000). The impact of patient-centered care on outcomes. The Journal of
Family Practice, 49(9), 796–804.
Street, Jr., R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication
heal? Pathways linking clinician–patient communication to health outcomes. Patient
Education and Counseling, 74(3), 295–301. https://doi.org/10.1016/j.pec.2008.11.015
118

Sullivan, M. (2003). The new subjective medicine: Taking the patient’s point of view on health
care and health. Social Science & Medicine, 56(7), 1595–1604.
https://doi.org/10.1016/S0277-9536(02)00159-4
Surrey, E., Soliman, A. M., Trenz, H., Blauer-Peterson, C., & Sluis, A. (2020). Impact of
endometriosis diagnostic delays on healthcare resource utilization and costs. Advanced
Therapy, 37, 1087–1099. https://doi.org/10.6084/m9.figshare.11417625
Torpie, K. (2014). Customer service vs. patient care. Patient Experience Journal, 1(2), 6–8.
https://doi.org/10.35680/2372-0247.1045
Veazie, S., Peterson, K., & Bourne, D. (2019). Evidence brief: Implementation of high reliability
organization principles. https://www.hsrd.research.va.gov/publications/esp/high-
reliability-org.pdf
Veronesi, G., Kirkpatrick, I., & Altanlar, A. (2015). Clinical leadership and the changing
governance of public hospitals: Implications for patient experience. Public
Administration, 93(4), 1031–1048. https://doi.org/10.1111/padm.12183
Veterans Affairs. (2022, September 15). VA.gov | Veterans Affairs | About [Homepage].
https://www.va.gov/about_va/
Veterans Experience Office. (2020a). Patient experience (PX) guidebook building the foundation
for patient experience at a VA facility. Veterans Experience Office.
Veterans Experience Office. (2020b). PX resources—Guidebook—Building the foundation for
patient experience at a VA Facility v2.0.
Veterans Experience Office. (2022). VA customer experience. Veterans Experience Office.
Veterans Experience Office. (n.d.). PX Framework for PX change agents. Veterans Experience
Office.
119

Veterans Health Administration (VHA). (2016). 20 reasons doctors like working for the
Veterans Health Administration. https://news.va.gov/30788/20-reasons-vha-doctors-love-
job/
Veterans Health Administration (VHA). (2006). Clinical Reminders Version 2.0 Patch PXRM24
CLINICIAN GUIDE.pdf. https://www.va.gov/vdl/documents/clinical/cprs-
clinical_reminders/pxrm_2_4_um.pdf
Veterans Health Administration (VHA). (2022). General Pharmacy Service Requirements.
https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10045
Veterans Health Administration (VHA). (2017). Selected veterans health administration
characteristics: FY2002 to FY2015.
https://www.va.gov/vetdata/docs/Utilization/VHAStats_2015.xlsx
Veterans Health Administration (VHA). (2018). Average expenditures per patient by healthcare
priority group: FY2000 to FY2018. https://www.data.va.gov/dataset/Average-
Expenditures-Per-Patient-by-Healthcare-Pri/4rcf-gbi9
Veterans Health Administration (VHA). (2021). Survey of healthcare experience for patients
reporting measures reference guide.
Veterans Health Administration (VHA). (2022). Veteran equitable resource allocation 2023
patient classification hierarchy with advance appropriation prices.
Veterans Health Administration (VHA). (2014, August). VA office of the inspector general.
https://www.va.gov/oig/pubs/vaoig-14-02603-267.pdf

120

Veterans Health Administration (VHA). (2020, August 14). VHA’s vision for a high reliability
organization || FORUM.
https://www.hsrd.research.va.gov/publications/forum/summer20/default.cfm?ForumMen
u=summer20-1
Veterans Health Administration (VHA). (2022b, August 2). VA.gov | Veterans affairs | Veterans
Health Administration [Homepage]. https://www.va.gov/health/
Veterans Health Administration (VHA). (2022c, September 6). VA.gov | Veterans affairs |
Patient care services [General Information].
https://www.patientcare.va.gov/primarycare/PACT.asp
Veterans Health Administration (VHA). (2022d, September 19). VA.gov | Veterans affairs |
Primary care [General Information].
https://www.patientcare.va.gov/primarycare/index.asp
Veterans Health Administration (VHA). (2022e, November 14). VA priority groups.
https://www.va.gov/health-care/eligibility/priority-groups/
Veterans Health Administration (VHA). (n.d.). Survey of healthcare experiences of patients
(SHEP) Program.
Widmer, R. J., Maurer, M. J., Nayar, V. R., Aase, L. A., Wald, J. T., Kotsenas, A. L., Timimi, F.
K., Harper, C. M., & Pruthi, S. (2018). Online physician reviews do not reflect patient
satisfaction survey responses. Mayo Clinic Proceedings, 93(4), 453–457.
https://doi.org/10.1016/j.mayocp.2018.01.021
Wolf, J. A. (2018). The consumer has spoken: Patient experience is now healthcare’s core
differentiator. Patient Experience Journal, 5(1), 1–4. https://doi.org/10.35680/2372-
0247.1304
121

Wolf, J. A., Niederhauser, V., Marshburn, D., & LaVela, S. L. (2014). Defining patient
experience. Patient Experience Journal, 1(1), 7–19. https://doi.org/10.35680/2372-
0247.1004
Zill, J. M., Christalle, E., Muller, E., Harter, M., Dirmaier, J., & Scholl, I. (2014). Measurement
of physician-patient communication—A systematic review, 9(12). https://doi.org/10.1371/
journal.pone.0112637
Zolnierek, K. B. H., & DiMatteo, M. R. (2009). Physician communication and patient adherence
to treatment: A meta-analysis. Medical Care, 47(8), 826–834.

122

Appendix A: Relationships Between Patient-Centered Care, Patient Experience, and
Quality Healthcare Domains

Note. Barry & Edgman-Levitan; 2012; Berwick & Fox, 2016; Bolger, 2012; Cleary, 2016;
Donabedian, 1966; Eklund et al., 2018; Guiding Principles for Experience Excellence,
n.d.; HEDIS Measures, 2022; Hibbard & Greene, 2013; Institute of Medicine, 2001;
Kraft et al., 2009; LaVela & Gallan, 2014; Prentice & Pizer, 2007; Reynolds, 2009;
Santana et al., 2017; Smith & Topham, 2016; Street et al., 2003; Stewart, 1995; Stewart
et al., 2000; Surrey et al., 2020; The Picker Principles of Person Centered Care, 2022;
What Is Patient-Centered Care, 2017; Wolf et al., 2014; Zill et al., 2014

Quality
• Safe
• Effective
• Timely
• Patient-Centered
• Efficient
• Equitable
PCC
• Patient Experiences
• Spans continuum of care
• Patient/provider
relationship
• Provider communication
• Ease
• Emotion
• Effectiveness
• Spans continuum of care
• Domains of PX:
• Timely (access to care)
• Provider communication
• Care Coordination
• Helpfulness,
Courteousness, and
respectfulness of office
staff
• Provider rating
123

Appendix B: V A Patient Experience (PX) Framework and Domains

Note. (Veterans Experience Office, n.d.)

124

Appendix C: CAHPS Clinician & Group Survey: Differences between the core items in 3.0,
3.1, and Visit 4.0 (beta) versions

125

Note. (CAHPS Clinician & Group Survey: Differences between the core items in 3.0, 3.1, and
Visit 4.0 (beta) versions, n.d.)
126

Appendix D: SHEP Composites & Reporting Measures Reference Guide
127

Note. (Survey of Healthcare Experiences of Patients (SHEP) Program, n.d.)

128

Appendix E: Interview Protocol
Question
#
Question Follow-up
Question
Research
Question
Alignment
Framework
Alignment
null How long have you been in your
current position?
Rapport
null Why did you join the VA? Rapport
null How long in the Department of
Veteran Affairs?
Rapport
1 In your own words, how do you
define Patient Experience?
3 Individual and
Organizational
Performance
2 How does Patient Experience
apply to your role?
1, 3 Organizational
Culture and
Individual and
Organizational
Performance
3 Could you tell me about the
importance of Patient
Experience?
Why? 1, 3 Organizational
Culture and
Individual and
Organizational
Performance
4 What does it mean, to you, to be
successful in Patient
Experience?
1, 3 Organizational
Culture and
Individual and
Organizational
Performance
5 How would you describe the
culture of this VHA facility
when it comes to PX?
Are leaders
supportive of
sensitivity to
operations,
preoccupation
with failure,
reluctance to
simplify, commit
to resilience, and
deference to
expertise?
1 Organizational
Culture
6 As a core HRO activity, does
executive leadership ever round
in your area?
Do you ever get
face time with
executive
2 Executive
Leaders
129

leaders? OR Are
leaders visible
and active?
7 What does communication look
like between executives and
frontline providers?
1, 2 Organizational
Culture and
Executive
Leaders
8 In which three ways do you
prefer to receive information
from Executive Leaders at work?
1, 2 Organizational
Culture and
Executive
Leaders
9 Could you give an example of
how executive leaders allow for
bi-directional communication?
If so, how do you
give feedback?
Do you have
recommendations
on how to do this
more effectively?
1, 2 Organizational
Culture and
Executive
Leaders
10 To what degree do you feel
Executive Leadership acts in a
way to create a psychologically
safe environment?
Do you have an
example you can
share?
1, 2 Organizational
Culture and
Executive
Leaders
11 Do you feel leadership
encourages and supports you to
find better ways of doing things?
1, 3 Organizational
Culture and
Executive
Leaders
12 What do you need from
Executive Leadership to be
successful in PX initiatives?
1, 2, 3 Organizational
Culture,
Executive
Leaders, and
Individual and
Organizational
Performance

Abstract (if available)

Abstract Negative patient experience (PX) in primary care clinical settings can greatly diminish quality health outcomes for patients (Alaloul et al., 2019; Doyle et al., 2013; Moreno et al., 2021; Price et al., 2014). This qualitative study is supported by a conceptual framework informed by the Burke-Litwin causal model of organizational change and performance (2018) and the Veterans Health Administration (VHA) high-reliability organizational (HRO) framework (Vaezie, 2019). Primary care providers (PCPs) at seven VHA level 1 sites of care were interviewed to learn about their experiences and perceptions of executive leaders’ behaviors and organizational culture and how these factors impact their PX efforts. Preliminary findings indicate numerous operational, cultural, and executive leadership issues that PCPs feel limit their medical practice. Participants exposed concerns about (a) executive leaders’ perceived lack of commitment to leadership and HRO leadership behaviors (bi-directional communication, purposeful rounding, and creating psychologically safe work environments); (b) poor or even harmful experiences with organizational culture and the subsequent negative impacts on the culture of safety and continuous process improvement; and (c) how those perceptions and experiences negatively influence both individual and organizational performance in the participating VHA sites. Recommendations to practice are discussed.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Primary care physicians' experiences working within the patient-portal to improve the quality of patient care

PDF

The attrition and lack of medical follow-up of patients in research in a primary care setting: a gap analysis

PDF

Health care disparities and the influence of nurse leader cultural competency: an evaluation study

PDF

Enhancing transfer of harassment prevention training into practice

PDF

Disclosure of abuse to empowerment: exploring psychological safety as a leadership tool to support women struggling with workplace performance

PDF

Evaluating emergency nurse leader capacity to reduce first-year employee turnover

PDF

We sant you! Kind of: Exploring the experiences of women pastors/leaders in Christian churches

PDF

The integration of medicine and compassionate care: an evaluation study

PDF

Close the health gap: improving patient access to psychiatric treatment through primary care and telepsychiatry integration

PDF

The bi-directional impact of work-family conflict and family-work conflict on entrepreneurs, executives and organizations in high stress careers

PDF

Knowledge, motivation, and organizational influences impacting senior living performance goals to reduce antipsychotics: an innovation study

PDF

Physician burnout in the COVID-19 pandemic: Healthcare organization and leadership implications for patient care and clinical team leadership with nurses

PDF

Addressing service recovery with radiation oncology frontline managers to improve the patient experience: an evaluation study

PDF

Inclusionary practices of leaders in a biotechnology company: a gap analysis innovation study

PDF

Disability, race, and educational attainment - (re)leveling the playing field through best disability counseling practices in higher education: an executive dissertation

PDF

Chameleons and kungas: the perceptions and experiences of military veteran faculty members in their transitions to academic service

PDF

A tale of two principals: the complexity of fostering and achieving organizational improvement

PDF

Emotional intelligence self-perceptions in non-clinical leaders: an examination into a healthcare organization

PDF

Understanding the quality of geriatric healthcare and family caregiver advocacy for patients with dementia

PDF

Understanding teacher leadership styles in relation to student outcomes

Asset Metadata

Creator Jennings, Tiffany Christine (author)

Core Title Barriers to practice: primary care patient experience and quality health outcomes in the Veterans Health Administration

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-08

Publication Date 07/21/2023

Defense Date 07/21/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag executive leaders,HRO,individual performance,OAI-PMH Harvest,organizational culture,organizational performance,patient experience,patient outcomes,primary care,quality care,Veterans Affairs,Veterans Health Administration

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Kellar-Martinez, Frances (committee member), Phillips, Jennifer (committee member)

Creator Email drtiffanycjennings@gmail.com,tcjennin@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113282119

Unique identifier UC113282119

Identifier etd-JenningsTi-12133.pdf (filename)

Legacy Identifier etd-JenningsTi-12133

Document Type Dissertation

Format theses (aat)

Rights Jennings, Tiffany Christine

Internet Media Type application/pdf

Type texts

Source 20230721-usctheses-batch-1072 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu