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Addressing service recovery with radiation oncology frontline managers to improve the patient experience: an evaluation study
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Addressing service recovery with radiation oncology frontline managers to improve the patient experience: an evaluation study
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Running head: SERVICE RECOVERY AND THE PATIENT EXPERIENCE 1
ADDRESSING SERVICE RECOVERY WITH RADIATION ONCOLOGY FRONTLINE
MANAGERS TO IMPROVE THE PATIENT EXPERIENCE: AN EVALUATION STUDY
by
Charles M. Washington
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
December 2019
Copyright 2019 Charles M. Washington
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 2
DEDICATION
Family is one of nature’s greatest masterpieces…I am blessed to have my family to love
and inspire me. This work is dedicated to my family who continue to support me during this
doctoral journey. To my life partner, Debra, what can I say except I love you and thank you for
your undying support. Words alone cannot express how much I appreciate your love, kindness,
support, and encouragement. There have been times when I didn’t know if I would survive this
process; you have been my rock and I love you with all my heart. To my sister Frances, you are
an important part of any legacy that I hope to have. Your brilliance, tenacity, and perseverance
are inspiring and reminds me that being steadfast in your convictions will ultimately yield the
desired fruits of our labor. I love you more than you can know, and I always will. To my
daughter, Brittany, you are the love of my life and you inspire me through your quiet
determination and conviction to harmony. You provide me with the reminder that balance is
essential to a quality live. To my grandson, Sebastian, my mini-me, you are the future. I hope to
emulate your sense of wonder and openness to life’s teachings.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 3
ACKNOWLEDGEMENTS
First, I give thanks to God for providing me the strength, tenacity, and perseverance that I
needed to make this journey. Any honor or accolades offered belong to him. I am humbled just
by being his child.
Our life lessons come from the journey, not from reaching the destination. I would like
to thank my dissertation team for their ongoing support, insight, challenge, and encouragement
rendered during this doctoral journey. To Dr. Tobey, thank you for your calm guidance and
patience with me as I struggled to balance work, school, and life obligations. Your expression of
confidence in me and your genuine excitement when I reached those “aha” moments were
priceless. To Dr. Malloy, when I needed someone to connect with as I formulated and
reformulated by writing to ensure that my expressions were not mired down, you helped me
“show” my audience my excitement as opposed to just “telling” them. To Dr. Robles, I thank
you for challenging me to be my best writer, my best researcher, and my best conveyor of
academic support to my peers. Collectively, you all steered me toward the illumination that
guided my doctoral pathway. While I learned so much from each of my USC instructors, you
were the beacon that shepherded me in my process. I cannot thank you and acknowledge your
impact enough.
I have a special place in my heart for all the members of Cohort 8. We weathered the
storm of anxiety, frustration, and pressure as well as rode the wave of enlightenment, potential
realization, and success. The saying “Iron sharpens iron” reflects my thoughts on how our
engagement added value to the educational process; I learned from each one of you and I believe
that your insight and compassionate critique helped make me a better researcher and student of
life. While the entirety of Cohort 8 is valued, I must offer a special acknowledgement to my two
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 4
fraternity brothers that shared this journey with me. Marlon Gray and Mario McCoy, our
support for each other is grounded in our fraternal bonds and I can honestly say that leveraging
our shared philosophies, fraternal experiences, and commitment to scholarship kept me focused
and motivated. I would share with you that which others may not understand…”‘06, good
brothers, onward and upward.”
We do not make our life journeys alone. I would like to acknowledge my study support
team that assisted me in my doctoral journey. Katie Lynch and Stephanie Benvengo offered
support in collecting my data and challenging me in formulating my understanding of it as it
pertained to my problem of practice. As quality assessment experts, their insight and guidance
helped steer me towards several important “aha” moments during the process. Without their
participation, this study would have progressed on a much longer path to understanding. To the
two of you, your contribution has been noted and fully appreciated.
As I further reflect on this journey, I must acknowledge my college professors in
radiation therapy technology that inspired me as much after receiving my bachelor’s degree as
when I was in the professional program at Wayne State University in Detroit. Diane Chadwell
and Adam Kempa, you are my academic rocks. Diane, you always encouraged me to do my best
and believed in me, from when I did my initial class presentation and completed it to your
expectation (albeit dripping in nervous sweat) to when you sponsored me to become a Fellow of
the American Society of Radiologic Technologists (the highest professional honor one can obtain
in our field). Adam, thank you for challenging me to continue to reach for the stars. It was you
that congratulated me when I achieved my MBA and in the same breath, told me that I needed to
press on toward my doctoral degree. You instilled in me the spark for education and inspired me
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 5
to emulate those values. I cannot thank you both enough for assisting me develop my
appreciation for my profession and the patients that we serve.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 6
TABLE OF CONTENTS
Dedication 2
Acknowledgements 3
List of Tables 9
List of Figures 11
Abstract 12
Chapter One: Introduction to the Problem of Practice 13
Importance of Addressing the Problem 13
Organizational Context and Mission 15
Organizational Performance Status 16
Organizational Performance Goal 17
Description of Stakeholder Groups 18
Stakeholder Group Performance Goal 19
Stakeholder Group for the Study 20
Stakeholder Performance Goals 20
Purpose of the Project 21
Project Research Questions 21
Conceptual and Methodological Framework 22
Definitions 24
Organization of the Project 25
Chapter Two: Review of the Literature 27
General Review of the Literature: Influences on the Problem of Practice 27
Influence 1: Patient Satisfaction in Healthcare Delivery 27
Influence 2: Measurement and Assessment of Patient Satisfaction in Healthcare 30
Influence 3: The Radiation Therapist and Manager Role in Patient Satisfaction 31
Clark and Estes’ Gap Analysis Conceptual Framework 32
Knowledge and Skills Influences 34
Motivation Influences 38
Organizational Influences 43
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context 48
The Relationships Among Knowledge, Motivation, and Organizational Influencers 49
Conclusion 53
Chapter Three: Methodology 54
Research Questions 54
Study Participants 55
Overview of Data Capture Choices 56
Research Design and Methods 57
Tool Assessment by an Expert Review Panel 59
Timeline and Plan 60
Quantitative Methods 61
Secondary Data Collection 61
Secondary Data Sampling Criteria and Rationale 62
Secondary Data Instrumentation 63
Analysis of Secondary Data 64
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 7
Frontline Management Team Surveys 65
Survey Instrument 67
Survey Collection Procedures 67
Survey Analysis 68
Quantitative Reliability and Validity 69
Qualitative Methods 72
Interview Participant Selection 72
Interview Instrument 74
Content Collection for Interviews 75
Analysis of Interview Content 77
Document and Artifact Sampling Strategy and Rationale 78
Document and Artifact Sampling Criteria and Rationale 80
Documents and Artifacts Reviewed 81
Content Collection for Document and Artifact Review 81
Analysis of Documents and Artifacts 81
Credibility and Trustworthiness 82
Ethics 83
Limitations and Delimitations 85
Conclusion 87
Chapter Four: Results and Findings 88
Data Source Collection Overview 89
Participating Stakeholders 90
Survey Participants 90
Interview Participants 91
Results for Research Question One 92
Secondary Data Results and Findings 92
Results for Research Questions Two And Three 95
Frontline Manager Survey Results and Findings 95
Document and Artifact Results and Findings 96
Interview Results and Findings 99
Knowledge, Motivation, and Organizational Results and Findings 101
Knowledge Results and Findings for Research Questions Two and Three 102
Synthesis of Results and Findings for Knowledge Influences 110
Motivation Results and Findings for Research Questions Two and Three 111
Synthesis of Results and Findings for Motivation Influences 118
Organizational Results and Findings for Research Questions Two and Three 118
Synthesis of Organizational Results and Findings 129
Application of Findings to Research Question Two 130
Application of Findings to Research Question Three 131
Summary of Validated Influences 131
Conclusion 132
Chapter Five: Recommendations for Practice to Address KMO Influences 134
Knowledge Recommendations 134
Knowledge and Skill Solutions 135
Motivation Recommendations 137
Motivation Solutions 139
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 8
Organizational Recommendations 141
Organizational Solutions 143
Integrated Implementation and Evaluation Framework and Plan 146
Organizational Purpose Need and Expectations 147
Level 4: Results and Leading Indicators 147
Level 3: Behavior 149
Level 2: Learning 152
Level 1: Reaction 158
Evaluation Tools 159
Data Analysis and Reporting 162
Summary 166
Strength and Weaknesses of the Research Approach 168
Limitations and Delimitations 170
Future Research 171
Conclusion 173
References 177
Appendix A: Dissertation-Specific Survey Questions and Categorizations 197
Appendix B: Interview Protocol and Procedures 203
Appendix C: Document and Artifact Review Form 208
Appendix D: Frontline Manager Survey Results and Findings 209
Appendix E: Document and Artifact Codebook 210
Appendix F: Sample Post-Training Survey Items Measuring Kirkpatrick Levels 1 and 2 215
Appendix G: Frontline Manager Interview Domains, Codes, Descriptions, and Frequencies 217
Appendix H: Sample Blended Evaluation Items Measuring Kirkpatrick Levels 1–4 218
Appendix I: Example of Metric Reporting of Level 3 Behavioral Data 221
Appendix J: Mock-Up of Infographic for Formative Level 1 & 2 Data 222
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 9
LIST OF TABLES
Table 1: Organizational Mission, Global Goal, and Stakeholder Performance Goal 21
Table 2: Knowledge, Influence, Type, and Assessment 38
Table 3: Motivational Influences and Assessment 43
Table 4: Organizational Influences and Assessment 47
Table 5: Study Research Questions, Advantages and Disadvantages 59
Table 6: Expert Review Team, Area of Expertise, and Rationale for Inclusion 60
Table 7: Sampling Strategy and Timeline 61
Table 8: Q-Review Patient Experience Survey Questions 64
Table 9: Data Arms, Targeted Instances, Assessed Instances, and Percentage Completed 89
Table 10: Frontline Manager Years of Experience, by Count and Percentage (n = 12) 91
Table 11: Frontline Manager Interview Participants (n=11) 92
Table 12: Statistical Assessment of Frontline Manager Adherence to 24-Hour Timing 93
Table 13: Document and Artifacts Codes, Frequencies, and Themes 97
Table 14: Document and Artifacts Basic to Organizing to Global Themes 98
Table 15: Frontline Manager Interview Overall Results and Findings 99
Table 16: Summary of Findings for Knowledge, Motivation, and Organizational Influences 132
Table 17: Summary of Knowledge Influences and Recommendations 135
Table 18: Summary of Motivation Influences and Recommendations 138
Table 19: Summary of Organizational Influences and Recommendations 142
Table 20: Outcomes, Metrics, and Methods of External and Internal Outcomes 148
Table 21: Critical Behaviors, Metrics, Methods, and Timing for Each Outcome 149
Table 22: Required Drivers to Support Critical Behaviors 150
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 10
Table 23: Components of Learning for the Program 156
Table 24: Components to Measure Reactions to the Program 159
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 11
LIST OF FIGURES
Figure 1: E4C’s Press Ganey patient satisfaction scores, 2008 – 2018. 17
Figure 2: Conceptual framework – KMO influences on service recovery. 52
Figure 3: Frontline manager years employed in current position. 91
Figure 4: Service recovery adherence over various timelines. 94
Figure 5: Distribution of document and artifact categories. 96
Figure 6: E4C service recovery compliance. 165
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 12
ABSTRACT
The subject of providing service recovery in radiation oncology has not been researched at
length. At present, the relationships among patient satisfaction, care compliance, and treatment
outcomes suggest patients who report dissatisfaction with their care perceive receipt of
suboptimal care. Patient satisfaction also plays a role in defining the quality of care received,
potentially affecting institutional reimbursement and reputation capital. This study explored
frontline management’s role in effective service recovery, the process of actively addressing
identified instances of patient dissatisfaction directly to improve the overall patient experience
through patient engagement and finding solutions to challenges early using an explanatory
sequential mixed methodology approach. Secondary data conveying patient perceptions of care,
survey of frontline managers to quantify the knowledge, motivation, and organization influencers
on intervention protocols, review of service recovery documents and artifacts, and probing
interviews triangulate the problem of practice and offers insights and solutions for consideration.
This dissertation broadly examines patient and institutional benefits of proactively addressing
patient engagement and solution-finding through service recovery, converting poor perceptions
of quality of care toward an appreciative engagement between radiation patients/consumers and
care providers.
Keywords: Patient satisfaction, patient experience, service recovery, radiation oncology
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 13
CHAPTER ONE: INTRODUCTION TO THE PROBLEM OF PRACTICE
While healthcare outcomes historically focused on disease and its more severe
consequences of disability and death, patient satisfaction emerged as an important measure of the
quality of healthcare delivery (Jackson & Kroenke, 1997; Oppel, Winter, & Schreyögg, 2017).
The direct link between patient satisfaction and treatment outcomes suggests patients reporting
dissatisfaction are more likely to perceive receipt of suboptimal disease management (Gesell &
Gregory, 2004; Halkett et al., 2010; Massagli & Carline, 2007). In an increasingly competitive
healthcare market, patient satisfaction plays a role in determining a hospital’s competitive
position and survival (Oppel et al., 2017). Furthermore, satisfied patients are more likely to
return to a hospital and to engage in positive word of mouth (Bowers, Swan, & Koehler, 1994;
Oppel et al., 2017).
Famiglietti, Neal, Edwards, Allen, and Buchholz (2013) reported on the link between
patient satisfaction assessments and service reimbursement for providers. Management’s
investment in service recovery, the process of addressing dissatisfaction to improve the patient
experience offers opportunity to positively impact patient perception of satisfaction (Hayden,
Pichert, Fawcett, Moore, & Hickson, 2010). As part of cancer management, radiation oncology
practice concerns itself with patients’ perceptions of the service it provides. As such, identifying
appropriate methods to address patient dissatisfaction through service recovery may salvage the
experience, potentially leading to a shift in satisfaction assessment (Hayden et al., 2010;
Schweikhart, Strasser, & Kennedy, 1993).
Importance of Addressing the Problem
It is important to solve the problem of poor patient satisfaction scores for three primary
reasons. First, the Centers for Medicare and Medicaid Services (CMS) links reimbursement of
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 14
service cost to facility performance on patient satisfaction assessments (Mohammed et al., 2016).
The CMS’s involvement in assessing healthcare standards is necessary, as Mohammed et al.
(2016) noted patient experience accounts for 30% of the total score that determines hospital
reimbursement. The authors surmised that lost revenue, potentially between $500,000 to
$850,000 annually per hospital, and associated derogatory reporting affect service provision and
erodes reputation capital (Buhlman & Matthes, 2011). That risk can be turned into reward, as
Press Ganey reports a hospital with $120 million annual revenues can improve patient
satisfaction and realize an estimated $2.2 million to $5.4 million in additional revenue annually
(Hall, 2008).
Second, based on the belief that hospital accreditation establishes standards that improve
the quality of patient care (Shaw & Collins, 1995), Sack et al. (2011) reported attaining
accreditation through The Joint Commission and other accreditation providers may be an
indicator of quality practice. Sack et al. (2011) reported that those that do not attain accreditation
may be unwilling to submit to assessment against standards. Third, not having this accreditation
can lead to a competitive disadvantage in the healthcare market. Because of this, the value of
investing in the attainment of improved patient satisfaction scores requires consideration. By not
improving patient satisfaction, the East Coast Comprehensive Cancer Center (E4C) risks erosion
of its reputation, reduced service reimbursement, and increased perception as a provider of poor
service quality. This researcher contends that introduction of service recovery practices offers
enhanced patient engagement to address areas of concern and provide a platform for experience
reconsideration (Hayden et al., 2010; Schweikhart et al., 1993).
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 15
Organizational Context and Mission
E4C is the world’s oldest and largest private cancer-focused care center and has provided
more than 134 years of patient care and innovative research, offering significant contributions to
understand better, diagnose, and treat cancer of all kinds. With the main campus in Gotham,
New York, and six satellite campuses in suburban Gotham and New Jersey, E4C represents one
of only 47 institutions in the United States designated a Comprehensive Cancer Center by the
National Cancer Institute. The E4C strives to provide leadership in the prevention, treatment,
and cure of cancer through excellence, vision and cost-effectiveness in patient care, outreach
programs, research, and education. In support of the mission, E4C employed 15,700 researchers,
hospital attending staff, administrative and support staff, allied health providers, and volunteers
in 2016. There were also 1,734 residents and clinical fellows. The institution differentiates itself
through innovative collaborations with IBM Watson, Quest Diagnostics, and the E4C Cancer
Alliance as well as an array of community outreach initiatives contributing to improved quality
of cancer care.
The primary role of all employees at E4C derives from the mission statement: to provide
the best care for all patients through excellent care, innovation, research, and education. The
radiation oncology practice at E4C is an integral part of the cancer management program with
over 50% of patients receiving ionizing radiation during their disease management (Faithfull,
Meyer, Huddart, & Dearnaley, 2001). The radiation oncology patient throughput eclipsed 9,000
distinct new patient starts, encompassing over 137,500 individual treatment visits and 540 daily
treatment visits at six campuses in 2017. The department employs physicians, advanced practice
providers, and frontline practitioners (radiation therapists, nurses, and patient service
representatives). The frontline practitioners account for over 60% of employees. The radiation
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 16
therapists engage the patient population more than any other frontline practitioner. Because of
this, the impact of their patient engagement activity affects operational success.
Organizational Performance Status
The organizational performance problem at the core of this study is departmental
underperformance on patient satisfaction scores. Radiation oncology’s goal is to implement
strategies to improve patient satisfaction scores by the end of July 2019. A goal in the
management of patient satisfaction is the implementation of a service recovery strategy that
addresses patient dissatisfaction wholly and swiftly. The thought is that active resolution will
demonstrate concern for quality patient care and focus on patient needs and expectations. The
department’s executive leadership established the goal of improving patient satisfaction scores
after continued low-percentile patient satisfaction scores as assessed by the Press Ganey Patient
Satisfaction Survey (PGPSS).
The PGPSS is an industry-leading, benchmarked tool using system level, practitioner
level, and cultural analyses to highlight patient-reported areas of deficiency in about 40% of all
healthcare institutions in the United States. The findings are typically used to help target patient
satisfaction improvement efforts (Ryan, Specht, Smith, & DelGaudio, 2016). Figure 1 depicts
E4C’s overall mean PGPSS scores compared to the mean of three comparative groups: all
facilities (average of all facilitates that have taken the PGPSS), the Consortium of
Comprehensive Cancer Centers for Quality Improvement (a peer group of recognized National
Cancer Institutions focused on quality care), and the Council of Teaching Hospitals (a peer
group of over 400 member teaching hospitals dedicated to quality care). Low scores persist
despite maintaining outstanding patient care outcomes, decreasing morbidity, and expansion of
services. By offering three different benchmarked groups to compare patient satisfaction
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 17
performance, performance comparison opportunities emerge to show that, albeit trending
upward, performance lags across comparative groups.
Figure 1. E4C’s Press Ganey patient satisfaction scores, 2008 – 2018.
The radiation oncology PGPSS questions assess patient wait times, explanation of what
to expect during care, staff concern for comfort, staff courtesy, description of side effects
explained, and overall departmental satisfaction (Press Ganey, 2015). Overall, the scores can be
insightful in the areas that impact patient satisfaction. Increasing departmental patient
satisfaction scores preserves reputation capital as well as financial viability. Patient satisfaction
plays a central role in the assessment of care delivery and links governmental reimbursement of
service cost to institutional patient satisfaction performance. Lastly, improving these scores
shows commitment to quality care. Bridging this gap underscores the drive for improvement.
Organizational Performance Goal
Directly tied to the mission statement and pertinent to the problem of practice of poor
patient satisfaction scores, institutional executive leadership established as one of the
overarching institutional goals for 2019 to deliver the ideal end-to-end experience to every
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 18
patient and family, every time, through a culture of innovation, collaboration, and continuous
improvement. This places an expectation on the management team of ensuring compliance to
practice standards and attention to the overall patient experience. While still in development for
2018, departmental leadership embraces the following performance goals: (a) by the end of the
2019 fiscal year, establish a strategy for the delivery of a quality patient experience across the
continuum of care at E4C, and (b) by the end of the 2019 fiscal year, establish metrics that
provide value-added reporting and demonstrate that E4C uses patient experience feedback to
improve care. These performance goals direct the focus of this study. A more focused goal of
addressing patient satisfaction through service recovery efforts provides an opportunity for
interventions to directly address the concern via deeper engagement and greater patient focus.
Description of Stakeholder Groups
In the delivery of care, each member of the radiation oncology team offers necessary
service and perspectives. While the physician provides the intellectual development of the
patient treatment plan, an important group to consider is the frontline management team.
Administration and management have the responsibility of operational and care standards,
maintenance of regulatory concerns, and the development of an attentive and competent staff.
The interface between radiation therapists, nurses, and patient service representatives and
patients occur more often than patients’ interaction with their physicians. Radiation therapists
deliver direct care to the patients as prescribed by the physicians, using both technical and
psychosocial skills in the delivery of care. Accurate and compassionate care focused on the
person and not the disease improves patient satisfaction.
Similarly, nurses offer weekly direct support and symptom care, including therapeutic
listening and personalizing their interactions. Lastly, the patient service representatives serve as
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 19
the department’s face in greeting, escorting, and scheduling patient activity. They facilitate
patient flow through the department and ensure open communication between practitioner and
patient. All noted aspects affect overall positive patient engagement which leads to positive
perceptions of care and ultimate achievement of the department performance goal. The team
operates in a matrixed service environment.
Ginter, Duncan, and Swayne (2018) contended a matrix-management structure is
appropriate when organizations have numerous projects that draw on common functional
expertise toward goal attainment, organizing around challenges to be solved collectively.
Further, study participants’ familiarity with departmental procedures, patient experience and
service recovery initiatives as well as their involvement in development of practice standards
provide a common platform of expectations across disciplines. Brady and Cronin (2001)
suggested care quality enhancement results from the comparison of perceived and expected
performance. With E4C’s high volume of interactive engagement, there is opportunity to study
the effectiveness of the frontline management team in driving the both care and a quality patient
experience.
Stakeholder Group Performance Goal
The radiation oncology department seeks patient satisfaction score improvement by the
end of Q4 2019. The department’s low-percentile patient satisfaction scores persist despite
positive patient care outcomes. The PGPSS was used to measure improvement in the patient
satisfaction experience on a quarterly basis through December 2019. With the healthcare
industry placing greater emphasis on public reporting of quality and safety data that ties to
reimbursement, the E4C radiation oncology department must ensure discipline and rigor
regarding outcomes and performance. Efforts to improve patient satisfaction scores speak to a
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 20
commitment to patient care, which manifests through action-oriented programming for the
stakeholder of interest in this study.
Stakeholder Group for the Study
The collective effort of all departmental stakeholders is required to attain the
departmental goal of improving patient satisfaction scores by the end of Q4 2019. The means to
this end comes through investment in greater patient engagement and direct problem-solving
through service recovery interventions. Therefore, the stakeholders of focus were the frontline
management team who ensures compliance with care standards and actions that affect patient
satisfaction. Supported by leadership, the department established the expectation that the
management will work to improve patient satisfaction scores by the end of Q4 2019 through an
appropriate management tool, inclusive of service recovery. Compliance with activities like
effective patient scheduling, timely delivery of scheduled care, effective communication of
expectations before and during care, invoking a remedial action for identified poor service
delivery and a caring demeanor affect the patient’s feelings of quality engagement. Failure to
consistently deliver in these areas negatively affects patient satisfaction. Poor patient interaction
limits the provision of positive patient experiences, leading to failure in meeting the overall goal
of improved patient satisfaction.
Stakeholder Performance Goals
While distinct from measurable targets, organizational goals outline the desired
organizational outcomes used to guide stakeholder action and appraise organizational
performance (Kotlar, De Massis, Wright, & Frattini, 2018; March & Simon, 1958; Mohr, 1973).
As such, stakeholder goals need to align with institutional direction. Table 1 outlines E4C’s
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 21
organizational mission, global goal, and associated stakeholder performance goals designed to
meet those outcomes.
Table 1
Organizational Mission, Global Goal, and Stakeholder Performance Goal
Organizational Mission
The E4C mission strives to provide leadership in the prevention, treatment, and cure of cancer through
excellence, vision and cost-effectiveness in patient care, outreach programs, research, and education.
Organizational Performance Goal
Implement a data-driven strategy, supported by value-added metrics and reporting, to improve patient
satisfaction scores by the end of Q4 2019
Department of Radiation
Oncology
Department Executive
Leadership
Frontline Management
Team
By April 2018, the
Department of Radiation
Oncology will report and
assess departmental
patient satisfaction
baseline scores.
By July 2018,
department leadership
will develop metrics and
an action plan to
improve departmental
patient satisfaction
scores.
By December 2019,
Frontline management
team will provide 100% of
service recovery for scores
below the self-reported
score of “3” within 24
hours of receipt.
Purpose of the Project
The purpose of this project is to conduct a gap analysis to evaluate the effectiveness of
frontline management staff members’ service recovery practices. This research explored the
quality of interventions designed to enhance patient experiences. While a thorough gap analysis
would touch on all department of radiation oncology stakeholders, this analysis specifically
focused on frontline management knowledge and skills, motivation, and organizational
influences relating to service recovery. The analysis begins by identifying a list of potential or
assumed factors that methodically ferreted out actual causes.
Project Research Questions
This explanatory sequential mixed-methods study aligns with the following research
questions (RQ) that address knowledge and skills, motivation, and organization influences of the
management team captured from surveyed and interviewed stakeholders:
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 22
1. To what degree is E4C’s radiation oncology department meeting its goal of providing
100% of service recovery for Q-Review
®
scores below the self-reported score of “3”
within 24 hours of receipt by Q4 2019? (RQ1)
2. What are the frontline manager’s knowledge, motivation and E4C’s radiation oncology
department influences related to achieving its goal of providing 100% of service recovery
for Q-Review
®
scores below the self-reported score of “3” within 24 hours of receipt by
Q4 2019? (RQ2)
3. What are the recommendations for organizational practice in the frontline manager’s
knowledge, motivation, and organizational resources related to achieving its goal of
providing 100% of service recovery for Q-Review
®
scores below the self-reported score
of “3” within 24 hours of receipt by Q4 2019? (RQ3)
Conceptual and Methodological Framework
The methodological approach and rationale used in a mixed-methods investigation
support comprehensive understanding about a research problem where the quantitative or
qualitative approach, by itself, is inadequate (Creswell, Klassen, Plano Clark, & Smith, 2011).
The explanatory sequential mixed methodology approach used in this study employs two distinct
components of assessment; a thorough quantitative sampling that numerically defines aspects of
practice followed by a purposeful qualitative assessment that deepens understanding, offer a
complete understanding of the study phenomenon (Abro, Khurshid, & Aamir, 2015; Creswell &
Creswell, 2018; Denzin, 2017). The design of a single study that offers both quantitative and
qualitative rigor offers greater control of methodological deficiencies or biases inherent in a
single method (Abro et al., 2015; Creswell & Creswell, 2018). Illuminating this point, Abro et
al. (2015) stated,
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 23
each method has its own weakness or disadvantage, for instance, a quantitative research
method may be unable to capture the inner meaning of the research problem, whilst a
qualitative method may miss the importance of the objective issues that have influences
on the final results of the study. (p. 104)
This study reviews the relationship between E4C’s service recovery efforts and patient
care experience. The assessment of this how question requires numerical data to support a
hypothesis-confirming statistical analysis. Quantitative analysis allows examination of the
relationship between differing variables by executing a fixed plan that does not evolve beyond its
design (Creswell & Creswell, 2018; Locke, Silverman, & Spirduso, 2016), and uses descriptive
questions to assess performance compliance with a standard to express cause and effect
relationships useful in predictive modeling. Creswell and Creswell (2018) noted descriptive
questions often uncover numeric relationships used to test hypotheses. While this rationale
justifies a quantitative methodology, the study requires a more in-depth assessment of service
recovery practice on patient perspective and meaning, lending itself to a qualitative evaluation.
Qualitative research offers greater depth and detail and centers on how people derive
meaning from their experiences (Stuckey, 2013). Understanding how frontline managers
perceive and practice service recovery requires unraveling patients’ personal perspective, and
Merriam and Tisdell (2016) noted assessing patient perspective through interviews using open-
ended questions assists in predicting similar future occurrences. This approach, where
researchers describe personal experiences regarding a phenomenon, is classified as
phenomenological research (Creswell & Creswell, 2018). The qualitative assessment of patient
value offers deeper research question meaning, demonstrating the value of a mixed-methods
approach.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 24
Creswell and Creswell (2018) indicated melding quantitative and qualitative disciplines
in one study provides greater breadth and depth of assessment. Mixed methodology justifies its
value compared to purely quantitative or qualitative research by increased confidence in results
through greater data integration and cultivating future studies (McKim, 2017). This research
sequenced quantitative data leading to a deductive evaluation of compliance followed by an
assessment of qualitative information via patient interpretive interviews. The design, described
as explanatory sequential mixed methodology, draws from quantitative and qualitative
assumptions that promote the use of varying methods, data collection, and analysis (Creswell &
Creswell, 2018).
While a mixed methodology reviews multiple data sets that may increase study time,
cost, and complexity of outcomes and findings synthesis, this study’s compound problem of
practice lends itself to this methodology by offering compliance outcomes, appreciation of
patient perspective, and problem understanding. Through this rigor, once concealed questions
and options emerge.
Definitions
Throughout this dissertation, critical terms and concepts important to the conceptual
understanding of the study emerged. This section provides definitions to promote a common
understanding of key concepts used throughout the work.
Patient experience: the sum of all interactions, shaped by an organization’s culture and
the engagement systems it sustains, that influence patient perceptions, across the continuum of
care (Wolf, 2017).
Patient health information: data related to a person’s medical history, including
symptoms, diagnoses, procedures, and outcomes. Health information records include patient
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 25
histories, lab results, x-rays, clinical information, and are protected for use solely for the
management of the patient’s care.
Patient satisfaction: the patient’s individual assessment and rating of the attributes of
both processes and outcomes of their treatment experience initially shaped by their expectations
(Quigley et al., 2018; Revicki, 2004; Weaver et al., 1997).
Radiation oncology: the medical discipline that utilizes ionizing radiation (x-rays, gamma
ray, electrons, and particles) to treat cancer and associated non-malignant diseases. The goal is
to cure or control the diseases while limiting complications to normal structures through
individualized treatment planning (Kutcher et al., 1994).
Service recovery: part of an organization’s quality management program designed to
facilitate resolution of consumer/patient dissatisfaction and negative perceptions, an effort to
maintain a positive relationship (Hayden et al., 2010; Schweikhart et al., 1993).
Organization of the Project
This dissertation has five distinct chapters. This chapter provided the key concepts and
terminology used in the discussion on the influence of patient experience on perceptions of
patient satisfaction supported by the importance of service recovery to address patient
dissatisfaction. This chapter also outlined the organization’s mission, goals, and stakeholders
while providing a review of the evaluation framework. Chapter Two provides a comprehensive
review of the current literature on the scope of the study. The chapter examines the relationships
among measured satisfaction, financial service reimbursement, and institution reputation capital.
The chapter looks at the role of frontline radiation therapy management in patient engagement
practice as expressed through an overview of the knowledge, motivation, and organizational
framework used in the study. Chapter Three details the specific knowledge motivation, and
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 26
organizational influences examined as well as the methodology used in selecting participants and
methods for both data collection and analysis. Chapter Four offers a discussion of the data
collected, inclusive of data assessment and analysis. Lastly, Chapter Five provides
recommendations for practice, based on what the data and literature showed, to close the gaps
between expected and actual patient care practices.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 27
CHAPTER TWO: REVIEW OF THE LITERATURE
This literature review examines the core challenges and gaps in obtaining optimal patient
satisfaction scores as an indicator of radiation therapy care delivery. The review starts with
generalized research on the impact of patient perception of care quality and treatment outcomes.
An overview of the literature on the relationship between measured satisfaction, financial service
reimbursement, and institution reputation capital follows. Next, the chapter reviews the role of
frontline radiation therapy practitioner management in patient engagement practices expressed
through an overview of the knowledge, motivation, and organizational framework used in the
study. This transitions into an in-depth exploration of specific frontline practitioner management
knowledge, motivation, and organization (KMO) gaps conceptualized by Clark and Estes (2008).
First, the review examines the factual, conceptual, and procedural knowledge influences
pertinent to engagement practices that affect patients’ perception of satisfaction. A review of
goal orientation and interest motivation influences presents the challenges for the stakeholder
group. Organizational cultural model influences and cultural setting influences offer points to
consider in understanding management engagement.
General Review of the Literature: Influences on the Problem of Practice
Review of the literature identifies several influences on the attainment of positive patient
experience and self-reported satisfaction. Management influences on the environment create the
stage for staff practice and goal attainment. The following perspectives directly affect patient
outcomes.
Influence 1: Patient Satisfaction in Healthcare Delivery
Framing the role of patient satisfaction in healthcare. The evolution of patient
satisfaction is a central area of assessment of patient perception of their disease care experience.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 28
In today’s health practice arena, managing patient treatment perspectives plays a prominent role
in the evaluation of their self-reported experiences, with these subjective appraisals viewed as
valuable health outcomes (Boquiren, Hack, Beaver, & Williamson, 2015; Kravitz, 1998; Pascoe,
1983). As self-reported questionnaires to assess patient satisfaction have proliferated, healthcare
providers now demand information about patient satisfaction. This information has a role in
evaluating primary health care and in explaining patients’ health-related behavior. Directly
asking patients is the only way to determine what patients want and if their needs are being met
(Boquiren et al., 2015; Kravitz, 1998). Pascoe (1983) described expectancy approaches as the
major models used to conceptualize patient satisfaction: contrast (adaptation to stimuli
judgment), assimilation (inconsistencies between expectation and performance), and
assimilation-contrast (expectations of standard attainment but there is latitude in acceptance of
the standard). These practitioner experiences foster care delivery as well as management
effectiveness in shaping outcomes. As such, Boquiren et al. (2015) postulated patient
satisfaction indicates the efficacy, caliber, and quality of healthcare services. Furthermore, a
satisfied patient participates more carefully and accurately in his/her care and achieves better
outcomes (Pascoe, 1983). With the importance of patient experience, standardization of results
poses challenges.
While patient satisfaction is an indicator of the quality of healthcare systems, questions of
measurement standardization challenge the reliability and validity of survey results (Boquiren et
al., 2015; Pascoe, 1983). Pascoe (1983) cautioned that the lack of standardization of
measurement practices limits result validity. Boquiren et al. (2015) noted that a long-standing
critique of patient satisfaction measures is the absence of a robust theoretical framework guiding
measurement development, which means measures are non-standardized and have questionable
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 29
validity and reliability. The authors surmised variation in measurement practice introduces a
lack of clarity and increases the uncertainty of outcomes. Nonetheless, patient perception
remains an influencer of the patient experience. The literature describes the link between patient
satisfaction and quality of care perceptions.
Link between patient satisfaction and quality of care perceptions. Patient satisfaction
assessment establishes a relationship with the perceived quality of care influencers impacted by
engagement. Oppel et al. (2017) contended patient satisfaction aids in assessing the quality of
care in the competitive healthcare marketplace and that management of human resource levels to
reduce staff shortages can affect patient satisfaction. The authors also noted that consistency in
practitioner presence with patients over a protracted period is important, and transient experience
minimizes the focus on relationship building. This infers that a knowledgeable, consistent team
affects perceptions of quality care. Famiglietti et al. (2013) noted that, as patient’s voice concern
regarding their perceived quality of care, hospitals many face reputation and financial challenges
that impact their competitiveness and viability. Further, maximizing the patient experience
requires care providers and management to understand and link the pedagogy associated with
active engagement practice to empathize efficiently with patients, improving their perception of
quality care. Thus, it must deliver efficient communication and care as designed.
Efficient communication with patients yields positive results; this phenomenon drives
healthcare organizations to assess communication efficacy continually. Brown and Piatkowski
(2017) noted the CMS mandated the use of Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey data for financial reimbursement to shift patient-
centered care and incentivize the improvement of patient satisfaction scores, linking patient
satisfaction and quality. Street, Makoul, Arora, and Epstein (2009) reported clinician-patient
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 30
communication influences patient outcomes indirectly and that communication enhances patient
understanding, trust, and clinician-patient agreement, adherence, and self-care skills and well-
being. Perceived satisfaction influences the perception of quality care, and the care team and
management play a significant role in shaping practice.
Influence 2: Measurement and Assessment of Patient Satisfaction in Healthcare
Measuring patient satisfaction. While there may be challenges in the measurement of
patient satisfaction, assessment scores continue to figure prominently (Urden, 2002; Ware,
Snyder, Wright, & Davies, 1983; Zusman, 2012). Patient satisfaction is multifaceted and affects
characteristics of both the providers and services, and patient perceptions of the quality of the
providers and care levels reflect in patient satisfaction ratings (Ware et al., 1983). While self-
administration of the assessment reduces data-gathering costs and increases confidentiality
(Ware et al., 1983), Urden (2002) noted maintaining quality and controlling cost drive healthcare
organization practices. Urden indicated that national benchmarking settings cannot readily occur
due to lack of measurement standardization, as factors such as timing and mode of data
collection may introduce bias. Urden warned of bias introduced through survey timing and
method of data collection. Zusman (2012) cautioned against patient-reported outcomes may not
be appropriate as patients may not be in the best position to assess their care. In critiquing tools
for inherent bias, measurement must consider patient care management practice. Data collection
leads to considerations of reported patient satisfaction.
Reporting patient satisfaction. Multifaceted patient satisfaction reporting expresses
expectation versus performance perceptions that depict approval of care levels. Jackson,
Chamberlin, and Kroenke (2001) found that patient satisfaction increasingly compares programs
or systems, evaluates the quality of care, identifies an opportunity for patient satisfaction
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 31
improvement, and identifies consumers likely to disenroll. Further, satisfaction is an attitudinal
response to value judgments patients make about their clinical experience (Jackson et al., 2001).
Beginning in October 2012, hospital patient satisfaction scores impacted the financial bottom
line for healthcare reimbursement based on quality measures, and that satisfaction can be related
to the patient’s unmet expectations (Zusman, 2012). Assessment of patient satisfaction is part of
the value-based purchasing initiative based on HCAHPS (Zusman, 2012). Measuring and
reporting expectations and perceptions of care influences care delivery, and the practitioner and
their leadership are important to consider.
Influence 3: The Radiation Therapist and Manager Role in Patient Satisfaction
Description of care provided by the patient-facing care team. The patient-facing care
team and manager stakeholder group exert influence on patient satisfaction through their
technical and psychosocial skills in delivering a prescribed care plan and management of
patients’ emotional comfort (Egestad, 2013; Halkett & Kristjanson, 2007; Leaver & Alfred,
2004). Leaver and Alfred (2004) noted that care expertise and accuracy are of utmost
importance in the delivery of prescribed treatment and related care. Discipline-specific
management plays a role in ensuring practitioner competency and adherence to institutional
expectations. Egestad (2013) reported patient encounters with practitioners can directly lead to
increases or decreases in patient anxiety levels; when the therapists are competent, patient
anxiety decreases. The authors noted that, when a care provider takes the time to build
relationships and takes ownership of treatment delivery, patients feel more secure. Egestad
(2013) reported patient anxiety increases when the therapists demonstrate professional
incompetence, and as such influence the patient’s experience.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 32
Further, Halkett and Kristjanson (2007) found patients place high importance on
emotional comfort during their radiation treatment, and emotional comfort and positive
experience occur through forming relationships with radiation therapists and receiving
information about their treatment and care. Subsequently, the authors concluded the relationship
between provider and patient facilitates the building of trust and confidence. Specific to
radiation therapists, Halkett and Kristjanson (2007) noted that their role in helping patients
achieve emotional comfort during treatment requires adequate direction and adherence to
standards of practice. Preparation of the care team is just as important as their role expertise in
care delivery and in attending to patient experience and satisfaction expectations.
Preparation for patient engagement. Radiation oncology practice requires compassion,
trust, and problem-solving expertise (Coffey, Leech, & Poortmans, 2016). Coffey et al. (2016)
noted that graduates from recognized and accredited academic programs can think critically,
examine practice, problem solve and make appropriate decisions in delivering patient care.
Explicit in describing their preparation, Coffey et al. alluded to the importance of the ability to
reflect on practice and contemplate improvement opportunities, mainly when supported.
The influencers noted in the literature guide practice and suggest that management plays an
important role in meeting institutional and patient expectations. Further, the appropriate
expression of that practice influences patient engagement satisfaction. On this premise, Clark
and Estes’ (2008) gap analysis framework offers a platform for exploration of performance gaps.
Clark and Estes ’ Gap Analysis Conceptual Framework
Clark and Estes (2008) describe a systematic, analytical framework that examines
performance goals of both an organization and its stakeholders, exploring knowledge and skills,
motivation, and organizational reasons for gaps between actual and intended performance (Clark
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 33
& Estes, 2008). When work outcomes do not meet expectations, employee knowledge and skill
assessment determines if they can solve challenges (Clark & Estes, 2008). Krathwohl (2002)
and Mayer (2011) identified four core knowledge types that determine if employees know how
to accomplish their goals: factual, conceptual, procedural, and metacognitive. Through these
core knowledge types, the authors described how foundational, relationship, process, and
reflective knowledge and skills related to intended outcomes. Motivation manifests as an
individual’s degree of willingness to exert and maintain a level of mental effort in attaining goals
(Clark & Estes, 2008; Rueda, 2011). Further, motivation leverages personal values, self-
efficacy, goals, and beliefs that drive employees toward success (Eccles, 2006; Rueda, 2011).
Lastly, organizational influences on performance gaps include work processes, material
resources, and organizational culture (Clark & Estes, 2008).
Each of the Clark and Estes’ (2008) gap analysis components will be addressed below in
terms of the E4C radiation oncology operational management team knowledge, motivation and
organizational needs to meet their performance goal of providing 100% of service recovery for
Q-Review
®
scores below the self-reported score of 3 within 24 hours of receipt by Q4 2019. The
initial section discusses the assumed influences on the performance goals based on the
management team’s operational knowledge and skills. Next, the management team’s
motivational influences map their ability to attain the goal. Lastly, discussion of assumed
organizational influences that affect the performance goal completes the comprehensive gap
assessment. Each assumed management team KMO performance influencer leads to the
methodological discussion in Chapter Three.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 34
Knowledge and Skills Influences
The achievement of professional goals and expected outcomes requires mastery of
domain-specific knowledge and skills and the transfer of that knowledge and skills into practice
(Rueda, 2011). Further, when work performance does not meet expectations, workers’
knowledge and skills should be assessed to see if they know how to accomplish their goals and
whether they can demonstrate critical thinking in solving novel challenges (Clark & Estes,
2008). Directly interfacing with patients and their families daily for periods spanning six
consecutive weeks, frontline practitioners require domain-specific knowledge and skills to fully
implement patient satisfaction compliance strategies. Clark and Estes (2008) cited the
importance of knowledge and performance alignment; low levels of knowledge and skills present
as variations between performance and standards, manifesting as knowledge problems. Various
types of knowledge provide a platform to understand the role of knowledge and skills in goal
attainment.
Understanding knowledge types helps leverage the potential of the gap analysis
methodology. Krathwohl (2002) and Mayer (2011) identified four core knowledge types:
factual, conceptual, procedural, and metacognitive. These authors described factual knowledge
as the foundational knowledge needed to appreciate a discipline or problem solve within a
domain. Conceptual knowledge relates to understanding the relationship between primary
components within a larger collective that allow co-functioning. Building on this platform,
procedural knowledge describes the process of performing a task to completion. Lastly,
Krathwohl and Mayer defined metacognitive knowledge as the ability to reflect on actions and
assess performance as it relates to intended outcomes. These knowledge types collectively
promote problem-solving.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 35
A comprehensive foundation demonstrates the role of knowledge and skills in learning
and problem-solving (Baker, 2006; Krathwohl, 2002; Mayer, 2011). While the literature applies
to a variety of issues in healthcare, this review focuses primarily on its application to knowledge
and skill challenges in the implementation of patient satisfaction compliance strategies among
the frontline practitioner group. The following sections will assess knowledge of the tools and
methods used to measure patient satisfaction, link between direct patient engagement and patient
satisfaction reporting, and appropriate use of open-ended, divergent questions to assess unspoken
patient needs.
Knowledge of the tools and methods used in measuring patient satisfaction.
Krathwohl (2002) described how a basic understanding of a domain or practice helps to
recognize operational details and elements of practice. The author cited basic knowledge
relating to identifying practice nomenclature and the aspects of practice, which this is the domain
of factual knowledge, the fundamental element of cognition known as data. Gudea (2005)
depicted data as the common denominator of all constructs. Further, Gudea noted that
information and knowledge are derived from data and positioned along a continuum that
eventually leads to wisdom.
The frontline practitioner and management team must understand the activities that
influence patient satisfaction survey scores on the PGPSS. Review of the patient survey
questions provides the practitioner insight into the tools patients use to gauge satisfaction.
Mayer (2011) noted the retrieval of knowledge from long-term memory facilitates the cognitive
process of remembering. Information that is relevant to a task at hand is familiar, subject to
automatic processing, and is most likely to be processed in sensory memory and forwarded to the
working memory buffer (Schraw & McCrudden, 2006). Information that is highly relevant may
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 36
receive some degree of controlled, conscious processing if it is central to a task (Schraw &
McCrudden, 2006). Without this knowledge, there is no foundation for more complex
knowledge processing (Aguinis & Kraiger, 2009). Conceptual knowledge builds conceptual
relationships.
Understanding the link between direct patient engagement and patient satisfaction.
Savage, Arif, Smoke, and Farrell (2017) describe how processing feedback and information
regarding patients facilitates understanding patient needs and the best practices in meeting them.
The authors argued meaningful patient engagement is central to a patient needs assessment.
Further, maximizing the patient experience requires frontline practitioners to understand and link
the pedagogy associated with active engagement practice to empathizing with patients and
improving their perception of quality care (Famiglietti et al., 2013; Gesell & Gregory, 2004;
Halkett et al., 2010).
In synthesizing these common points, high-quality patient engagement leads to positive
patient satisfaction (Famiglietti et al., 2013; Gesell & Gregory, 2004; Halkett et al., 2010; Savage
et al., 2017). While patient engagement is much discussed in healthcare, definitions vary.
Coulter (2011) offered a patient engagement definition focusing on the relationship between
patients and providers as they work together to “promote and support active patient and public
involvement in health and health care and to strengthen their influence on health care decisions,
at both the individual and collective levels” (p. 10). Carman et al. (2013) defined patient and
family engagement as patients, families, their representatives, and health professionals working
in active partnership at various levels across the health care system to improve health and
healthcare. Characterized by the information flow between patient and provider, this
engagement directly affect the patient’s feeling of satisfaction with their care delivery (Carman
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 37
et al., 2013). Active participation is a multidimensional phenomenon that requires dynamic
performance of knowledge and learned activities and use of cognitive strategies to facilitate
understanding (Rueda, 2011). With this, frontline managers need to not only understand the
components used in measuring patient satisfaction but also have an appreciation of the
importance of patient engagement and impact on outcomes to ensure appropriate delivery
through the staff.
Appropriate use of open-ended, divergent questions to assess unspoken patient
needs. Effective physician-patient communication promotes higher quality care and involves
style, content, and mindful questioning (Chiò et al., 2008; Halkett, 2010). Improved doctor-
patient communication increases patient involvement, adherence to recommended therapy,
patient satisfaction, enhanced quality of care and health outcomes (Ha & Longnecker, 2010).
Attentive listening skills, empathy, and open-ended questions are skillful communication tools
(Ha & Longnecker, 2010). Frontline practitioners and managers need exposure to practical
applications of questioning to enhance patient information flow and quality of care. Based on
the knowledge literature reviewed, Table 2 outlines the organizational mission, the goals that
drive the improvement methodology of this work, and three knowledge influences that connect
knowledge needs of the practice.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 38
Table 2
Knowledge, Influence, Type, and Assessment
Knowledge Influence Knowledge Type Knowledge Influence Assessment
The frontline management team needs to
know the trigger points for service
recovery procedures
The frontline management team needs to
understand the link between service
recovery, patient engagement, and patient
satisfaction.
Declarative
(Factual)
Declarative
(Conceptual)
Frontline staff managers asked to
complete a survey that requires
factual knowledge on patient
satisfaction.
Frontline staff managers
interviewed in a focus group setting
and asked to summarize their
conceptualization of the link
between their patient interaction
and patient satisfaction.
The frontline management team needs to
know how to engage patients during
service recovery procedures.
Procedural Observe interactions of frontline
staff managers and patient
questioning during engagements,
specifically looking for evidence of
information gathering.
Motivation Influences
Motivation manifests as an individual’s degree of willingness to exert and maintain effort
in attaining goals, and leaders can leverage that drive by demonstrating value and appreciation of
those efforts (Benson & Dundis, 2003; Dolea & and Adams, 2005). Motivation is an internal
psychological and transactional process characterized by interactions between individuals, their
work environment, and connectivity within the broader societal context (Franco, Bennett, &
Kanfer, 2002). Implementation of patient satisfaction compliance strategies is contingent upon
Organizational Mission
The E4C mission strives to provide leadership in the prevention, treatment, and cure of cancer through
excellence, vision and cost-effectiveness in patient care, outreach programs, research, and education.
Organizational Global Goal
Implement a data-driven strategy, supported by value-added metrics and reporting, to improve patient
satisfaction scores by the end of July 2019.
Stakeholder Goal
By September 2018, 100% of the frontline staff members will implement patient satisfaction
compliance strategies in their daily activity.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 39
frontline practitioner managers’ motivation level. Characterized by active choice, persistence,
and mental effort, motivation drives the ability to start, maintain, and complete tasks (Rueda,
2011). Knowing how to complete a function does not adequately address the potential for
success, as motivation leverages personal values and beliefs that drive practitioners towards
success (Eccles, 2006; Franco et al., 2002; Rueda, 2011).
Similarly, Pintrich (2003) stated leaders benefit from understanding performance drivers.
There are benefits to investing in work environments that ignite personal motivation, such as
what people want, their sources of motivation, and cultural influences (Pintrich, 2003). Two
motivational influences relevant in assessing frontline practitioners’ motivation are goal
orientation theory and interest.
Goal orientation theory. Directional goals associated with goal orientation theory,
which explores why individuals choose to engage in tasks, separate into two major categories:
mastery and performance (Yough & Anderman, 2006). Mastery goals are held by learners when
they fully understand and consistently perform a skill or task driven by the desire for self-
improvement (Yough & Anderman, 2006). Learners focused on mastery are persistent in
attempting to solve problems, are learning goal oriented, and promote positive learning (Molden
& Dweck, 2000; Yough & Anderman, 2006). In contrast, performance goals function on an
internal and external competition framework; the driving force becomes demonstrating ability
that is superior to others. Performance goal learners strive to outperform others. Schraw and
McCrudden (2006) noted that, when considering procedural competency, task mastery requires
component skills, practice integrating them, and knowing when to apply what was learned.
While mastery and performance goals are distinct, they may not be mutually exclusive. Some
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 40
researchers argued performance goals are adaptive and can be beneficial for learners, particularly
when they pair with mastery goals (Harackiewicz, Barron, Pintrich, Elliot, & Thrash, 2002).
Intrinsic and extrinsic factors notwithstanding, mastery and performance approaches can
be approach or avoidance based (Yough & Anderman, 2006). Subject interest and desire for
self-improvement fuels the mastery approach, while a mastery avoidance perspective desires not
to misunderstand the information provided (Yough & Anderman, 2006). From a performance
approach, the learner wants to demonstrate to both superiors and peers that they are better than
the rest; in performance-avoidance, the goal is not to appear incompetent (Yough & Anderman,
2006). Environmental context and culture frame learning and motivation, as the environment
dramatically affects goal orientation (Scott & Palinscar, 2006; Yough & Anderman, 2006).
Without a contextual or cultural framework, frontline practitioner manager motivation may lack
robustness, limiting effectiveness in task execution.
Frontline management should master probing engagements with patients. Goal
orientation theory plays a substantial role for frontline practitioner managers in radiation
oncology. Adriaenssens, De Gucht, and Maes (2015a) looked at goal orientation and
achievement of work-related goals using hierarchical multiple regression analysis. Their research
used self-reported questionnaires to assess 170 out of 274 emergency nurses from 13 secondary
Belgian hospitals. The mastery approach goal orientation was strongly related to an increase in
work engagement while the performance-avoidance goal orientation strongly related to a
decrease in work engagement (Adriaenssens et al., 2015a). While the performance approach and
mastery avoidance goal orientations were not predictive for the two outcome variables, the
mastery approach goal orientation appeared to be beneficial while a performance-avoidance goal
orientation was not. Thus, mastery orientations may yield more high-quality patient engagement
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 41
outcomes, linking better patient experience and satisfaction outcomes (Famiglietti et al., 2013;
Toode, Routasalo, & Suominen, 2011).
Interest. Two types of interest affect motivation. Situational interest is spontaneous,
captures the learner’s attention, and increases when a task is relevant to goals, whereas
personal/individual interest is less spontaneous, internally activated, and value-based (Schraw &
Lehman, 2009). Expert engagement facilitates the relationship between short-term situational
interest and long-term subject mastery, increasing the quality of information processing (Schraw
& Lehman, 2009). According to Schraw and Lehman (2009), situational and personal interest
drive a person’s motivation, engagement, and persistence in performing tasks. Situational
interest positively affects extrinsic motivation like instructors and textbooks while personal
attention positively affects intrinsic motivation (Schraw & Lehman, 2009). If the frontline
managers value interactions with patients and are internally and externally interested in their
effort, positive outcomes in patient satisfaction occur. If they are not motivated, tasks become
rote, uninteresting and will not hold their interest. Schraw and Lehman noted both extrinsic and
intrinsic motivation are central to engagement, leading to the development of new skills and
knowledge as well as confidence in learning new areas of information.
Frontline management need to be interested in the quality of their engagement with
patients. Research shows that, when students’ interest peaks in a task or activities, they engage
longer and with more effort and productive learning behaviors, including generative questioning,
self-regulation, enhanced strategy use, and problem-solving (Lipstein & Renninger, 2006;
Mitchell, 1993; Renninger & Hidi, 2002; Renninger & Shumar, 2002). Extrapolating this to the
frontline practitioner managers, radiation oncology leadership should assess their s and introduce
programming that will stimulate interest and higher engagement. Using tools based on Maslow’s
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 42
and Herzberg’s needs theories to examine motivation, Lambrou, Kontodimopoulos, and Niakas
(2010) reported, when leadership has insight into employee motivational drivers, they can
leverage staff needs and interests to meet intended outcomes. Similarly, Renninger and Hidi
(2002) postulated interest develops through triggered situational interest as related to a temporary
change in stimulus environment of information and that overall expression of interest extends
through maintained situational interest and well-developed individual interest. Patients value
effective engagements with frontline practitioner. The key is to identify interest opportunities
and establish venues for self-reflection, higher engagement, and outcome improvement.
While Rueda (2011) connects a person’s interest level to their values, the relationship
between the interest level to the demonstration of compassionate patient care warrants review.
Through interviews of 24 clinicians identified as exemplary, Graber and Mitcham (2004)
modeled effective clinician/patient interactions, identifying four distinct levels of patient
interaction: practical, personal/social/personal feeling, and transcendent. With primary
engagement expression ranging from detached concern to love/compassion and primary
motivational source from a sense of duty to feeling/intuition, the authors surmised that nurses,
therapists, and physicians could efficiently operate while maintaining close relationships with
patients. Further, they cited evidence that suggested patients welcome caring and compassion
from their clinicians. In summary, Graber and Mitcham (2004) noted caring and compassionate
clinicians “should be supported by healthcare organizations that wish to be valued by their
patients in providing quality, holistic care” (p. 93). Interest in high-quality engagement
manifests in greater patient satisfaction potential. Table 3 outlines the organization mission, the
series of cascading goals that drive the improvement methodology of this work, and the two
motivational influences identified in this literature review.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 43
Table 3
Motivational Influences and Assessment
Organizational Influences
While employees may demonstrate required knowledge, skill-based competencies, and
the necessary motivation to complete expressed expectations successfully, organizational factors
may still negatively influence expected outcomes (Rueda, 2011). Organizational infrastructure,
practice-guiding policies and procedures, resources, and aspects of the culture itself often
Organizational Mission
The E4C mission strives to provide leadership in the prevention, treatment, and cure of cancer through
excellence, vision and cost-effectiveness in patient care, outreach programs, research, and education.
Organizational Global Goal
Implement a data-driven strategy, supported by value-added metrics and reporting, to improve patient
satisfaction scores by the end of July 2019.
Stakeholder Goal
By September 2018, 100% of the frontline staff members will implement patient satisfaction
compliance strategies in their daily activity.
Motivational Indicator(s)
Staff appears to be content with the minimal performance of tasks. They have been observed to only
engage in superficial engagements with patients and must be directed to anticipate patient needs.
Observation of employees attending to personal engagements (phone calls or internet) while patients
are waiting for service
Assumed Motivation Influences Motivational Influence Assessment
Goal Orientation – Frontline staff
managers should want to master their
responsibilities inclusive of probing
engagements with patients as opposed to
only complying at the minimal expectation
level when engaging patients.
Interviews with frontline staff managers, asking them
open-ended questions promoting them to describe their
thoughts on the goals of their patient engagement and
comment on the value of not only meeting the patients
stated needs but also questioning them on any unstated
needs. Look for intrinsic drivers.
Interest - Frontline staff managers need to
be interested in the quality of their
engagement with patients on patient
satisfaction scores and realize that their
involvement makes a difference in patient
care perceptions (as opposed to patients
having preconceived notions on it or it not
being something that they influence).
Engage staff managers in focus group interviews to
discuss their thoughts on the impact of their
engagement with patients and their perception of the
interest they have for positive impact on patient
satisfaction.
-or-
Survey each frontline staff manager asking, “Patient
satisfaction is influenced by the interest I have in our
daily engagement.”
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 44
directly affect employee behavior and their perception of the work and ability to effectively
complete outcomes as intended (Clark & Estes, 2008; Rueda, 2011). Important to note is
organizational culture and the influence it exerts on employees. Rueda (2011) describes an
organization’s culture as that unseen, often automated, and value-based expectation driver that
permeates across both the organization and the employees charged to meet its goals.
Further, Clark and Estes (2008) alluded to the impact of culture on employees through
work processes that leverage employee knowledge, skills, and motivation through a series of
procedures designed to produce outcomes. The authors noted organizational resources as key to
supporting employee effort along and the valuation of those resources in cost-effectively
achieving goals. Missing or ineffective organizational processes and inadequate resources are
barriers to performance goal achievement and widen gaps between actual and expected
performance (Clark & Estes, 2008). Summarizing these points, Schein (2017) surmised that
organizational culture offers insight into group-defining structural stability, depth (often an
unconscious part of an organization), breadth (pervasive across the entire organization), and
integration of elements into a larger organizational paradigm). Similarly, the E4C organization’s
structure and culture influence the ability of the radiation oncology management team to meet its
operational goals.
Understanding organizational influencers are fundamental in leveraging the potential of
the gap analysis methodology described by Clark and Estes (2008). The importance of
understanding organizational culture requires basic definitions of two separate, yet related,
aspects of culture: cultural model and cultural setting. Gallimore and Goldenberg (2001)
describe the cultural model as the often-intangible practices and beliefs of an organization: its
values and customs. The authors described the cultural setting as the tangible expressions of
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 45
those cultural beliefs and values manifested in how it carries out those beliefs through procedures
and actions. Cultural models and settings play a role in E4C’s organizational performance gaps,
impacting problem-solving potential. While the literature applies to a variety of issues in
healthcare, this review focuses primarily on its application to operational challenges that may
influence the full implementation of patient satisfaction compliance strategies housed in service
recovery efforts. The following sections will assess potential gaps, tools, and methods used in
measuring service recovery compliance through action-oriented commitment and appropriate
resource allocation in supporting of service recovery procedures,
Cultural model influence: E4C has an action-oriented commitment to gain expected
results by taking on difficult challenges with urgency, high energy, and enthusiasm.
Service recovery refers to an organization’s entire process for facilitating resolution of
dissatisfactions (Hayden et al., 2010). The expected result that service recovery performance
occurs as designed. Brook, Siewert, Weinstein, Ahmed, and Kruskal (2017) described
healthcare legislation and the associated payment reforms as shifting the focus from traditional
fee for service models to adding measurable and considerable value to the patient experience.
The authors noted effectively implementing this new paradigm requires excellent, timely and
appropriate patient-centric care as measured through feedback obtained from patients.
Service recovery efforts explore the patient perception of the quality of the care received
and depict concern and caring for the patient experience. The hypothesis is that addressing
patient changes near real time will enhance the experience and ultimately impact patient
satisfaction. To affect the patient experience and perception of our valuing their experiences,
interventions by the management team must be swift, engaging, and enthusiastic. Further, Um
and Lau (2018) suggested the need for action-oriented intervention to limit dissatisfaction. From
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 46
an organization platform, managers are expected to engage in challenges with a high level of
urgency, energy, and enthusiasm to demonstrate their value for the patient experience via the
service recovery process. Subsequently, non-adherence to this cultural model provides an
opportunity to service recovery practice not to meet expectations, potentially resulting in missed
opportunities in addressing patient issues.
Cultural setting influence: E4C is committed to providing adequate resources to
ensure staff development, information transfer and timely feedback to facilitate consistent
operation delivery. Clark and Estes (2008) cited the need for organizations to consistently
provide tangible supplies, capital, and resources required to achieve goals. Service recovery
requires appropriate resources to enable timely and consistent patient engagement, including
human capital. Kennedy (2017) stated service quality and patient satisfaction can affect an
organization’s value-based payments and new approaches to service education and training. The
author noted that department-specific content infused with patient feedback, value creation, and
science of service quality principles was developed to provide a deeper understanding of the
impact of staff performance on patient experience, value creation, and value-based revenue.
Consistently offering service recovery at a high level requires a commitment to the maintenance
of appropriate material and human resources. Clark and Estes (2008) also discussed the potential
to overlook the value of providing material resources, including new technology to promote
increased attention to service outcomes.
Kennedy (2017) stated,
organizations that understand how patients perceive and rate service quality likely will be
better able to improve it. Thoughtfully conceived service education content and training
methods can give staff the knowledge and tools to satisfy patients, help continuously
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 47
improve the service experience, keep the organization’s service promises, and help
sustain an organization for the future. (p. 159)
Linked to cultural influences, Schein (2017) suggested individual bias may influence
organizational investment in needed areas. In considering service recovery, a corporate leader
who prefers to operate on a lean operational platform may negatively affect the attainment of
required resources, limiting outcomes. Consistent review of needed tools shapes the ability to
perform as planned, and the organization should commit to the provision of necessary materials.
The management team must understand the activities that influence the patient experience.
The importance of action orientation in attaining results and commitment to investing in
resource support affects organizational success obtained through service recovery practices
toward the interaction between patients and frontline practitioners. Based on the organizational
literature reviewed, Table 4 outlines the organizational mission, the series of cascading goals that
drive the improvement methodology of this work, and two organizational influences that connect
organizational culture needs of the practice.
Table 4
Organizational Influences and Assessment
Organizational Mission
The East Coast Comprehensive Cancer Center (E4C) mission strives to provide leadership in the
prevention, treatment, and cure of cancer through excellence, vision and cost-effectiveness in patient
care, outreach programs, research, and education.
Organizational Global Goal
Implement a data-driven strategy, supported by value-added metrics and reporting, to improve patient
satisfaction scores by the end of July 2019.
Stakeholder Goal
E4C’s radiation oncology management team will engage 100% of all service recovery efforts for Q-
Review® scores below the self-reported score of “3” within 24 hours of receipt by Q4 2019.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 48
Table 4, continued
Conceptual Framework: The Interaction of Stakeholders ’ Knowledge and Motivation and
the Organizational Context
The purpose of a conceptual framework is to visually represent the concepts, beliefs,
assumptions, expectations, variables, and theories that shape a study and how these components
relate, inform and influence each other (Maxwell, 2013; Merriam & Tisdell, 2016). The
conceptual framework helps understand the interconnectivity between concepts and influencers
in crafting the study’s goals, research questions, methodology, and validity challenges (Maxwell,
2013). Jabareen (2009) described how the integration of ideas and concepts stratify the
interrelationship and articulate their respective phenomena to create a framework-specific
philosophy. The framework is specific to the problem of practice and becomes the foundation
for support and integration of single study components strengthened through relationships
(Jabareen, 2009; Maxwell, 2013). Individually reviewed earlier, the independent challenges are
now collectively considered through graphics and narrative, demonstrating interrelationships and
connectivity. The depiction of these complex relationships through words and illustration
provide a pathway to understanding the emerging conceptual hypothesis on improving cancer
patient satisfaction and experience through acute service recovery triggered by patient-reported
poor experiences.
Assumed Organizational Influences Organizational Influence Assessment
Cultural Model Influence –E4C has an
action-oriented commitment to gain
expected results by taking on difficult
challenges with urgency, high energy, and
enthusiasm.
Survey or interview questions are querying
management team willing to act on challenges without
additional planning, identify and invoke new
opportunities quickly, display a can-do attitude in good
and bad scenarios, and consistently demonstrates
initiative.
Cultural Setting Influence – E4C is
committed to providing adequate resources
to ensure staff development, information
transfer and timely feedback to facilitate
consistent operation delivery.
Survey to assess agreement with the robustness of
current staffing models and adequate resources to
facilitate consistent service recovery practices.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 49
The conceptual framework is unique to the area of study and the complexity of its study-
specific relationships. Jabareen (2009) noted that part of the value of the integrated conceptual
framework resides within ontological, epistemological, and methodological assumptions
regarding influencers of practice. The author describes ontological assumptions relating to
knowledge of the way things are, real existence, and real action. Epistemological assumptions
relate to how things are and how things really work in an assumed reality, while methodological
assumptions relate to the process of building the conceptual framework and assessing what it can
tell us about the real world (Jabareen, 2009). Clark and Estes’ (2008) gap analysis theoretical
framework, also known as KMO methodology, supports conceptual framework modeling where
stakeholder knowledge and skills, motivation, and organizational influencers describe gaps
between actual performance and expected goals. While each influencer outlines potential gap
challenges in practice, the conceptual framework solidifies how the separate concepts
collectively influence practice.
This study evaluated how the interrelated influencers affect this research question: What
are the management team’s knowledge, motivation and E4C’s radiation oncology department
influences related to achieving its goal of providing 100% of service recovery for Q-Review
®
scores below the self-reported score of “3” within 24 hours of receipt by Q4 2019? The
literature review reveals potential influences deriving from adequate preparation and support of
the management team in driving toward goal attainment.
The Relationships Among Knowledge, Motivation, and Organizational Influencers
Influenced by the organization’s cultural model and cultural setting expression, the
management team’s knowledge affects goal attainment. Expected outcomes require mastery of
domain-specific knowledge and skills and the ability to transfer that knowledge and skills into
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 50
practice (Rueda, 2011). Interfacing with frontline care providers who engage patients, managers
require a command of domain-specific knowledge and skills to implement service recovery
strategies. Conceptual and procedural knowledge facilitates the management team’s
appreciation of the link between service recovery and patient experience. Further, maximizing
the patient experience requires the management team to understand and link effective
engagement practice to empathize with patients, improving their perception of quality care (Chiò
et al., 2008; Famiglietti et al., 2013; Gesell & Gregory, 2004; Halkett et al., 2010). The
motivational influencers of goal orientation and interest require review in this framework.
Goal orientation and interest level may influence the management team. Adriaenssens et
al. (2015a) noted mastery approach goal orientation was strongly related to an increase in work
engagement, and mastery orientations will yield more high-quality patient engagement outcomes
(Famiglietti et al., 2013; Toode et al., 2011). Without this context, management team motivation
may lack robustness. From a cultural model platform, managers are expected to engage in
challenges with a high level of urgency, energy, and enthusiasm to demonstrate their value for
the patient experience. Warrick (2011) noted the expectation of urgency and enthusiasm
influences motivation by building excitement for an activity in cultural modeling. In the case of
E4C, this may drive management toward increased desire into the recovery process. In
considering service recovery, a corporate leader who prefers to operate on a lean operational
platform may negatively affect the attainment of required resources. Consistent review of
infrastructure shapes the ability to perform as planned, so the organization should commit to the
provision of necessary materials. Subsequently, cultural settings that do not adequately prepare
or outfit staff should not expect intended results as the impact on management motivation
surfaces as frustration, limiting persistence and productivity (Clark & Estes, 2008).
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 51
The interrelated influences flow between knowledge, motivation, and the organization.
Motivation can influence management team knowledge attainment. If managers’ interest level is
low, they may not be attentive or open to leveraging knowledge, suggesting a challenge in active
choice. Conversely, if a lack of quality training opportunities challenges the ability to attain
knowledge, the management team may become frustrated and disinterested in ensuring
appropriate service recovery efforts. Similarly, if the management team has the knowledge and
the motivation but lack resources to provide service as designed, they will not meet their goals.
These depictions underscore the interrelated influences of KMO influencers.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 52
Figure 2. Conceptual framework – KMO influences on service recovery.
Figure 2 depicts relationships between KMO influences on service recovery. The figure
describes the directive influence of the E4C organization engulfing an inner management team
stakeholder group. These layers of concentric connectivity offer a systemic view of the
relationships, as the larger organization directly surrounds the smaller stakeholders, providing its
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 53
more global perspective to the inner providers. The inner circle shares a central point with the
larger, outer circle, depicting a common theme, allowing the inner circle to influence the external
as well. This relationship between outer and inner circles provides a synergistic platform for
mutually achieving expectations.
The inner circle is nestled at the lower end of the outer circle, placing the weight of the
overlap of the two circles at the point of output, depicted by the arrow. Suggestive of the
resulting effort of the whole, the arrow directs attention to the rectangular representation of the
research question. All actions are interrelated. This interrelationships between the knowledge
and skills, motivation, and organization reflect influences experienced in E4C.
Conclusion
This chapter summarized the literature exploring efficient service recovery practice and
perceived valuation of related interventions to address performance gaps. Starting with
generalized literature that supports the expressed method as problematic, an evaluative approach
ascertained the value of an expectation and assessed whether the associated tasks perform as
intended by the providers. The chapter then focused on the KMO influencers related to the
management team’s ability to intervene through service recovery practices in patient-reported
care challenges effectively. Through inductive assessment methods designed to explore the
nature of the problem of practice, Chapter Two described a conceptual study framework that
visually and narratively described the concepts, beliefs, assumptions, expectations, variables, and
theories that shaped the study and how those components relate, inform and influence each other
in terms of the study’s goals, research questions, and methodology. Wholly, the literature review
chapter formulated the justification and outlined the relevance of the research to support the
study’s methodological approach presented in Chapter Three.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 54
CHAPTER THREE: METHODOLOGY
Patients’ perceptions of the quality of the service they receive surfaces as a part of their
radiation oncology cancer management outcome. While Shaw and Collins (1995) asserted
facilities provide higher quality of when they meet accepted accreditation standards, Sack et al.
(2011) maintained that the converse is also true: facilities that do not submit to the rigor of
accreditation may not provide quality care. As such, E4C committed to establishing a care
provision strategy and appropriate metrics to augment quality patient experiences across the
continuum of care by using patient experience feedback to improve care by the end of the 2019
fiscal year. This performance goal directs the focus on the problem of practice through service
recovery efforts of swift intervention when patients report dissatisfaction.
Merriam and Tisdell (2016) explained that a dissertation’s design, sample selection,
collection and analysis, and trustworthiness should be comprehensively addressed in the
methodology chapter. To accomplish this, Chapter Three initially discusses the use of secondary
data and frontline manager surveys followed by interviews and review of documents and
artifacts. Sections on both quantitative and qualitative methods describe specifics of sampling,
instrumentation, and data collection and analysis for each data source used. Assessment of
reliability, validity, credibility and trustworthiness are followed by a discussion of collective
ethics, limitations, and delimitations to frame the discipline used to design the study’s methods.
Research Questions
This exploratory mixed methodology study aligns with the following research questions
to address knowledge and skills, motivation, and organization influences on the management
team captured through surveys and interviews:
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 55
1. To what degree is E4C’s radiation oncology department meeting its goal of providing
100% of service recovery for Q-Review
®
scores below the self-reported score of “3”
within 24 hours of receipt by Q4 2019? (RQ1)
2. What are the frontline manager’s knowledge, motivation and E4C’s radiation oncology
department influences related to achieving its goal of providing 100% of service recovery
for Q-Review
®
scores below the self-reported score of “3” within 24 hours of receipt by
Q4 2019? (RQ2)
3. What are the recommendations for organizational practice in the frontline manager’s
knowledge, motivation, and organizational resources related to achieving its goal of
providing 100% of service recovery for Q-Review
®
scores below the self-reported score
of “3” within 24 hours of receipt by Q4 2019? (RQ3)
Study Participants
Answering the research questions called for the frontline management team at E4C, to
inform the researcher about service recovery understanding and opportunities. A nurse manager,
radiation therapist managers and supervisors, and administrative/clerical managers and
supervisors provide operational oversight and set expectations for patient care delivery in their
functional areas. All are full-time service practitioners who contribute to a broader operational
team matrix. The following section organizes the study participants by research question. Some
participants were used to address just one of the problems and others to address two or more of
the research questions.
The first research question was designed to assess compliance with E4C service recovery
standard. As such, the Q-Review® secondary data quantitative originally captured for patient
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 56
satisfaction purposes established compliance with departmental standards. Surveyed patients
indirectly provided this information.
The second research question was designed to assess the KMO influences pertinent to
service recovery practices. Twelve of the 15 frontline managers took a survey designed to
address this research question quantitatively. Eleven of them were also interviewed to add
context to the quantitative data.
The study’s third research question was designed to address practice recommendations
informed by the data. The 11 interviews provided direct insight to address this question.
Overview of Data Capture Choices
Creswell and Creswell (2018) stated that both quantitative and qualitative research
questions need to be well tuned in a mixed-methods study to align with the study’s direction.
Linking the methods of analysis and the research questions supports the conceptual framework
and helps ensure a study’s success. Data capture strategies employed in this study triangulate
data from four ethnographic sources: secondary data, survey, interviews, and documents and
artifacts. Triangulation increased study validity and reduced the risk of chance associations
(Bogdan & Biklen, 2007; Creswell & Creswell, 2018; Maxwell, 2013; Merriam & Tisdell,
2016). All four methods were natural selections for this study.
First, secondary data offered a large sampling of patient-reported perspectives on service
facilitating a purposive review and the ability to explore compliance with expected service
recovery procedures. Second, frontline manager surveys offered collection of managerial
perceptions of KMO influences related to service recovery and group interaction and
communication assessment methods. Third, interviews offered the small sample size which
lends itself to a non-randomized approach; the ability to explore the views, experiences, beliefs,
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 57
and motivations of the management team; and a deeper understanding of social phenomena than
can be gained through questionnaires (Creswell & Creswell, 2018). Lastly, document analysis
offered less time commitment through data selection instead of data collection, full availability
throughout the organization, and swift evaluation of data (Bowen, 2009).
Research Design and Methods
This evaluative study used an explanatory sequential mixed method research design to
answer the three research questions that support its conceptual framework. The methodology
used both quantitative and qualitative assessment tools to provide breadth and depth of
understanding of results and subsequent findings (Creswell & Creswell, 2018). This method
offered five beneficial points. The first is triangulation through distinctly converged and
corroborated results from different method to validate findings. The second is complementarity:
clarified and elaborated on results from both methods. Third is development or facilitated results
of one method to inform the other. The fourth is initiation, meaning contradictions and new
framework perspectives facilitate study adjustments, and, lastly expansion reflects extended
breadth and range of assessment (Greene, Caracelli, & Graham, 1989).
Analysis of secondary data. Unlike primary data, secondary data benefits the researcher
by reusing information gathered for one purpose and relating it to another, saving time and
resources in data collection design and expense (White, 2010). The data offered the time of
reporting, time of any patient contact required of the frontline management staff, and time of
resolution. The review of this secondary data offered useful quantitative data regarding
compliance with departmental service recovery efforts.
Surveys. Fifteen study participants used an online and paper-based survey which
collected management demographic and KMO resource information, quantitatively assessing
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 58
service recovery practice, management, and practice compliance. These surveys offered
measured data to address the second research question.
Interviews. The qualitative assessment provided insight into why quantitative outcomes
occur. Fifteen frontline managers offered their perspective on their knowledge base, beliefs and
interest, and thoughts on resource availability. Regarding the interview population size of 15,
Guest, Bunce, and Johnson (2006) noted that, with purposive samples of homogeneous
individuals, 12 interviews should achieve qualitative saturation. All frontline managers have the
same expectations regarding service recovery, making the group homogeneous. A series of
semi-structured interviews provided a depth of overall assessment of the service recovery
practice explored in the study. Adams (2015) cited that, when using mixed-methods research,
semi-structured interviews add depth to findings and offer discovery opportunities via open-
ended questions and probing to explore concepts beyond those that emerged from analysis. The
follow-up questions offered insight into the second and third research questions.
Review of documents and artifacts. Document and artifact review, a part of data
triangulation, helps surface meaning, offers context, and uncover insight important to the
research problem (Merriam & Tisdell, 2016). A wealth of meeting minutes, in-service
presentations, and artifacts evidence the evolution of E4C service recovery, defining practice
expectations and development discussions. Review of these items offers an understanding of
practice and challenges. Table 5 summarizes the advantages and disadvantages of the research
methods used in this study.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 59
Table 5
Study Research Questions, Advantages and Disadvantages
Research
Method
Advantages Disadvantages
Secondary Data Timesaving through use of data
that has already been mined
Feasibility of longitudinal
studies
Reduced cost of data sourcing
Inappropriateness of data being used for
unintended study assessment
Lack of control over data quality
Survey Easy to field within a known
population
The potential for many
respondents
Low degree of control over extraneous
variables
The response rate is unknown
Limited availability for follow-up
Documents and
Artifacts
Permanent, unbiased source of
information
Trend activity over a long
period
Relatively inexpensive
Information cannot be created – all that
is there is all that is there
Conditions under which the data was
initially collected may not be known
Documents may be limited or
confidential
Interview The depth and context of
response can be assessed
Clarification of information
possible with follow-up
questions
Can be time-consuming
Biases may surface in the process
Coordinating schedules may be difficult
Tool Assessment by an Expert Review Panel
Presser et al. (2004) cited that, while not much is known about question pretesting, it is
an accepted way to evaluate in advance whether questions may cause problems for
interviewers or respondents. Expert reviews commonly identify challenges of data analysis
and question comprehension (Presser & Blair, 1994; Rothgeb, Willis, & Forsyth, 2007). With
the use of survey and interview tools to capture important data for the study, a panel of six
content and practice experts offered review of the survey and interview tools. The
composition of the team included education, administration, research, and community
practice leaders, comprising a matrix of leadership experience pertinent to service recovery
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 60
practice. Table 6 outlines the composition of the expert review team, their area of expertise,
and the rationale for their selection.
Table 6
Expert Review Team, Area of Expertise, and Rationale for Inclusion
Professional
Discipline
Years in
Leadership
Value-Added With Team Participation
Reviewer 1 PhD-prepared
Educator in Radiation
Therapy
20 Expert in radiation oncology practice,
inclusive of patient focused care and
service recovery within the domain.
Reviewer 2 PhD-prepared
Educator in Radiation
Therapy
12 Expert in radiation oncology practice,
inclusive of patient focused care and
service recovery within the domain.
Reviewer 3 E4C Masters-prepared
Administrator in
Neurosurgery
6 Expert in management team
development. Competent in institutional
service recovery initiatives.
Reviewer 4 E4C Masters-prepared
Administrator in
Neurology
7 Expert in management team
development. Competent in institutional
service recovery initiatives.
Reviewer 5 Masters-prepared
Autism support
practice owner
10 Expert in community-based healthcare
service provision, inclusive of
management of patient dissatisfaction.
Reviewer 6 E4C Masters-prepared
Research Coordinator
17 Expert in research protocols and
development of inquiry tools.
These professionals, each offering varied perspectives on service recovery practice,
reviewed the tools prior to use and engaged in discussion with this researcher to identify
areas of needed clarity, appropriateness, and relevance. The exchanges occurred via email
and two one-hour web-based engagements and produced revisions to improve the tool prior
to use.
Timeline and Plan
Creswell and Creswell (2018) described a longitudinal study as one where the data
collection occurs over time, and this study reflects that definition in its execution. This
evaluative mixed-methods study used both quantitative and qualitative assessment
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 61
methodologies. Table 7 presents both quantitative and qualitative sampling and recruitment
criteria and rationale, illustrating how the data collection strategies support the overall
development of the study.
Table 7
Sampling Strategy and Timeline
Sampling
Strategy
Number in
Stakeholder
Population
Number of
Proposed
Stakeholder
Participants
Start and End Date for
Data Collection
Secondary
Data
Census (patient
self-reporting)
7000+ existing
documents
NA June 2019 – July 2019
Surveys Purposeful 15 12 June 2019
Interviews Purposeful 15 11 July 2019 - August 2019
Documents Purposeful NA NA June 2019 – July 2019
Comprised of four arms, one for each assessment area described, the study identified
specific numbers of targeted occasions for data collection events to follow the timeline. To
maximize consistency and accuracy of information in the qualitative phase of the study,
interview transcriptions and document and artifact assessment occurred within 24 hours of
collection and were assessed after each batched entry for codification. From this point, an
evaluation of credibility and trustworthiness ensued.
Quantitative Methods
The quantitative assessment component of the study used responses from a survey
initially designed to offer patient-reported insight into their perceptions of care quality to
augment the PGPSS.
Secondary Data Collection
Creswell and Creswell (2018) stated surveys provide numeric descriptions of trends,
attitudes, and opinions using questionnaires and surveys intended to generalize outcomes to a
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 62
population. To accomplish the initial assessment of compliance with service recovery initiatives,
this researcher assessed existing data collected from department-specific Q-Review
®
surveys
reflecting patient self-reported perspectives on E4C care received they received. The Q-
Review® survey tool, designed initially for an immediate review of patient feedback for patient
experience improvement, offers valuable information to facilitate swift service recovery
interventions for patients who perceived receipt of poor care. Every patient scheduled for an
appointment E4C’s radiation oncology department is offered the opportunity to participate.
Frontline staff explain to the patient that the department values their opinions of the care
received. They are offered the opportunity to receive a text message survey of seven questions
two hours after they check in to their appointments. Staff informs the patient that the
information is voluntary and solely used for quality assessment. The frontline staff informs the
patient that they may opt out at any time with neither consequence nor penalty. A brochure
provided to the patient outlines what to expect, the engagement process, and thanks them in
advance for their participation. In 2018, the survey yielded a 20% response rate. While the
responses offered insight into patient perspective on care quality, a low response rate required an
analysis of non-response bias as part of the assessment metrics. The data, stored in a password-
protected database, was stripped of all participant identifiers and downloaded into a database for
coding, cleaning, and assessment.
Secondary Data Sampling Criteria and Rationale
While the secondary data used for the initial quantitative assessment were collected for a
specific purpose, they informed the assessment of the research questions. The following criteria
were used to ensure secondary data aligned with the research questions.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 63
Secondary data criterion 1. E4C captures patient-reported outcomes on their care
experiences, and the data offers insight on experiences that trigger departmental service recovery
efforts and subsequent timing of interventions. The data represent all disease sites requiring
treatment intervention.
Secondary data criterion 2. The mined data identify neutral or scores below 3 on a 5-
point Likert scale. These specific scores serve as the trigger for service recovery intervention.
Secondary Data Instrumentation
The secondary data instrument came through assessment of existing Q-Review
®
survey
data. The data conveyed the nature of the event, time and location of treatment, patient
demographics, management response times, the status of complaint resolution sharing, and
recovery close-out. Participants received a seven-question, positively focused survey assessing
their satisfaction with aspects of their care and effectiveness of the providers. Each question was
to be answered with one of five options (5=strongly agree; 4=agree; 3=neutral; 2=disagree; and
1=strongly disagree), and each answer of a 3 or lower triggered a service recovery intervention
by the management team.
All seven survey questions were used in the service recovery assessment. The
department’s intent targets all areas of assessment as potential sources of dissatisfaction.
Domain-specific areas of dissatisfaction can be managed by the matching areas represented in
the frontline management team. The design offered an opportunity to stratify data by domain,
offering targeted areas of improvement opportunity. Table 8 lists the questions used in the
survey, the type of each question, and the type of scale used.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 64
Table 8
Q-Review Patient Experience Survey Questions
Survey Question Question Type Scale Type
1. How would you rate the friendliness of the physician? Interval Likert rating
2. How would you rate the explanations the physician
gave you about your condition?
Interval Likert rating
3. How would you rate the concern the physician showed
for your questions or worries?
Interval Likert rating
4. How would you rate the courtesy and communication
showed by the clerks and receptionists?
Interval Likert rating
5. How would you rate the courtesy and communication
shown by the radiation therapists who operated the
machines for your treatment?
Interval Likert rating
6. How would you rate the staff’s efforts to include you
in decisions about appointment scheduling?
Interval Likert rating
7. How likely are you to recommend our practice to
others?
Interval Likert rating
Analysis of Secondary Data
Analysis of the data collected from the patient-reported Q-Review® survey focused on
descriptive statistics to answer the first research question about attainment of 100% service
recovery compliance for targeted responses. Identification of service recovery opportunities,
subsequent communication with the patient regarding the event, and follow-up timing of closure
was captured in the Q-Review® database and reviewed by the frontline management team
weekly. For this study, this researcher downloaded the raw data into a spreadsheet for
descriptive statistical evaluation. Stripped of participant identifiers, the data maintained
information confidentiality before assessment. The initial phase of the statistical assessment
included an inspection of the data. Alkin (2011) asserted correcting inaccurate data from a
database, reduces the potential for statistical inaccuracies. The entire Q-Review® data series
captured from initial implementation required cleaning to disregard earlier findings that reflected
a slightly varied series of questions. This allowed data review during the period indicating the
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 65
use of the current seven questions when timeframe and identification methods were known to be
consistent.
The cleaned data served as the primary resource for calculation of the Likert-scale
interval question responses, inclusive of counts and their percentages, mean, mode, and median.
Also, dispersion statistics encompassing standard deviation, variance, range, and standard error
mean, as appropriate, described the data reviewed. Microsoft Excel generated all calculated
descriptive metrics and recorded within the data spreadsheet. Overall compliance with service
recovery standards compared the calculated time from service recovery target identification to
initial patient engagement and then to the departmental standard. Monthly compliance facilitated
trending of agreement over time. For this study, the frontline management team was assessed
collectively. This data analysis related to the study’s conceptual framework provided evidence
of the gap between the service recovery performance standard and actual goal attainment
detailed in Chapter Four.
Frontline Management Team Surveys
This study employed a non-probability methodology for the dissertation-specific survey
by eliminating the use of selection randomization techniques to select participants. Kohler,
Kreuter, and Stuart (2018) summarized that probability does not exist in practice applications
and that non-probability samples provide adequate information for descriptive inferences of
small homogeneous populations. The reference to small, similar populations lends itself to the
sampling being purposeful in that specific members of a group are targeted for participation
based on their knowledge and familiarity with the study subject. This is the case in this study, as
the frontline managers are directly charged with mastery of service recovery practice. Survey
sampling identifies participants who adequately represent a target population through
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 66
quantitative data collection. sample selection and data collection methods must adhere to the
group being represented. In this study, the sampling targets the entire E4C frontline manager
team.
Frontline management team survey criterion 1. The E4C radiation oncology frontline
management team is responsible for the effective management of service recovery invoked when
surveys convey patient-reported dissatisfaction with an aspect of care. The management team
represents four frontline operations domains that oversee areas of practice that can influence the
patent perception of care.
Frontline management team survey criterion 2. The E4C radiation oncology frontline
management team manage practitioners who provide patient care. These managers individually
and collectively make judgment decisions on technical, psychosocial, and quality adherence to
practice standards. While E4C sets expectations of care delivered, the culture may reflect
varying degrees of adherence to those expectations.
Frontline management team survey criterion 3. The KMO components in a gap
assessment suggests the management team has the most influence in ensuring service recovery
efforts meet organizational expectations. Group members interact with their sectional care
providers, monitor compliance, are charged with correcting operational gaps by appropriately
pivoting practice delivery to maximize situational challenges and follow up with strategies to
meet the service recovery goal. The survey offered additional numeric quantification of practice
that impacts designed service recovery protocols. Collectively, assessment of the quantified
information discerned compliance with service recovery standards as well as expectations and
efficiency.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 67
Survey Instrument
Fink (2013) noted that the researcher needs to be attentive to survey question design, as
each question should be meaningful to respondents, use standard language and grammar rules,
and be concrete (Fink, 2013). The researcher should avoid biased words and phrases, be
cognizant of their biases, and use caution when asking for personal information (Fink, 2013).
Lastly, each question should have just one thought (Fink, 2013). Therefore, the frontline
management team survey offered numeric, ordinal, interval, and ratio focused quantitative
assessment. This informed the researcher of aspects of KMO influences prompting potential
performance gaps in practice.
As pedagogy and survey length design affect participation, the pedagogy used in the
survey framed the process with demographic assessment, followed by a series of questions
specifically designed to address each research question through an examination of KMO
influencers, consistent with Clark and Estes’ (2008) gap analysis methodology. Represented in
Appendix A are the 16 survey questions along with the scale of measurement and link to the
specific research question(s), demographic stratification methods, and question designation.
This overall rigor ensures survey validity. Appendix A also outlines t the associated KMO
construct, potential analysis, and visual representation conducive to the data.
Survey Collection Procedures
For this study, the survey used for the frontline manager group focused on the sampling
criteria and rationale. All noted radiation oncology frontline managers were targeted to
participate in the study. Participants were introduced to the survey through announcements by
department leadership and manager meetings, which were followed by an email reiteration of
invitation to participate. In that the purposeful group was known to the researcher, email
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 68
addresses and telephone contact lists existed and were used for communication. The voluntary
nature of participation, study purpose and importance, and commitment to anonymous
involvement and confidentiality highlighted areas of significant concern. Follow-up email
correspondence two weeks after the initial email offered a personalized participation invitation
reiterating a desire for their participation along with the survey protocols, assurance of
confidentiality and privacy maintenance, and verbiage on the process if they chose not to
participate.
An online assessment platform facilitated completion of the survey by the frontline
management team. Loomis and Paterson (2018) noted online survey administration offers an
alternative to traditional methods using mail, telephone, and on-site techniques for gathering
data. The use of online service methods was strongly considered because of the ease of use, as
the entire study participant group was very familiar with online surveying. While criticisms of
internet surveys regarding nonresponse bias and differences in the data surface, online surveys
are easily stored with easy accessibility for later review and revision, as necessary.
Survey Analysis
Surveys aid in assessing the statistical results of the data to validate the study hypothesis,
enabling next-step decisions based on objective data and contemplation of variable relationships
and influence on the data assessment (Creswell & Creswell, 2018). As in the secondary data
assessment, quantitative analysis of the frontline management team survey included statistical
descriptors of service recovery KMO influencers. Data analysis regarding the research questions
and conceptual framework were reported through the online platform to facilitate descriptive
statistic calculation. Participant identifiers are stripped from the data to maintain information
confidentiality in, an important maintenance component of this study. Demographic data
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 69
assessment served to stratify the survey findings. The survey data served as the primary resource
for calculation of responses to address the second and third research questions.
In addition to the descriptive analysis, group differences were examined for each of the
survey items per the types of staff managed (nurses, radiation therapists, PSRs), level of
education, and whether the respondent received training on recovery practices using t-tests.
Salkind (2017) describes that performance of a series of difference of means tests, like t-tests, is
the appropriate analysis method to use when examining group differences.
Quantitative Reliability and Validity
Assigning a numerical value to occurrences quantifies observed experiences, and the
primary indicator of research quality surfaces as the validity and reliability of the study’s
measuring tools (Kimberlin & Winterstein, 2008). Reliability refers to assurance that study
protocols were followed consistently and as described (Merriam & Tisdell, 2016). Validity
considers how research results might be incorrect, plausible alternative interpretations and threats
to resulting conclusions (Maxwell, 2013). Collectively, validity speaks to the credibility of
findings while reliability explores the extent of consistency in the findings (Merriam & Tisdell,
2016). With this, consideration of internal and external validity merit discussion
Internal validity. Cross-sectional survey data capture information across a participant
population without regard to timing (Heeringa, West, & Berglund, 2017). The entire population
is selected, and data are collected to help answer research questions. In this case, all patient
surveys were assessed to measure if the service recovery standard was met. This type of data
collection method entails simultaneity bias, whereby the direction of effect between an
independent variable and criterion variable is impossible to detect. As such, the research design
of the study does not account for common threats to internal validity of history, selection, and
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 70
maturation, which all introduce limitations based on timing. While any bias challenges study
validity, internal validity was not a limiting factor, as neither service recovery interventions nor
the practice guidelines were evaluated. The study relied on statistical controls to account for
potential alternate explanations in differences in the outcome variables.
External validity. External validity measures the degree to which research results can be
generalized as being valid across populations not assessed. Can this study be related to other
populations with accuracy and reliability? The quantitative part of this study uses a purposeful
approach to sampling. Generalizability to other service recovery operations in the hospital is not
the goal of the study; the goal seeks to explain radiation oncology compliance with service
recovery and to assess any gaps in KMO influencers in that practice. The final goal looks to
recommend reforms to meet those goals specific to the study’s problem of practice, and, as such,
generalizability inherently is limited.
Measurement reliability and validity. Fink (2013) noted that valid research measures
the study’s construct as intended through the instruments used to gather data. Salkind (2017)
extended the validity concept to include content and criterion validity. Content validity
accurately samples all items for which the test is designed, and criterion validity reflects the set
of abilities to test in current and future settings (Salkind, 2017). The secondary data collection
instrument demonstrated limited validity and reliability. E4C selected questions from the
vendor’s source of commonly asked survey questions gathered from clients and edited for
generalized use. The creators of the Q-Review® survey found a strong and positive correlation
between their instrument and the PGPSS, as key patient satisfaction indicators were highly
correlated between the surveys, demonstrating the concurrent validity of the shorter electronic
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 71
survey (Quality Reviews, Inc., 2017). No other measurement reliability and validity testing or
psychometric assessment by the vendor were noted.
Regarding the validity and reliability of the dissertation-specific survey protocols and
questions, doctorate-prepared practitioners in social work and learning and organizational
development critiqued the interview tools against the problem of practice and research questions.
Their suggestions netted refinement of the interview instruments to establish greater congruence
with the research questions than formulated initially, facilitating reduction of bias and greater
alignment before use. The vetted survey was piloted with five managers familiar with service
recovery practice from the researcher’s organization. The intended survey time of three (3)
weeks minimized threats to validity via history, selection, and maturation factors. There was
some risk noted to the testing threat, as participants could assume that a theoretical response
possibly may be viewed more favorably than an actual personal perspective.
Creswell and Creswell (2018) cautioned that, when using an explanatory sequential
mixed methodology approach, additional validity challenges may surface. The authors asserted
that the accuracy of the overall findings may be compromised if the researcher is not complete in
the qualitative follow-up of the quantitative data, directly linking the two. This researcher vetted
all potential means of data collection on compliance with service recovery data, review of the
complete policies and procedures covering service recovery, and the rigor involved in survey
protocol and questions. Further, Creswell and Creswell (2018) noted validity enhancement
increases if there is a direct link between the participants of both the quantitative and qualitative
components. Service recovery begins with the frontline management team, and exploration of the
qualitative methods illuminates these points.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 72
Qualitative Methods
Creswell and Creswell (2018) noted qualitative findings in a mixed-methods study add
depth, context, and perspective to the quantitative findings. Attride-Stirling (2001) described the
value of qualitative research stems from it being steeped in methodological rigor in all stages.
The qualitative component of this study used semi-structured interviews of frontline
management staff. The interviews reflected the influence of the quantitative findings and the
inherent aspect of an explanatory sequential methodology. Rounding out the qualitative section,
documents and artifacts provide the researcher preparatory information that can influence
findings to address all three research questions.
Interview Participant Selection
The frontline manager interview sampling strategy for this study used a non-probability
technique with an emphasis on purposive methods. A fundamental characteristic of purposive
non-probability technique selects samples based on researcher judgment and target specific
characteristics, beliefs, and attitudes of a population (Johnson & Christensen, 2014; Merriam &
Tisdell, 2016; Rahi, 2017). The researcher interviewed all management team members, ensuring
a collective perspective representation of the four practitioner groups that provide direct patient
care and influence service recovery efforts. The entire frontline management group of the
targeted population provided perspective on service recovery practice. Thus, this qualitative
assessment offers sources of variation including the level of manager in the organization,
manager gender, and manager background/training in service recovery.
This part of the study included 15 members of the radiation oncology management team.
Through the matrix-management relationship with each member, this researcher consistently met
with each person in both management and individual meetings each month to discuss service
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 73
recovery. Recruitment consisted of personally appealing to them to participate in the interview,
as personalized communication denotes value and importance in the engagement (Tesone, 2012).
This request was followed up via email to reiterate the request, the parameters of expectations,
and personal thanks for considering the request. All responded in the affirmative and agreed to
be interviewed May 2019 through August 2019. While these 15 management team members
represent 77% of the overall E4C primary campus management team, it represents all of those
charged with managing departmental service recovery practices. While small sample sizes in
qualitative studies commonly equate to uncertain representativeness proving only suggestive
answers to generally framed questions (Maxwell, 2013), the uniqueness of the sampled group
offsets that potential.
Frontline management team interview criterion 1. The E4C radiation oncology
management team participated in content-collecting interviews. These criterion targets
individuals who oversee areas of practice that can influence patient care and service recovery.
All current management team members participated in the development of the service recovery
procedures, providing an informed group of practitioners with assumed in-depth knowledge of
service recovery expectations and experience in training staff in its intended use. This group
interacts with their sectional care providers, monitors compliance, and is charged with correcting
operational performance gaps.
Frontline management team interview criterion 2. Management team members
identified as challenging to current service recovery were interviewed to understand their views.
This group commonly see themselves as champions of best practices These managers
individually and collectively make judgment decisions on technical, psychosocial, and quality
adherence to practice standards. While E4C sets operational expectations of how care is
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 74
delivered, the culture may reflect varying degrees of adherence to those expectations, entirely
framing this criterion’s importance in KMO influencer review.
Interview Instrument
Interviews are commonly used to gather pertinent content for enlightenment and growth
(Merriam & Tisdell, 2016). Conforming to accepted explanatory sequential mixed methodology
rules, the qualitative assessment came after the completion of the quantitative assessment to
build directly on the quantitative findings (Creswell & Creswell, 2018). The authors noted
research interviews are engagements that have structure and purpose of supporting study and
inquiry (Creswell & Creswell, 2018). The rigor associated with research interview implies the
need for adequate preparation and skill, suggesting that the process can be learned and mastered
(Creswell & Creswell, 2018).
This study’s interview instrument consisted of 19 semi-structured open-ended questions
with appropriate subsidiary probing questions. While participants were asked the same
questions, the question structure prompted open-ended responses. This structure allows
participants to contribute as much detailed information as they want, allowing the researcher to
ask additional probing questions that clarify the primary query to address the research questions
directly. A benefit of open-ended interview interviews is participants can fully express their
responses in detail, providing content rich with qualitative perspective, albeit more cumbersome
for the researcher to filter through the narrative responses for adequate coding (Turner, 2010).
However, according to Gall, Borg, and Gall (2003), this reduces researcher biases within the
study, particularly when the interviewing involves many participants. Crafted to follow the
discipline outlined in the study’s conceptual framework to address the research questions,
Appendix B lists the frontline manager interview questions used for qualitative content review.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 75
Content Collection for Interviews
Securing content from well-constructed interview tools requires attention to rigorous pre-
interview preparation and the delivery of the interview itself (Creswell & Creswell, 2018).
Development of an appropriate interview protocol goes beyond the development of the
instrument itself. The following sections describe the components of content collection.
Interview preparation. Thorough interview preparation maintains an unambiguous
focus on maximum benefit to the study. Turner (2010) cited the work of McNamara that
supports this contention by applying eight preparatory principles in the development of the
interview: (a) choice of location setting that offers little distraction; (b) complete explanation of
the interview purpose of the interview; (c) maintaining confidentiality; (d) interview format
explanation; (e) indication of approximate time commitment for participation; (f) provision of
follow-up contact information; (g) providing an opportunity to ask questions prior to start; and
(h) application of an appropriate data collection methodology inclusive of security practices.
This study used a semi-structured format, which offers greater flexibility, and allows for
expansion of presented ideas as well as elaboration on content meaning (Merriam & Tisdell,
2016). This type of interview invites exploration and offers the researcher opportunities to gather
thoughts on new ideas and topics of study while looking at any variation in manager perspective.
This format allowed the use of probing questions to deepen the study perspective and assist in
triangulating the collective data.
Due to the principal investigator’s interest in the study and the stakeholder participants all
reporting directly to him, there can be influences that introduce confusion participants if he
performs the interviews directly. Even with the best intentions, participant feelings of non-
confidence and bias may manifest as thoughts of being coerced or influenced. To eliminate the
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 76
potential for bias, interviews were conducted by an institutional expert in qualitative research.
Related to coercive and biased potential, Smith and Smith (2018) noted the qualitative
interviewer should also be appropriately trained and sensitive to the impact the interview has on
the participant perspective. As qualitative research is interpretive, interviewer and researcher
reflexive identification of biases, values, and personal background can limit accuracy of data
assessment (Creswell & Creswell, 2018). As such, interviewer skill mastery of limiting these
biases ensures fair assessment of data. Reflecting on this potential, the interviewer was
didactically prepared to conduct qualitative interviews.
Pilot testing. The use of pilot testing assists in surfacing interview design flaws or
limitations, allowing an opportunity for correction before their use (Creswell & Creswell, 2018).
The authors noted the testing should be conducted with participants who have similar interests as
those who will participate in the implemented study. As such, a pilot testing performed with six
managers outside of E4C’s radiation oncology department who offer service recovery
intervention. Feedback from the group facilitated interview question refinement before use.
Interview procedures. All participant interviews were in person, allowing for
assessment of body language and another unconscious signaling (Maxwell, 2013). The
interviews occurred in locations familiar and comfortable to the participants. When a manager
agreed to participate, interview location selection accommodated their preferences, requiring
flexibility on the part of the interviewer. The interviewer captured participant content in written
notes and audio recordings using an encrypted device. Recordings allow the use of direct quotes
and verbatim expressions when conveying the content detail (Weiss, 1994). The interviews were
scheduled for 60 minutes, and no additional follow-up interview sessions were performed.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 77
In starting the interviews, the interviewer introduced themselves, offered perspective on
their credentials, and reiterated the intent of the interview to establish credibility and trust. A
scripted narrative provided consistency in the provision of information and reiteration of
important components of the data collection. Consistent with McNamara’s preparatory
components, the following points were made to participants prior to the interview: (a) provision
of relevant information of the link between the research, practice at E4C, and doctoral effort of
the principal investigator; (b) description of how the project explores service recovery
performance within the department; (c) exploration of how the management team manages
different aspects of service recovery; (d) length of time and explanation of areas of service
recovery being probed; (e) reiteration of confidentiality statement and associated maintenance
practices (secure retention in either a locked file cabinet immediately after discussions or a
password-protected file on a computer); (f) timeline and process for destruction of interview
content; (g) confirmation of receipt of interview informed consent; and (h) note taking strategies
(handwritten and recorded). The interview protocol also included an introductory narrative for
each section of segmented interview questions. The interview protocol is in Appendix B.
Analysis of Interview Content
The review and assessment of interviews occurred throughout this study. This
sequencing provided an opportunity to reflect on the evolution of the study, allowing for
consideration of any directional pivots. Codified interview data notes, transcripts, and
recordings populated analysis software, enabling a structured and consistent means of managing
data for assessment. Software use deepened understanding through data tree and root node
visualization for each KMO influences.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 78
The culmination of the interviews was analysis of their content. Transcription of the
audio occurred via a transcription vendor. Turner (2010) suggests there is value in employing a
third-party consultant (or analytical software) to determine content value based on their
evaluation of the transcribed data. While consultants and software have cost, the value resides in
the attainment of expert perspective, helping to alleviate researcher biases or over-analysis of the
data. The formatted transcripts allowed the use of a standard and widely used qualitative content
analysis software tool purposefully built for qualitative and mixed-methods research.
In this evaluation study, thematic content analysis shaped the coding. After compilation
of the transcribed information, the researcher independently reviewed each transcript and
interpreted and compiled the data into sections or groups of information, known as codes
(Creswell & Creswell, 2018). Kvale (2008) described these themes as a manifestation of
consistent phrases, expressions, or ideas common among research participants. Axial coding,
relating categories and concepts to each other through inductive and deductive assessment,
facilitated categorization into themes that aligned with the research questions. The codes were
organized through associated relationships within each KMO area and research questions. The
researcher performed thematic content analysis to support the rigor obtained through a single
coder assessment, performing quality assurance reviews of earlier coded transcripts as new
thematic content emerged in subsequent interviews.
Document and Artifact Sampling Strategy and Rationale
The use of documents and artifacts for data collection option offers additional
perspectives in mixed-methods research when quantitative methods alone do not fully answer the
research questions (Bretschneider, Cirilli, Jones, Lynch, & Wilson, 2017). The specialized
content reflects aspects of the practice being reviewed, inclusive of its values and culture, which
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 79
makes it a unique perspective to consider during triangulation. Bowen (2009) described the value
of reviewing documents and artifacts in that they provide background and context, insight on
historical events, perspective for asking additional questions, a means of tracking change and
development, and verification of findings from other data sources. This study described the
frontline management team’s guiding principles, compliance, and remediation patterns through
review of existing physical and online documentation. Physical and online documents and
artifacts, are sources of data in qualitative research (Merriam & Tisdell, 2016). All
documentation sources were available to each participant for review. Disclosure to the
participants of the document review occurred before the start of the study. Also, discussion of
this documentation and its maintenance profile occurs periodically during monthly departmental
quality assurance conferences.
As in all data collection, there are advantages and limitations. Advantages are that they
may be the best source of data on a particular subject, and the data found in documents can be
used in the same manner as data from interviews or observations. Also, the data can furnish
descriptive information, verify, emerging hypotheses, advance new categories and hypotheses,
offer historical understanding, and track change and development. Lastly, the data are stable, and
the presence of the investigator does not disturb its quality of the data. Limitations are that
research data must contain information or relevant insight regarding the research questions and
must be obtainable in a reasonably practical yet systematic manner. Also, there may be a lack of
confidence from the fact that documentary material is not explicitly developed for research
purposes, may be incomplete from a research perspective, and may be biased towards the
perspective of the writer or incomplete (Bowen, 2009; Merriam & Tisdell, 2016). Considering
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 80
these points, this researcher contends that review of the artifacts and documentation of E4C adds
perspective.
As previously mentioned, familiarity between frontline management and administration
offered ease in documentation review. Merriam and Tisdell (2016) noted “congruence between
the documents and the research problem depend on the researcher’s flexibility in construing the
problem and related questions” (p. 189). This researcher opted to start with document review
before interviews. This decision reiterated practice parameter expectations and compliance
performance to the researcher, building a knowledge platform with other data gathered through
different sources. As such, document and artifact selection criteria focus selection of appropriate
material.
Document and Artifact Sampling Criteria and Rationale
Document and artifact criterion 1. Residing online and in printed binders, all
departmental policies, procedures, training tools, and employee sign-off records relating to
service recovery were reviewed. The review included inspection of documentation
implementation dates and revision dates to note frequency of review and edits. All noted
documentation was accessible by every sector of the management team to aid in ensuring
consistent opportunity to review and adhere to service recovery expectations.
Document and artifact criterion 2. The Q-Review® software captures service recovery
efforts electronically; all historical and current reports reported on timing, frequency, and service
recovery resolution. The online reporting offered compliance trends stratified against the
management team’s section, providing an opportunity to pinpoint both overall and site-focused
intervention needs. Further, the reporting provided an element of quantitative data as well as
qualitative narrative notations guiding assessment and subsequent staff remediation needs.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 81
Documents and Artifacts Reviewed
The documents and artifacts reviewed were the service recovery policies, procedures,
personal notes, vendor frequently asked questions, and documents on service recovery efforts.
The managerial staff participated in all procedural development, and inclusion of these
documents provided insight into service recovery expectations and offered insight into the
assessment of potential KMO influences on compliance with the departmental target.
Content Collection for Document and Artifact Review
Creswell and Creswell (2018) noted review of public and private documents offers
qualitative insight into the natural operational setting. The authors noted the advantages of the
review as enabling consideration of participant language used, stemming from easily accessible
an unobtrusive sources of information, representing data to which attention has been given, and
needing no further transcription. Document and artifact collection have disadvantages to
consider as well, as not all scribes are equally articulate or have varied perspective, the
documents or artifact may be hard to find or protected, they may need transcribing or scanning
for computer assessment, and documents may be inaccurate (Creswell & Creswell, 2018). The
documents and artifacts used in this study were manager meeting minutes that discussed service
recovery and organizational policies and procedures.
Analysis of Documents and Artifacts
The review and assessment documents and artifacts occurred throughout the entire study.
This sequencing provided an opportunity to reflect on the evolution of the study, allowing for
consideration of any directional pivots. The documents and artifacts reviewed offered
opportunity for study-specific coding, culminating in a data dictionary codebook, enabling
concise communication of the collected research data that promotes understanding and accurate
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 82
interpretation. Coding facilitated the organization of the reviewed data to create categories
inductively and deductively, leading to themes, assertions, findings, and propositions. This
iterative process culminated with the development of tracked subthemes that link to the
conceptual framework and research questions. The data collection form used is in Appendix C.
Credibility and Trustworthiness
Ensuring credibility and trustworthiness of collected data and subsequent outcomes and
findings requires rigorous attention to detail, particularly in mixed-methods studies (Kemper,
Stringfield, & Teddlie, 2003). Cope (2014) referred to credibility as the truth reflected in the
data, requiring stringent verification of the findings. Similarly, Sandelowski (1986) described
the need to demonstrate the link between collected data and its application in practice to establish
credibility. Extending that thought, Graneheim and Lundman (2004) stated trustworthiness
examines not only credibility but also the maintenance of consistency, dependability, and
transferability. Attainment of credibility and trustworthiness required strict attention to
maintenance of the rigor of study controls, review of conclusion interpretations of the data
providers and integrated triangulation techniques.
The triangulation of data offered multiple views of information linking quantitative and
qualitative aspects of service recovery, establishing credibility and trustworthiness in the data
and findings. Interviews with the management stakeholders, conducted by an independent
interviewer, strived to elicit their professional and application practice perspectives experienced
during service recovery, framed through the lenses of KMO influences. This perspective shaped
the conceptual framework for the study; these stakeholders, by design, have the responsibility of
ensuring compliance with service recovery expectations and improving patient satisfaction.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 83
Merriam and Tisdell (2016) solidify the importance of trustworthiness in studies in citing
the link between the credibility of the researcher and related agents and the perception of the
importance of the study. The researcher offered recognized expertise in radiation oncology
operations and staff development by leveraging practice as well as educational and
administrative experiences gained through tenures at two world leaders in cancer management.
The study was vetted through two institutional review boards and supported by E4C institutional
and departmental leadership. Sharing this rigor with potential participants cemented
trustworthiness of the project and its intent.
Ethics
The foundation of modern medical research ethics developed after World War II, as the
atrocities of war prompted introduction of ethical conduct principles and standards in biomedical
research (Koyfman & Yom, 2017). Ethical research entails respect for participants’ autonomy,
confidentiality and self-determination, ensuring full disclosure of risks and benefits of
participation and voluntary consent in valid and rigorous investigations (Emanuel, Wendler, &
Grady, 2000; Townsley, Selby, & Siu, 2005). As Donaldson (2017) noted, “behaving honestly,
ethically, and with integrity is an individual responsibility” (p. 247). The author charged
radiation oncology researchers to pursue knowledge with the utmost respect, honesty, and
compassion for participants. Through these considerations, sound ethical standards and
principles govern radiation oncology treatment and research practices, requiring keen attention to
the full protection of patients and research participants (Donaldson, 2017; Koyfman & Yom,
2017; Maxwell, 2013). In assessing the KMO performance gaps, the researcher’s maintenance
of ethical standards and principles ensures accurate understanding of the stakeholder’s ability to
meet service recovery expectations.
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An important ethical consideration resides in the relationship between stakeholder and
researcher, as all primary stakeholders reported directly to the researcher. This relationship
introduces the potential for employee concern regarding findings that might uncover knowledge
or motivational challenges. Glesne (2011) cautioned that researchers must expressly adhere to
maintaining participant anonymity, as not adhering to this premise decreases a study’s integrity.
Rubin and Rubin (2012) noted that, during data collection, information may surface that exposes
employee knowledge or motivation limitations that, during normal operations, would result in
disciplinary interventions. Similarly, Glesne (2011) stated that, if the information relates to the
study, there is an obligation to communicate the dangerous information so that anonymity is
fully maintained.
Attention to the relationship between researcher and participants is also necessary for
limiting undue influence and coercion opportunities, particularly as manager of the study
participants. Specific to this study, the researcher directly managed the primary stakeholder
group of the study, providing operational expectations, annual performance assessment,
provision of accolades, and as needed, disciplinary actions to each manager. Further, the
primary stakeholder group knew how important this study was to the researcher. As both Glesne
(2011) and Rubin and Rubin (2012) noted, this level of intimacy presents an ethical dilemma that
requires management. Maintenance of study ethical integrity required securing assistance from
the organization’s human resources personnel to have someone from that team engage the
primary stakeholders during survey and interview assessments directly.
As noted, this researcher’s interest in the study relates to organizational expectations on
attaining performance goals around service recovery execution and appreciation for the practice.
That leadership interest potentially introduces confusion among the primary stakeholders. Even
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 85
with the best intentions, participant feelings of non-confidence and bias may manifest as
thoughts of being coerced or influenced. To combat that potential, execution of detailed
informed consent was paramount. Merriam and Tisdell (2016) noted that, while informed
consent, right to privacy, and dispelling deceptive practice need rigorous consideration, the
researcher’s willingness to reflect on their values and sensitivity to address challenges as they
occur is most important. Limiting coercion and undue influence requires assurance that the
informed consent is thorough, not rushed, and not offered at a time inconvenient to the staff
managers (Merriam & Tisdell, 2016). Again, specific to this study, participants were assured
participation was voluntary and that there was no pressure to participate or answer in any way
perceived to be favorable to the researcher.
Limitations and Delimitations
Even the most thorough and exacting studies demonstrate limitations through systematic
biases the researcher did not or could not control and which may influence results and
conclusions (Price & Murnan, 2004; Simon & Goes, 2013). Fully understanding these
limitations and identifying them offers other researchers building on the current research
opportunity to addressing them in the future (Simon & Goes, 2013). This study requires
assessment in both quantitative and qualitative domains.
Quantitatively, the legal constraints of not disclosing full identification of E4C on the Q-
Review® survey tool limits the number of responses received. While the response rate of the
self-reported survey is 20%, some patients communicated they did not adequately respond to the
survey because the institution name did not appear on it. The legal explanation of not allowing
inclusion of the name is maintenance of patient anonymity. This limitation continues to be
reviewed by the institution. This contrasts the qualitative perspective.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 86
Simon and Goes (2013) cited reliability and validity as limitations in qualitative studies.
The stakeholder group of the study is tight-knit group of professionals. Data validity and
reliability depended their willingness to be open and honest in their communication during
interviews. Maxwell (2013) described two specific validity threats that may influence the data:
bias and reactivity. The author outlined the potential for researcher selection of information that
they think fits their theories and selection of data that catches the interest of the researcher. Both
instances employ subjective judgment, or bias (Maxwell, 2013). The author stated that
influences introduced by the researcher can affect the data.
Validity speaks to the congruence of reported findings to reality (Merriam & Tisdell,
2016). From a reliability position, is the information trustworthy and believable? The researcher
is obligated to offer a robust series of questions and interview protocol ensuring consistency in
interview delivery, limiting variation that can introduce data integrity challenges. The study’s
conceptual framework triangulates survey results that inform goal compliance measures,
interviews that offers greater depth of perspective, and documents/artifacts describing policies
that set expectations. Triangulation provides checks and balances on data, limiting the impact of
any single source of data (Maxwell, 2013; Merriam & Tisdell, 2016). Delimitations that evolve
from these limitations require consideration as well.
Delimitations arise from a study’s limitations in scope or by researcher conscious
inclusionary and exclusionary decisions (Simon & Goes, 2013). Typically driven by researcher
choice, the Simon and Goes (2013) contended that study objectives and questions, participants,
and theoretical framework may embrace biases and confound the research questions of the study.
In the case of this service recovery study, delimitation requires review of each decision made
during study conceptualization with consideration to those areas that may not be explicit.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 87
Regarding this study, the participants were members if of the frontline management team
directing staff who engage patients under care. It is possible that variations among managers in
different core disciplines may affect service recovery implementation and maintenance.
Subsequently, compliance with expectations may affect outcomes and findings.
Conclusion
This chapter explored how speculated influences of KMO challenges manifest as gaps in
management service recovery goals. The quantitative assessment of the data related to service
recovery performance coupled with the survey data validated the assumed causative factors of
those performance gaps. These quantitative and qualitative data provided greater breadth and
depth of understanding of the problem of practice, leading to the identification of potential
solutions. Chapter Four offers an assessment of the quantitative outcomes and qualitative
findings of the management service recovery process in E4C’s radiation oncology practice.
Lastly, Chapter Five transitions those outcomes and findings into research-based performance
solutions and considerations, providing a platform for related study.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 88
CHAPTER FOUR: RESULTS AND FINDINGS
Guided by the framework of this explanatory sequential mixed-methods study, Chapter
Four reports a summary of the quantitative and qualitative data analysis and findings regarding
the problem of practice and research questions. The problem of practice studied in this research
evaluates the effectiveness of service recovery practices at E4C’s radiation oncology department
and explores aspects of service recovery. This study’s conceptual framework and three research
questions directly relate to a review of gaps in frontline management knowledge and skills,
motivation, and organizational influences.
As an evaluation study, the research framework and questions used examine elements of
service recovery and their relationship to improving patient engagement, patient satisfaction, and
service recovery sustainability in practice. These are the three study research questions:
1. To what degree is E4C’s radiation oncology department meeting its goal of providing
100% of service recovery for Q-Review
®
scores below the self-reported score of “3”
within 24 hours of receipt by Q4 2019?
2. What are the frontline manager’s knowledge, motivation and E4C’s radiation oncology
department influences related to achieving its goal of providing 100% of service recovery
for Q-Review
®
scores below the self-reported score of “3” within 24 hours of receipt by
Q4 2019?
3. What are the recommendations for organizational practice in the management team’s
knowledge, motivation, and organizational resources related to achieving its goal of
providing 100% of service recovery for Q-Review
®
scores below the self-reported score
of “3” within 24 hours of receipt by Q4 2019?
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 89
This chapter starts with a review of the data sources with a review of participating
stakeholders and is followed by finding and result assessment by research question. Regarding
the first research question, findings are only presented once as there is one-to-one and exclusive
mapping of the secondary data for that question. Further, the results for both the second and
third research questions employ mixed-methods reporting, combining survey quantitative data
with qualitative document and artifact and interview information.
Data Source Collection Overview
Quantitatively, the study assessed existing secondary data, patient health information,
filtered to evaluate service recovery timeline compliance for reported areas of dissatisfaction.
Also, a frontline manager survey exploring their KMO influencers on service recovery practice
offered quantitative data. Qualitatively, a document and artifact review connected service
recovery procedural documentation focused on preparation and early implementation.
Performed concurrently, interviews explored management perception and understanding of
service recovery practice. An overall total of 885 independent data instances were collected
during the five-month collection and review period. Data collection followed the four-arm
platform described in Chapter Three. Table 9 presents the number of instances targeted and the
associated number assessed by study arm.
Table 9
Data Arms, Targeted Instances, Assessed Instances, and Percentage Completed
Targeted
Instances
Assessed
Instances (n)
Percentage
Completed
Secondary data (patient-reported surveys) NA 775 NA
Frontline manager surveys 15 12 80.0%
Frontline manager interviews 15 11 73.3%
Document and artifact analysis 33 33 100%
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 90
Review of the separate data sources prior to triangulation offers perspective that deepens
understanding of the service recovery explanatory experience of this study. The following
section reviews the managerial staff surveyed followed by a description of the interviewees.
Participating Stakeholders
The stakeholder group of focus for this study encompassed the frontline managers at
E4C’s Department of Radiation Oncology. This population comprised a purposive 15 full-time
managers that supervise frontline practitioners that deliver and facilitate radiation oncology
treatment delivery across disciplines. While the study used four data sources, two of the sources
did not engage the stakeholders directly during the study. The next section reviews the
composition of the data sources that directly engaged the stakeholder participants.
Survey Participants
During the survey period of June 11, 2019 through June 20, 2019, 12 surveys of the 15
targeted were collected, yielding an 80% participation rate. Each of the 12 surveys were fully
completed. Of the 12 survey respondents, eight reported having a bachelor’s degree, two
completed a master’s degree, and two cited having a high school diploma. Also, of these 12
respondents, six were radiation therapy managers, four were administrative managers, while two
were noted as “other,” classifying themselves as non-discipline-specific managers active within
service recovery.
The study also captured the variation in participant experience. Figure 3 represents the
number of years employed by E4C in their current managerial position, while Table 10 displays
the count and percentage of respondents by their number of years of experience. The overall
experiential longevity in healthcare practice was not assessed as part of this survey.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 91
Figure 3. Frontline manager years employed in current position.
Table 5
Frontline Manager Years of Experience, by Count and Percentage (n = 12)
Years of experience in role Count Percentage of sample
0 – 1.99 years 4 33.3%
2 – 3.99 years 2 16.7%
4 - 5.99 years 3 25.0%
6 or more years 3 25.0%
Interview Participants
A semi-structured interview protocol was used to conduct the interviews. As service
recovery expectations are part of participants’ position function, there was no need to identify
additional criteria to enable their participation. The same 15 potential interview subjects
identified for the survey were targeted for interviews. From the pool of 15 potential frontline
managers invited to participate, 12 subjects formally responded to the invitation and 11 were
interviewed, yielding a 73.3% interview completion rate. While fewer respondents completed
the interview than the survey, saturation was achieved after the completion of eight interviews.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 92
Table 11 shows the breakdown of the 11 interview participants by gender, service discipline, and
years in current position.
Table 6
Frontline Manager Interview Participants (n=11)
Gender
Male 5 (45.5%)
Female 6 (54.5%)
Discipline
Radiation Therapy 5 (45.5%)
Administrative 3 (27.3%)
Other 3 (27.3%)
Years in Current Role
0–1.99 4 (36.3%)
2–3.99 3 (27.3%)
4–5.99 2 (18.2%)
6+ 2 (18.2%)
Results for Research Question One
Quantitative assessment formulates the foundation of this study and is assessed first. As
such, the presentation of the secondary data provides one-to-one, exclusive mapping specific to
that question.
Secondary Data Results and Findings
The secondary data, collected between June 2017 and June 2019, showed 775 instances
of reported scores of 3 or lower on a 5-point Likert scale. Table 12 lists the descriptive and
dispersive statistics of the service recovery efforts over a two-year assessment period.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 93
Table 12
Statistical Assessment of Frontline Manager Adherence to 24-Hour Timing
Timing
Variable
Mean of Percent
Completion
Standard
Deviation
Range Minimum Maximum
24-hours 32.43% 0.14094 0.415 17.80% 59.30%
While available data for several points of invocation time for service recovery completion
was collected, only the 24-hour time is pertinent to the service recovery target assessed in this
study. Over the span of the assessment period, the target of 100% service recovery within a 24-
hour period was not achieved. The mean score of 32.43% registers well below the 100% target.
The standard deviation of 0.1409 shows times to response are tightly clustered, mirroring the
results around subsequent measured data, with a curve spread of 41.5%, or 0.415 range. This
surfaces with a broad range of 24-hour compliance scores (17.80% to 59.30%); the broad range
of performance variability suggests a potential to stabilizing performance at the higher range of
performance.
To understand frontline manager perspectives on service recovery more fully, a sixteen-
question online survey queried them on their thoughts on practice aspects. The descriptive and
dispersive results of the frontline manager survey are in Appendix D. The quantitative arms of
the study yielded three discoveries. First, since its implementation, the targeted goal of starting
service recovery interventions in 100% of appropriate cares within 24-hours has never been met,
which connects to the first research question. Second, while all stakeholders of interest
understand the importance of service recovery and profess they have command of the knowledge
to invoke it, some do not practice it consistently, which connects to the second and third research
questions. Third, there are various opinions regarding the adequacy of resources available to
provide staff development, timely feedback, and facilitation of information transfer, which
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 94
connects to the second and third research questions. The next step in the study forwards this
quantitative baseline to explore the depth of these occurrences and investigate reasons and
rationale for the outcomes qualitatively.
Application of Findings to Research Question One
The first research question was designed to establish the degree of performance
compliance with the expectation that service recovery will be started within 24-hours of receipt
of patient feedback scored at a level of 3 or below for E4C’s radiation oncology department. As
noted earlier, the findings of the secondary data show one-to-one and exclusive mapping to this
question. In review of the findings, the stakeholders have never met the targeted mark over the
span of the assessment period. While only the 24-hour time for service recovery is pertinent the
research question, the performance levels of the frontline managers present performance
perspectives that may surface. Figure 4 depicts the performance of the stakeholder group over
several timelines. This graph shows a higher percentage of compliance, albeit not fully realized
at any level, occurs over time.
Figure 4. Service recovery adherence over various timelines.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 95
Results for Research Questions Two And Three
Possible challenges in any of the KMO domains are addressed via the second and third
research questions. The findings confirm a problem of practice exists, as the expectations as
outlined have not been met. The broad range of 0.415 observed in the 24-hour assessment
(Table 12) suggests a potential to stabilizing performance at the higher range of performance.
Department leadership should continue to monitor and, more importantly, report on this
information as reform solutions surface in response to achieving the performance goal. In an
explanatory sequential mixed methodology study, qualitative assessment deepens the initial
assessment of the uncovered quantitative findings. As such, the presentation of the document
and artifact review and the frontline manager interviews follow the quantitative frontline
manager survey findings, providing that depth needed for problem clarity.
Frontline Manager Survey Results and Findings
To understand frontline manager perspectives on the service recovery process more fully,
a 16-question online survey queried practitioners on their thoughts on practice aspects. The
descriptive and dispersive results of the frontline manager survey are in Appendix D.
Quantitative research offers insight into a phenomenon by collecting and assessing for
phenomenon explanation. In this mixed-methods study, it serves as a foundation to understand
the service recovery platform performance at E4C’s department of radiation oncology. Use of
this information facilitates generalizations or predictions about a population, in this case the
practice of service recovery. The quantitative arms of the study yielded several discoveries:
• While all stakeholders of interest understand the importance of service recovery and
profess that they have command of the knowledge to invoke it, some do not practice it
consistently (maps to RQ2 and RQ3)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 96
• There are various opinions regarding the adequacy of resources available to provide staff
development, timely feedback, and facilitation of information transfer (maps to RQ2 and
RQ3)
The next step in assessment to answer the second research question forwards this quantitative
baseline to explore the depth of these occurrences and investigate reasons and rationale for the
outcomes qualitatively.
Document and Artifact Results and Findings
A total of 33 documents and artifacts comprised four distinct categories: metric
communication, policies/procedures, minutes/notes, publications/handouts. Figure 5 depicts the
distribution of the 33 documents and artifacts across the noted categories which served as the
initial qualitative data captured in the study.
Figure 5. Distribution of document and artifact categories.
Review of the 33 documents and artifacts noted 22 codes which yielded nine basic
themes. Table 13 reflects the flow of the codes, their frequency, issues identified by the codes
and the resulting themes.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 97
Table 13
Document and Artifacts Codes, Frequencies, and Themes
Codes (frequency) Issues Considered Identified (Basic) Themes
- Vision (3)
- Expectations (3)
- Outcomes (3)
- Rationale (3)
- Importance (2)
• patient satisfaction
• care compliance
• real-time feedback
• quality of care
• patient needs
• connection with patient
• patients being heard
• investment
1. Service recovery is a high
priority for the E4C radiation
oncology
2. Clear expectations frame and
compel behavior
- Process development (5)
- Staff training (8)
- Discussion (4)
- Policy and procedure
development (2)
- Staff feedback (3)
- Staff challenges (3)
• patient communication
• staff familiarity
• competency
• feedback value
3. Policies and procedures need
to be clear to promote
expected outcomes
4. Training protocols reinforces
standards and expectations
5. Participant feedback
facilitates process
improvement
- Engagement (5)
- Discussion (2)
- Pilot launch (5)
- Communication (6)
- Main stakeholder
feedback (5)
- Other stakeholder
feedback (4)
• bandwidth
• retooling and
adjustment
• feedback
• measurements
6. Successful project results
require engagement and
review
7. Program adjustment should
reflect expected practice
- Metrics (2)
- Reporting (5)
- Onboarding new staff (1)
- Staff meetings (2)
- Retraining (1)
• dissatisfaction trends
• addressing deficiencies
• feedback to staff
• measurements
• frustration
• competency
8. Program sustainability
requires performance review
9. The program benefits from
periodic maintenance
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 98
The nine themes were then arranged into two broad groupings based on the related
conceptual content. Table 14 depicts the sequential flow of nine basic themes into more explicit
organizing themes then deduced into two unifying global themes. The document and artifact
codebook reside in Appendix E.
Table 14
Document and Artifacts Basic to Organizing to Global Themes
Themes as Basic Themes Organizing Themes Global Themes
1. Service recovery is a high
priority for the E4C
radiation oncology
2. Clear expectations frame
and compel behavior
Importance of service
recovery
Successful service recovery
implementation is of
important to E4C
3. Policies and procedures
need to be clear to promote
expected outcomes
4. Training protocols
reinforce standards and
expectations
5. Participant feedback
facilitates process
improvement
Framing service recovery
practice
6. Successful project results
require engagement and
review
7. Program adjustment should
reflect expected practice
Preparation and refinement
are essential to success
Service recovery
sustainability requires a
commitment to consistent
program review
8. Program sustainability
requires performance
review
9. The program benefits from
periodic maintenance
Service recovery
maintenance
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 99
Interview Results and Findings
Eleven interviews were completed as the final assessment of the qualitative phase of the
study. The semi-structured interviews yielded information not initially anticipated as thematic
data results. Table 15 depicts results and findings captured during the interviews organized by
KMO categories and two inductive categories that surfaced during analysis.
Table 15
Frontline Manager Interview Overall Results and Findings
Category Codes Themes Global Theme
Knowledge
Influence
• Criteria for
Success
• Definition of
service recovery
• Connection to
patient
Satisfaction
• Policy &
Procedures
• Participants had similar
definitions of service recovery,
centered on the patient
experience.
• Most participants correctly
understood the department’s
policies and procedures for
service recovery, with a few
exceptions.
• While immediate outcomes for
service recovery were well
understood, long-term goals of
service recovery were unclear.
Participants
understand the
connection
between patient
experience and
satisfaction, but
lack clarity on the
long-term goals
for service
recovery.
Motivation
Influence
• Personal
motivations
• Extrinsic
motivations
• Staff interest
o Staff
receptivity to
feedback
• The desire to facilitate a
positive experience for patients
was a high internal motivating
factor.
• Department emphasis on
service recovery and job
expectations served as a form of
external motivation.
• Staff were generally receptive
to service recovery, but
successful onboarding and
tactful follow-up are key.
• Calling patients with a neutral
rating or about a systemic issue
negatively affected motivation
Motivation is
aligned with
understanding the
institutional goals
for service
recovery.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 100
Table 15, continued
Category Codes Themes Global Theme
Organizational
Influence
• Expectations &
Importance
• Feasibility of 24-
hour period
• 3-star threshold
• Need for support
o Staffing
challenges
• Participants perceive that the
department has high
expectations for service
recovery.
• Participants understand the
rationale for the 24-hour follow-
up, but have difficulty meeting
this expectation.
• Participants pushed back
against the expectation that they
carry out service recovery after
a 3-star review.
• High expectations increase call
volume: Staffing support is
needed to meet department
expectations.
Participants
understand that
service recovery is
a high priority,
however struggle
to meet
department
expectations.
Patient Reactions
to Service
Recovery Call
• Handling difficult
interaction
• Positive patient
experience
• Patient changes
tone/ fear of
retaliation
• Patients expressed surprise at
receiving a phone call after the
survey was complete
• Some patients tempered their
comments, worried that it
would negatively affect
interactions with their care team
The process of
introducing
patients to the
survey and
handling difficult
calls should be
key components of
service recovery
training.
Training &
Recommendations
• Feedback for
efforts
• No formal
process
• Feedback on
service recovery
survey items
• There is no formal training
process for service recovery;
staff relied on their own
experience and expertise
• Staff were interested in
feedback about their service
recovery performance
• Managers wanted input on how
survey items were selected and
explained to patients
A standardized
training process
will clarify
organizational
goal for service
recovery and
enhance both
knowledge and
motivation.
The distribution of key codes and concepts across interviews, organized by domain, are
in Appendix G. In a dataset this size, reporting frequencies alone can be misleading and
warrants explanation. For instance, “lack of clarity on data use” was coded 10 times, but only
appears across five transcripts, meaning that significant statements related to this concept were
concentrated among a handful of participants. The document in Appendix G focuses on the
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 101
distribution of more inductive codes and key concepts within those codes as some code
distributions provide less useful insights than others, such as when the participant’s statement
was a direct response to a question in the interview guide. In this case, it is more useful to report
the underlying concept. In one case, all 11 respondents spoke about definition of service
recovery because they were directly asked about it. Of that number, 10 people tied their
definition directly to patient experience and voice.
Knowledge, Motivation, and Organizational Results and Findings
Based on the data collected, the study results and findings are framed categorically by
KMO influence. Research questions two and three addressed and synthesized in the following
sections. RQ1 looks at compliance with the expectations and will be assessed using the
secondary data. For RQ2 and RQ3, the findings emerge through assessment framed by Clark
and Estes’ (2008) KMO gap analysis model. The specific KMO gap categories for the study’s
research questions were
1. Knowledge influences: declarative (factual), declarative (conceptual), and procedural
2. Motivation influences: goal orientation theory and interest theory, and
3. Organizational influences: cultural models and cultural settings
Each of the influences assumed the existence of gaps in practice. These presumed gaps
where either validated, partially validated, or not validated at all based on the qualitative
analysis. It is important to note here that in this purposive study, construct validity considers the
degree to which a finding conforms to the original position/claim proposed (McEwen &
McEwen, 2003); the question becomes how close the inference agrees with the findings. The
assessment reviews validation of a gap existing between expectation and actual/perceived
performance and agreement. KMO influences were noted as being validated when there was
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 102
30% or less agreement from quantitative data and any qualitative disagreement. An influence
was deemed not valid when there was 75% quantitative data agreement and no qualitative areas
of disagreement. All variations of reported data in between meant the influence was labeled
partially valid. An example of those are quantitative data that had varied agreement levels and
challenges noted qualitatively. Partially valid influences met the metrics when some participants
had a valid need and others had no need.
Knowledge Results and Findings for Research Questions Two and Three
The knowledge results and findings were captured through several survey and interview
responses and were thematically coded for assessment. The importance of knowledge command
in practice frames the knowledge finding section. An example of an overarching mindset that
embraces the intent of service recovery practice was brought forward when one participant said,
I think service recovery is how much energy we put towards talking to patients that feel
as though their service wasn’t to the standard that [E4C] has set. I think since my time at
[E4C], they’ve always held a very high standard. And, when that standard is not met, it
is not a sweep it under the rug issue. It’s action needs to be taken to address it. So, at
[E4C] I think service recovery is extremely important. (C08)
This perspective expresses the integration of service recovery protocol into practice and a
commitment to improving patient experience by being willing and prepared to address patient
needs. With this quote as an introduction to knowledge influence exploration, the following
sections detail how frontline managers’ knowledge and skills affect the operational performance
goal of providing 100% of service recovery for Q-Review
®
scores below the self-reported score
of 3 within 24 hours of receipt by Q4 2019.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 103
Knowledge influence 1: The frontline management team needs to know the trigger
points for service recovery procedures. The findings partially validated this influence with
evidence that a gap exists in knowledge of the trigger points for service recovery procedures.
The frontline managers in the study were prepared with training on the importance of service
recovery, as there were 14 instances of coded responses in the 33 documents and artifacts
supporting the basic theme of clear expectations framing and compelling behavior as well as the
importance of service recovery. When asked about their ability to fully identify the steps
required in the service recovery protocols in the quantitative survey, 11 of the 12 frontline
managers noted high agreement with this statement, yielding 91.7% overall agreement with
54.5% citing a strongly agree response, validating their knowledge of invoking service recovery
when needed.
The overall agreement strength in the survey question that asked about confidence in
frontline manager ability to know when to use service recovery techniques when it is appropriate
was not as strong; six respondents agreed or strongly agreed with the statement with five
somewhat agreed. While most frontline managers professed they could identify the trigger point
for service recovery, their confidence in knowing when to invoke it was less definite.
Most participants correctly understood the department ’s policies and procedures for
service recovery, with a few exceptions. Most participants mentioned that the department’s
guidelines for service recovery were to call all patients with a 3-star rating or lower within 24
hours. This validates the premise that frontline managers understand when to invoke service
recovery interventions, albeit with some noted variation. Some participants misunderstood the
window to be 48 hours, or that a repeat patient may not need to be called. One respondent noted,
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 104
I think it’s goal was to call everyone within 48 hours. The expectation is try two times.
If you don’t get through the first time, leave a voicemail, call again. And if you don’t get,
leave another voicemail for them to call you back. But at that point the two efforts is
enough. (C08)
This response reflects confidence in incorrect information. Furthering thoughts of uncertainty
around command of service recovery timeframe and process knowledge, another frontline
manager said,
Yeah, and sometimes, to be honest with you, I use my judgment. If it’s the same thing
and I’ve already spoken to him last week, I really don’t. I just let them know, “Hey,
heads up,” but I don’t feel like bothering them again, calling them again. (C03)
This response demonstrates that, while there may be understanding of the core trigger knowledge
component of practice, there was some variation in process understanding between professed
knowledge as seen in the survey response and what surfaced in this interview response. To
summarize results for the first knowledge influence, most participants correctly understood the
department’s policies and procedures for service recovery, but there were exceptions. This
means the influence is partially validated, and it is and highly probable that a gap exists.
Knowledge influence 2: The frontline management team needs to understand the
link between service recovery, patient engagement, and patient satisfaction. The findings
validate that frontline managers do understand the links among service recovery, patient
engagement, and patient satisfaction. The frontline managers were trained on the importance of
those links. Again, there were 14 instances of coded responses in the 33 documents and artifacts
supporting the basic theme of clear expectations frame and compel behavior as well as the
importance of service recovery. The reviewed documents and artifacts focused specifically on
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 105
the importance of and focus on patient satisfaction, patient needs, and connection with the
patient. A note in one of the documents and artifacts was to “give patients voice – let them know
we care.” This typifies the focus on patient engagement as an important part of service recovery.
When the survey asked about the frontline managers’ conceptual knowledge of the link between
service recovery and patient engagement, all 12 respondents noted high agreement with this
statement, yielding 100% agreement with 58.3% citing a strongly agree response to the question.
These results may mean there has been transfer of the idea of the link from theory into the
frontline managers beliefs and adoption into practice.
Participants had similar definitions of service recovery, centered on the patient
experience. When asked to describe service recovery in their own words during the interview,
participants grounded their definition of service recovery in patient experience, allowing patients
to be “heard” and presenting an opportunity to “regain patient trust.” Service recovery was
widely understood to be in response to a negative patient experience. An example of
understanding this conceptual knowledge premise was provided:
I would define service recovery as a point where a patient is dissatisfied enough to be
vocal. And that the team needs to be responsive whether or not they could actually
correct the situation. I think they just need to hear and show the patient that they’re
listening. (C07)
This frontline manager detailed the importance of patient engagement and the value of that
exchange with some urgency, concern, and acknowledgement of the need to be attentive to their
needs. The understanding of what drives a patient to reach out when dissatisfied reinforces the
command of a more complex and higher taxonomy level.
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By framing service recovery in terms of patient experience, participants understood
experience to have a direct influence on how patients rated satisfaction with their care. When
prompted, most participants agreed that it had a “direct” influence. The interviews confirmed the
link between service recovery and patient engagement. One interview participant framed this
thought by saying,
The more the patient has a positive experience and feels like their therapist cares about
them, the staff around cares about them, then their satisfaction is, you know, it’s linked
directly. (C01)
This respondent describes the power of the relationship between the frontline provider and the
patient. Service recovery offers opportunity to connect with the patient when they experience
challenges in care caliber. To summarize knowledge influence 2, participants correctly
understood link between service recovery and patient engagement and satisfaction; no
performance gap existed.
Knowledge influence 3: The frontline management team needs to know how to
engage patients during service recovery procedures. The findings partially validated
evidence of a performance gap in frontline managers knowing how to engage patients during
service recovery procedures. Mastering the full breath of procedural knowledge requires effort.
In reviewing the related documents and artifacts that spoke to staff familiarity, competency, and
feedback value, 25 coded instances within the 33 documents supported three basic themes:
policies and procedures need to be clear to promote expected outcomes, training protocols
reinforces standards and expectations, and participant feedback facilitates process improvement.
These documents and artifacts denote the need to be comprehensively trained to maximize the
service recovery platform to provide the patient and the team with the greatest potential to meet
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departmental expectations. Linked to this knowledge influence, the survey queried the frontline
managers by asking if service recovery training prepared them to address patients when they are
not satisfied with their care. The question yielded 11 respondents answering in the “agreement”
range, but there was a spread over that range with the majority closer to the neutral responses:
three strongly agree, three agree, and five somewhat agree.
There may be some uncertainty in conviction level. It is important to realize the
questions speaks to service recovery outcome, which needs to be considered across the entire
service recovery platform and requires comprehensive understanding.
While immediate outcomes for service recovery are well understood, long-term goals of
service recovery are unclear. Almost half of the interview participants were unsure as to how
service recovery data would be used, which ultimately affected other domains (motivation and
organizational influences) for carrying out service recovery-related tasks, particularly when
patients called about structural issues such as wait times. While participants felt that a successful
service recovery call meant that a patient felt heard, metrics for long-term success need to be
clarified. In support of this position, one respondent noted,
I don’t know what’s been done to prevent it happening again. Because I feel we could do
more to prevent it from happening again. Whether it be going to speak with that patient
when they come back next. Or ensuring…wait times are just so hard to control. But, I
feel like the patient filled out the survey, we call them we apologize for the wait, we see
what we can do. But then is anything actually ever done? So, I think that’s where I
struggle with it. I don’t know, there is no, there doesn’t seem to be a tabulation like at the
end of like if we’re actually fixing anything. (C02)
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This level of uncertainly can erode the service recovery platform. The respondent expresses
uncertainty of how the information is being used to improve practice. While the complex nature
of this position touches other domains, the core needs of preparing frontline managers with tools
to engage patients effectively through service recovery resides in the knowledge domain.
Further supporting this position, another frontline manager expounded on this area of concern: “I
don’t know what anyone does with these. Other than me assigning, me sending an email to those
attending when they have a comment that references them” (C09). This supposition that there is
a disconnect between the higher-level expectation and the functional reality in this part of the
process. Not having the full continuity of being prepared to address potential challenges affects
overall program success.
Patients expressed surprise at receiving a phone call after the survey was complete.
Participants noted that most patients did not expect anyone to follow up on their feedback; rather,
that this information would be “sent into the void.” Often, this would lead to a positive service
recovery experience, as patients felt that their concerns were being listened to, which evidences
metacognitive reflection. One respondent states,
I think a lot of patients are very surprised and have very positive feedback that we
actually did call, especially when they have something that they were concerned about.
So it’s gotten a lot of people who are like, “Can’t believe you actually called, like, This is
great. Thank you so much for following up.” And that’s great. (C04)
This narrative offers the respondent’s reflection and thoughts on the responses received during
service recovery. A metacognitive process ensued to confirm appreciation of the results.
Another frontline manager notes similar reflections on patient engagement:
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Surprised that we’re actually calling them back. That the survey actually went
somewhere. And that’s a good percentage, high 90%. I was shocked. The truth is the
majority of the patients, they’ll say oh, thank you for calling us and I was just frustrated.
The team was great. It’s a 5-minute phone call. That one particular guy I had to call
three or four times, he just wanted to talk. He was an older guy and he just appreciated
the fact that I was calling. (C07)
Realizing the wealth of personal satisfaction surfaces between the words of this frontline
manager. This manager engaged this patient on several occasions because of the patient’s needs.
While there is an expectation of this level of engagement, the tone that the respondent exudes in
this narrative shows an understanding of the process and its value.
Some patients tempered their comments, worried that it would negatively affect
interactions with their care team. Some frontline managers noted that perceived anonymity of
the survey sometimes allowed patients to be more upfront with their issues than on the telephone.
During some service recovery calls, patients tried to retract their comments for fear of retribution
on the part of the medical staff or that it would create a tense relationship with their doctor:
They’re like, I’m sorry. They felt like, you could tell they were like just weary of
medical and people in general. And they’re like, “yeah, please. No, my therapists are
great, my doctor’s great. Please, like, everything’s fine. You know, I just had one
instance.” They don’t want to create bad blood during their treatment, you know, for fear
of retribution or something. (C01)
The manager states that patients may be surprised by a call and fearful of ramifications of
providing a low score. Sharing this detail suggests that the exchange had an impact on the
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manager, as noted in their assessment of the patient responses. Another example of
metacognitive thoughts surface in this participant interview response,
If it was truly anonymous, I wonder if patients would have been that much more kind of
forthright, or saying, “This is what my issue is” because a survey tool, for the most part,
we were looking at new visits that were coming in. So, if you have a new visit that’s
coming in as a patient that may give a score lower than five stars or four stars, and
they’re starting their journey with our department and their concerns may have been wait
times in clinics, and now we’re tying this to the physician who’s now overseeing my care
and I’m starting my journey here, will I say exactly what’s happening? Or will I not say
what’s happening. (C02)
This response reflects curiosity in the personal reflection in this patient exchange and a deeper
thought process as supposition and perspective are shared. This higher level of engagement is
evidence of them “thinking about their thinking.”
Synthesis of Results and Findings for Knowledge Influences
The findings partially confirm that a knowledge gap exists in providing the expected
service recovery interventions within 24 hours of receipt of a report of patient dissatisfaction.
While frontline managers demonstrated competence in conceptual knowledge and the
inductively deduced area of metacognitive knowledge of service recovery practice, their
disparate command of factual and procedural knowledge are barriers to attaining the expected
service recovery goals. This sector of the study identifies the need for frontline managers to
improve their factual knowledge of the trigger points of service recovery and their command of
the procedural knowledge associated with engaging patients in service recovery practice. With
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participants expressing varied levels of performance and expression of confidence in performing
service recovery aspects, prompting the influence being partially validated for an existing gap.
Motivation Results and Findings for Research Questions Two and Three
The motivation results and findings were captured through several survey and interview
questions and were thematically coded for assessment. An overarching quote that reflects the
importance and perspective of the motivation domain surfaces through the words of this frontline
manager,
Placing an important emphasis on this because it’s a priority from my boss, from my
boss’s boss, or placing this emphasis because it is important to me as an individual. And I
think about those distinctions very clearly because, using me as an example, I think that I
was a bridge of the two. This was obviously something that was an important institutional
initiative; it was important to my department leadership; it was important to me to push
this forward. But patient experience is like very important to me as a person, and even
what has led me even to choose this path. (C05)
The internal drive that a person has influences their effectiveness and success in the workplace.
This position speaks to personal pride in performance. It speaks linking intrinsic interest into
operational drive. Considering the prominence of motivation as a key factor of operational
success, the review of the findings in this section warrants attention.
Motivation influence 1: Frontline staff managers should want to master their
responsibilities inclusive of probing engagements with patients as opposed to only
complying at the minimal expectation level when engaging patients. The findings partially
validate the highly probable gap of frontline managers being motivated to perform beyond
minimal patient engagement. Engagement mastery is the focus in this motivational influence.
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Schunk and Ertmer (2000) argue that learner self-regulatory competence can be enhanced
through systematic interventions designed to teach skills and raise students’ self-efficacy.
Speaking to the need for consistency in maintaining expectations, inclusive of preparatory
opportunities for service recovery practice, the document and artifact theme of “training
protocols reinforce standards” is supported by the following quote from one of the reviewed
documents: “As a department, we are excited to expand this pilot as it will provide us with great
feedback of what we are doing well and opportunities for improvement to better serve our
patients.” This excerpt supports the premise that there is a desire to delve deeper into the patient
experience and improve the potential to address patient needs. Further linked to this motivation
influence, the survey queried the frontline managers by asking if they realize the quality of their
engagement can impact the effectiveness of their service recovery efforts. This question asks
about awareness of the connection between the caliber of patient engagement and the intended
outcome of service recovery. In this question, all 12 respondents stated they understood the level
of impact that their patient engagement has on the effectiveness of their service recovery actions
with 11 of them strongly agree with the concept. This strongly affirmative response shows
confidence in the connection between the caliber of their interventions and service recovery.
The desire for frontline managers to facilitate a positive experience for patients and
was a high internal motivating factor. Looking at the interview findings, most participants
found personal value in performing service recovery because they felt that they were helping
provide a more positive experience for patients. Participants took pride in their role facilitating
patient experience. One respondent noted, “Having immediate feedback from the patients is
good overall. The time and effort, I personally enjoy it. I like speaking to patients and hearing
them. I like the thank you at the end” (C01). This feedback supports the premise that the
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engagement supports the internal motivation needs and mentions the intrinsic reward received,
presumably via acknowledgement of doing their job well; this satisfies their internal goal
orientation needs. Another responder said,
I worked in smaller practices and we always made it a point to call right away if there
was an issue. So, I think that an institution this size to implement this process … and put
a 24hour period. I think you bring a level of a small community feel to the patient in this
giant institution, that they almost feel like they’ll be lost. So I think it’s great. (C07)
Again, the message gleaned from this response alludes to the benefit of the “personal touch” for
patients experiencing challenges in their care delivery. The engagement may offer a greater
positive feel for the patient, directly adhering to the assessed motivational influence.
The emphasis on service recovery and job expectations served as a form of external
motivation. The survey tool asked participants the degree to which they probe patients with
follow-up questions in assessing their source of dissatisfaction during service recovery. There
was a broad array of responses. Three noted that they always followed up with patients, five
noted that they often engaged patients in this setting, three noted that they performed this patient
engagement sometimes, and one noted that they never probed patients in assessing their
dissatisfaction. While this level of engagement may occur in the clinical setting, the
predominant opportunity for this engagement occurs during service recovery discussions with
patients as part of the initial discussions that occur post receipt of notices of dissatisfaction. The
diversity in responses suggests a need to reengage the frontline manager staff to standardize
performance tied to motivational challenges. One participant noted he was drawn to service
recovery specifically for the career advancement and visibility that it offered, adhering to an
alternative approach to mastery:
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So I as a supervisor was very motivated and engaged to do very well. I wanted to
advance; I had my own personal career aspirations, so this was an opportunity for me to
spearhead or work on a high-impact project as well as impact an area that is super-
important to me personally and professionally. (C05)
This response depicts the personal external motivation present that promotes future for
professional advancement and greater growth. This perspective speaks more to a performance
goal orientation than a mastery approach. While motivational influences are present,
consideration in reparation should consider driver variance. Another responder furthered this
perspective by saying, “I think it’s part of their job expectation to make sure we have happy
customers, happy patients to make it a good patient experience” (C03). While aspects of mastery
are not directly cited, this response expresses desire to do a good job to ensure a positive patient
experience.
The support provided with these motivational findings lead this researcher to assign a
partially validated alignment with the focus of the influence assessed. While variable aspects of
motivation are noted, they were not solely entrenched in mastery being the primary driver. This
suggests the need to consider that a gap exists that should be addressed in solution consideration.
Motivation influence 2: Frontline staff managers need to be interested in the quality
of their engagement with patients on patient satisfaction scores and realize that their
involvement makes a difference in patient care perceptions. The findings partially validate
that frontline managers may not be interested in the quality of their engagement with patients on
patient satisfaction scores and realize that their involvement makes a difference in patient care
perceptions. This assumed motivation influence reflects the thought that frontline manager
interest in service recovery practice impacts engagement quality, which, in turn, influences
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patient satisfaction. Several of the study data offered perspective on this influence, both directly
and indirectly. Reinforcement of important operational concepts often occur through meetings
between management and frontline staff. Supporting this supposition, one survey question
pertained to frontline manager commitment to service recovery improvement and asked about
the number of team meetings held each month where the manager reiterated the importance of
improving the patient experience. Responding to the query regarding frequency of such
meetings, nine of the 12 respondents noted one meeting per month and one noted that two to
three engagements occur monthly. There were two respondents who cited that they never held
monthly meetings where service recovery discussion occurred. This finding reflects a
divergence in practice congruence with motivation of service recovery practice. As basic
opportunity exists within the stakeholder group, this variance shows varied levels of commitment
to reiterating service recovery importance and need for improvement. There is a varied degree of
interest in this phase of service recovery practice; not reiterating the need to improve the patient
experience may convey that there is a diminished level of importance for the practice.
Staff were receptive to service recovery, but successful onboarding and tactful follow-
up are key. Managers perceived that their staff were generally motivated to perform service
recovery. However, they noted that, sometimes, frontline and clinical staff can become defensive
when feedback is passed along after a service recovery call. For instance, some participants
noted that staff felt frustrated when they dealt with a patient in person and did not perceive a
need for the issue to be re-litigated on a service recovery intervention call. One frontline
manager noted the following regarding their staff engagement: “They’re very interested. They
have a vested interest in making sure patients were highly satisfied. And they know that it’s an
important goal and initiative of our department” (C03). This quote speaks to the fact that staff
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interest exists and that there is alignment between their performance and patient satisfaction.
Another manager noted this point regarding physician engagement and feedback specific to them
directly:
I think the doctors can take it very personally if there’s a bad rating on their appointment.
So, if it’s anything they can see as not directly related to them because there might be a
question about the attending interaction and they might have five stars, then there might
be a question about something else and they have less starts they’re very quick to say,
“This clearly wasn’t my fault,” and that’s not the point of the service recovery. (C04)
The interesting point of this exchange was not so much the physician’s response to the poor
rating, but an understanding of the value of the process and the need to depersonalize any
feedback to address the dissatisfaction. Yet another respondent said,
I could see that there’s frustration on some team members. That, we just spoke to this
patient, and we did the best we could. And they’re still giving us a bad score. So I think
they need to understand that, yes, the patient was vocal and they give this score. But this
is their chance to actually document it. (C07)
This reflective comment accepts there are differences in perspective, as an individual’s valuation
system is influenced by their personal experiences, beliefs, and biases.
Calling patients with a neutral rating or systematic issue negatively affected
motivation. Like the knowledge theme that noted, while immediate outcomes for service
recovery were well understood, long-term goals of service recovery were unclear, some
participants expressed trepidation about calling patients for an issue that they knew could not be
immediately addressed on the call. Participants expressed hesitancy about calling patients who
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gave a 3-star rating, as participants felt it difficult to perform service recovery without an
understanding of long-term solutions. In support of this finding, one respondent said,
I don’t mind calling the patients. I think it is tricky sometimes when it is that three.
Because they’re really not that mad. And then sometimes you call them and they’ll get
mad that you call or they’ll bring up a different situation. Or, they’ll just have other
questions that I can’t answer. So that’s a little difficult. I don’t mind speaking to the
difficult patients. but I think it has to be under the right circumstances.” (C011)
From this quote, two points emerge: frontline managers do not feel like they are prepared for the
varied potential responses react with frustration and hesitancy, and there may be disagreement in
the value of engaging patients that they perceive are not reporting dissatisfaction. Another
frontline manager responded, “I’d like to see some change that we’ve implemented other than
calling up a patient and apologizing. It kind of goes along with what I was saying before if you
don’t do anything with it what’s the point” (C02).
Practitioners need to be invested in the entire service recovery process. This shared
perspective speaks to investing the managers with the intent and outcomes of the program as
well. The respondent expresses a need for fuller disclosure levels regarding the practice of
service recovery. Another respondent offered, “Calling everyone and documenting the
complaint, if nothing is being done, to me is a very big waste of everyone’s time. So that’s how
I feel” (C09). The message conveyed here is that this manager is unaware of the full breath of
the feedback scheme associated with service recovery. This reveals that potentially adequate
information transfer from learning to practice did not occur. There may not have been adequate
reiteration during team meetings, which is consistent with an earlier finding.
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Synthesis of Results and Findings for Motivation Influences
The findings partially confirm that a motivation gap exists in providing the expected
service recovery interventions within 24 hours the receipt of a report of patient dissatisfaction.
Frontline managers’ goal orientation and interest are challenges to achieving the goals and
meeting expectations. The study identifies the need for frontline managers to master their skill
while a performance approach also surfaced. Also, there needs to be effort in exploring frontline
manager interest levels that impact service recovery execution.
Organizational Results and Findings for Research Questions Two and Three
The organizational results and findings were captured through several survey and
interview questions and were thematically coded for assessment. An overarching quote that
reflects the importance and perspective of the organizational influence domain manifests through
the words of this frontline manager: “Service recovery or patient experience has always been a
pillar of kind of everything we’ve done. [Department leadership] really places strong emphasis
on that” (C05). This quote offers the perspective that service recovery commitment is steeped in
leadership emphasis with focus on improving the patient experience along with the maintenance
of technical expertise. This overarching position frames the following assessment of organization
influence results and findings.
Organizational influence 1: The E4C organization needs to have an action-oriented
commitment to provide service recovery with urgency and enthusiasm. The findings
validate that a performance gap exists in E4C maintaining an action-oriented commitment to
provide service recovery with urgency and enthusiasm. There were 14 instances of coded
responses in the 33 documents and artifacts supporting the basic theme of the high priority of
service recovery within the organization. One document captured narrative that spoke directly to
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the conveyance of service recovery importance to operations. That document stated, “As a
department, we are excited to expand this pilot as it will provide us with great feedback of what
we are doing well and opportunities for improvement to better serve our patients.” This notation
frames the commitment to service recovery as an important part of practice and professes the
need to focus on improvement from a patient engagement perspective. While this declaration
sets the expectation for staff performance, the question of adequate transfer still needs
assessment. In other words, are we practicing what we preach?
The frontline managers were surveyed about the department promoting an action-oriented
commitment to gain expected results by taking on difficult challenges with urgency when
invoking service recovery. All 12 respondents were in various stages of positive agreement: six
noted strong agreement, four agreed, and two somewhat agreed with the statement. While not as
strongly positive as seen in other questions, the consensus of agreement was established in this
question, albeit with variation. This variation in commitment possibly demonstrates variation in
concept transference from training to practice. That variance factors into the performance reality
that the commitment to service recovery has not been confirmed in the results of the secondary
data collected. The interviews revealed frontline managers perceive that there are high
expectations for service recovery performance. Captured during the interviews, participants
sensed that the department priorities have shifted toward service recovery based on staff
meetings and high standards set for follow-up. One respondent noted,
From when I started, [service recovery] was taking off. At that time, it was clearly
defined that this was something that we’re interested in moving forward with. We’re now
going into the end of this year. There’s definitely a shift in priority. (C07)
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The response alludes to a shift in priority that occurred when review of the performance was
shared with staff, accompanied by expectation reminders regarding performance. This point
surfaces questions of reporting consistency between initial and current state of service recovery.
Another respondent reflected on the organization expectations:
They have high expectations, you know. They expect, you know, four or five stars is
okay. You know, three stars, you need to respond and you need to respond quickly.
Yeah, it’s a high expectation. And you need to put notes in and address it. (C01)
This respondent articulates the high expectations for the received review and the need to
demonstrate urgency in addressing them, however, the tone perhaps suggests that the respondent
questions the need to set the intervention trigger at a level of 3. High department expectations
for service recovery may cause some staff to feel “defeated” when they cannot meet the
threshold for follow-up, affecting motivation. Supporting this premise, one frontline manager
noted,
I think the department has very high expectations of any of us doing the service recovery.
And, sometimes, we can feel a little bit defeated to meet those expectations. So, with a
very strict 24-hour rule, making sure we’re not calling the patient, but, if there’s any issue
or following up, and then calling the patient back. (C04)
The frustration noted prompts consideration of the presence of underlying challenges in meeting
performance expectations. Feelings of defeat may lower a person’s self-efficacy, leading to
thoughts of inadequacy. This thought of performance challenges based on organization
expectations surfaced in another thematic section.
Organizational expectations inform the path to outcomes. The documents and artifacts
uncovered the theme that “successful projects require engagement and review.” This review
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shows openness to critique and revision as necessary to obtain expected results. In the frontline
manager survey, the stakeholder group was asked to reflect on the statement of E4C promoting
an action-oriented commitment to gain expected results by taking on challenges with enthusiasm
when invoking service recovery. As seen in the question about urgency, all 12 respondents were
in various stages of positive agreement: five noted strong agreement, five agreed, and two
somewhat agreed with the statement. While not as strongly positive, a consensus of agreement
was established in this question, with variation. This variation in enthusiasm commitment
possibly demonstrates inconsistency in concept transference from training to practice. Less than
enthusiastic responses can manifest when there are performance inhibitors present. The
interviews uncovered a theme of participants pushing back against the expectation that they carry
out service recovery after a 3-star review. Participants felt that many patients understood the 3-
star to mean “neutral,” and often expressed surprise when they received a call back. The
inclusion of 3-star calls increased call volume, especially when most 3-star calls were in
reference to wait times, which staff felt they could not address. A respondents noted,
I think that’s aggressive. I think three for most survey’s is a neutral. And, I think
patients get confused with that. So either let it be known in advance, maybe to patients
that three is going to get a call back. Or have it at two or under. (C010)
Similarly, another interviewee stated,
I think that the questions are confusing to patients. Maybe not confusing to patients, but
it’s ambiguous. So, three stars to a lot of people, it could mean it was good, or it was
good enough, meaning it’s not a real concern to them. I would say a lot of the calls that’s
what you get. Is, oh, three stars. It wasn’t as good as everything else, but it wasn’t a big
deal. That could be patient waiting for 30 minutes, which isn’t that long. I think the
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three-star threshold is just a bit ambiguous. Probably have to change in order to better
triage which patients are actually frustrated with or have a concern. (C08)
These two responses note frustration and confusion on the part of the patient when frontline
managers contact them as triggered and expected. They cite their own frustration in addressing
patients in these instances only to find challenges in the process. The managers do offer their
perspective on improvement opportunities, suggesting they are potentially thinking
metacognitively regarding the process.
Organizational influence 2: The E4C organization needs to be committed to
providing adequate resources to ensure staff development, information transfer and timely
feedback to facilitate consistent service recovery. The findings validate a gap in E4C’s
commitment to providing adequate resources to ensure staff development, information transfer
and timely feedback to facilitate consistent service recovery. Three survey questions sought to
address resource provision. The first question asked the stakeholders to reflect on E4C’s
provision of adequate resources to ensure timely feedback to facilitate consistent service
recovery delivery. There was a wide variation in responses in this question. Ten respondents
cited slightly to extremely adequate agreement, two responded slightly adequate, six responded
moderately adequate, and two responded extremely adequate. There were two who noted a
slightly or moderately inadequate feedback loop to ensure realization of practice as designed.
The range of responses gravitate more toward the lower to neutral agreement suggesting
inconsistency in the belief that timely practice feedback was provided.
The second question asked the stakeholders to reflect on E4C’s provision of adequate
resources to ensure information transfer to facilitate consistent service recovery delivery. While
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nine respondents cited moderately adequate agreement, three noted a neutral or slightly
inadequate resource allotment to ensure realization of practice as designed.
The variation in responses denote an opportunity to assess implementation of practices
learned through didactic engagements. The third question asked the stakeholders to reflect on
E4C’s provision of adequate resources to ensure staff development to facilitate consistent service
recovery delivery. Again, a wide variation in responses was present. While eight respondents
cited various degrees of agreement, four were neutral or in various degrees of disagreement.
This response variation suggests that respondents feel the need to receive more attention in this
area.
Collectively, these three questions offer insight into the belief that greater resource
allotment in all three areas are believed to be needed. This expression contradicts the
organizational position cited in the documents and artifacts. Review of the 33 documents and
artifacts offered a theme that policies and procedures need to be clear to promote expected
outcomes. The interviews noted a theme that participants see the rationale for the 24-hour
follow-up but have difficulty meeting the expectation. Participants generally agreed that the 24-
hour callback time enhanced patient experience and allowed the feedback to be fresh in the
patient’s mind, but they lacked the staffing to manage the high volume of calls. Some
participants also lacked clarity on whether they needed to respond within 24 hours of receiving
the service recovery assignment, or within 24 hours of the call itself. One respondent noted,
So 24 hours would be completely fine to do in my setting. So long as it’s 24 hours from
the time that I’m notified that there’s an issue. Like, it shouldn’t be 24 hours from
[when] they read that survey because I think the time starts once the survey completed.
Once it gets sent. So, that’s a gray area. If the survey’s sent, they get it a 7 o’clock, I
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don’t know if they get pulled all in the morning or if the patient leaves here at 7 p.m. and
they fill out a survey, or do they get it at a certain time of day? So, if it’s something that
at 7 p.m. and they’re leaving here. And they just saw the nurse and they’re leaving and
they get a survey and they fill it out. Then a clinical practice supervisor is only getting it
say nine in the morning. That’s already half of the 24 hours already gone. (C010)
This response reveals the thought that appropriate resources are not available to fulfill the
commitment to the service recovery process. The statement mentions incongruence between
what is expected and what can be performed realistically, based on volume and staffing.
Time to complete the service recovery process also surfaced during the interviews. Not
having an appropriate amount of time to realize the 24-hour commitment posed a challenge for
some frontline managers. One person noted, “Staffing has been an issue, and the expectation is
you need to call within 24 hours and sometimes that’s unrealistic, depending on the patient
volume and the staffing. So I think it’s a challenge” (C03). This statement speaks to the
frustration felt in not having a full opportunity to meet the 24-hour expectation. The respondent
articulates a personal experience suggesting the timing was a challenge to meeting expectations.
Despite high expectations, participants also felt that they lack staffing support to
successfully carry out service recovery. One respondent noted, “I think the more people that we
have participating the better. Because we can get too busy or caught up in certain things and not
remember to do this” (C011). This comment notes there is potential to forget to complete the
service recovery process, particularly when they get busy or have to balance other
responsibilities. This response suggests that other operational matters may be prioritized at a
higher level that service recovery practice. Adequate time to perform the service recovery
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 125
alludes to the need for greater levels of resources. Supporting this position, another frontline
manager said,
I wouldn’t have time to make all those phone calls. I’d have to delegate to someone. I
don’t have someone in place. So, I don’t think that, from my perspective, I have a lot of
resources other than them giving us the systems to collect data. They’ve given us
systems to collect data, but I don’t think that, and it’s always the first step, right? But
there needs to be more to it. (C02)
This perspective mentions a need for more resources. While service recovery is designed as an
engagement opportunity for frontline managers to have with patients, this respondent has a more
hands-off approach to service recovery.
Organizations need to provide support to employees to effectively improve processes,
including clear goals, training support, and feedback, leading to greater potential to deliver
empathetic care that impacts practice quality practice. This commitment to preparation prior to
the service recovery program implementation at E4C reflects directly throughout the documents
reviewed.
There is no formal training for service recovery; staff relied on their own experience
and expertise. Interview participants noted that, while they had a good understanding of the
definition and expectations for service recovery practice, almost everyone interviewed noted
there was no formal training specific to navigating the day-to-day service recovery-related tasks.
Further, supervisors noted they learned how to perform service recovery calls by shadowing their
supervisor or by drawing on their own experience from previous roles. One frontline manager
noted this as an example of their patient-facing experience with service recovery:
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 126
I actually had one of the newer staff members, the new project coordinator, ask to sit in
on our calls with the other assistant manager and I. I believe she sat with [the assistant
manager] and found it extremely beneficial. That is someone who doesn’t come from
working directly with patients or addressing those concerns at least routinely. So, I’m
sure, for her, it was extremely beneficial. I really think it’s dependent on the job scope.
Someone like [t the assistant manager] or I or the clinical supervisors, who have worked
their whole career here in triaging patient concerns, it wouldn’t be necessary. So, I didn’t
have anyone sit in with me. I just went for it. (C08)
This shared perspective notes the receptiveness that staff have for ad hoc training opportunities
in the absence of structured, formalized training sessions. They allude to self-reliance on
personal experiences to serve as the platform for training, not the organization. Furthering the
thought that the organization should offer training opportunities for service recovery, another
manager shared,
I think formal classes [are needed]. And it can’t just be one class; I think you can’t teach
someone in one setting. I think it’s a series of learning modules, and how to perform
service recovery, role-playing, what happens if they’re irate and they’re even more irate.
And I think just providing the staffing resources. (C03)
This essence of this statement extends the message of the previous quote: service recovery
practice requires structured and formalized training. This quote goes as far as noting the type of
learning opportunities that would be beneficial, inclusive of role-playing that could prove
instrumental in preparing to engage patients.
Staff were interested in obtaining feedback about their service recovery performance.
Review of the documents and artifacts captured desire to offer opportunities to revise and
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 127
enhance the tools used in service recovery surfaced. For example, “feedback on survey
structure” netted five instances that spoke to providing feedback geared toward tool and process
refinement. One respondent asked about the development of more visit-type specific surveys to
better capture niche data. Furthering this thought, three different instances asked, “if we need
separate survey for follow-up and initial consultation appointments.” This feedback speaks to
insight offered to consider revisions for improvement. In looking at the survey, a question on the
provision of feedback and direction opportunities surfaced when looking at the frequency of
leadership engagements per month with the managers to review service recovery performance.
Nine respondents have one meeting per month and two have 2 to 3 engagements monthly. There
was one respondent who said they never held monthly meetings with their leadership where
service recovery discussion occurred. The data indicate non-uniform commitment to offering
feedback and suggestion opportunities among the group.
Managers want feedback on whether they were correctly following service recovery
procedures. Many participants noted they would be interested in receiving this feedback, as it
supports both job performance and the patient experience. One manager shared thoughts on
receiving feedback specifically on the mechanics of service recovery beyond patient
engagement,
Yes, not necessarily about the actual interaction with the patient and phone call
interaction, but more about when we’re doing the recovery, like when it’s happening.
Yeah, I guess it’s more like when it’s happening and how it’s happening. So, it’s
supposed to be within the 24 hours, and if it’s not [being done], we could get feedback
about that. (C04)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 128
This individual cites a desire to have feedback on performance to enhance not only the patient
experience but perspective on the caliber of their performance. While they know the
expectations as conveyed, they note that they would benefit from feedback.
Managers want a deeper understanding on how survey items were selected and
explained to patients. Interview participants pointed out that the purpose of service recovery
may not always be clear to patients and suggested incorporating trainings to better explain survey
purpose. This would also help outcomes if the organization provided staff a deeper
understanding of when the patient survey was administered. This manager reflected on this
position:
But maybe if there were, during those wait times, if we had some video that played in the
waiting area. [Service recovery], this is how we use it, and this is why we do it. I don’t
know if those are feasible. But if there was some way to educate them, I think it would
be helpful. (C07)
This response speaks to offering better preparation for the patient which, in turn, is helpful to the
staff. This suggests that there is a desire to improve the program which occurs then there is a
level of value present.
Regarding the composition of the survey, nine participants interviewed noted that most
calls had to do with wait times, and they felt that there could be ways to re-phrase this question
or include new ones that may be more useful. One manager noted,
I brought it up personally, and I know other people have. If we can maybe tweak those
questions. Were you waiting more than an expected period of time without any
knowledge? I think just, if we leverage that question slightly different, I think we would
get better results. I do think that we can at least knock off 60% of those [calls] if we
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 129
could rearrange those questions. Or, word them a little bit different. Because a lot of it,
if you look…I haven’t specifically looked at the data, but I’m willing to bet that 90, high
80s percent is because of wait times and so forth. It’s just, if we can word that a little bit
different, I’m willing to bet that we can knock down a significant portion. Then getting
that 24-hour window will be a lot more manageable. (C07)
This respondent recommends the organization consider retooling the patient survey questions to
better frame them to solicit more focused information. The statement shows the participants do
think about the process and may have suggestions on its improvement. The challenge is ensuring
that a venue to offer that exists consistently. Another thought on question composition suggests
uncertainty on what patients were being asked, as noted in this response:
I was going to the meetings and I wanted to have some input on some of the questions,
and I got called and told that this was more of a tool for physicians. So, I no longer went
to the meetings and then recently I happened to see that there was a question there about
nursing, but I wasn’t included in that decision. (C02)
This manager made assumptions regarding survey composition, decided to withdraw and then
wanted to reengage when specific questions regarding their section surfaced. The narrative also
discusses a devaluation of the process occurred when the assumption was made that it did not
concern a specific domain.
Synthesis of Organizational Results and Findings
The findings partially confirm an organizational gap. The cultural models and settings,
as well as process variations in understanding and delivery, limit the efficient delivery of the
expected service recovery interventions within 24 hours the receipt of a report of patient
dissatisfaction. The study identifies the need for an action-oriented commitment to service
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 130
recovery beyond professing its importance as well as the need to provide adequate and
consistently offered resources. The inductively deduced influence of needing to provide
comprehensive experiences and consistent feedback opportunities again beyond noting its
importance during initial introduction.
Application of Findings to Research Question Two
The second research question asks about knowledge, motivation and organizational
influences related to achieving its goal of providing 100% of service recovery for Q-Review
®
scores below the self-reported score of 3 within 24 hours of receipt by Q4 2019. While the
stakeholder group demonstrates technical, managerial, and interpersonal skills as part of their
professional practice, there are gaps in the KMO domains that limit their ability to perform their
service recovery responsibilities as both defined and expected. Although the frontline managers
demonstrated conceptual knowledge in understanding the link between service recovery and the
patient experience, they have mixed levels of competency in tactual knowledge of the points at
which to invoke service recovery as well as lack the procedural skills to consistently invoke and
manage service recovery.
The knowledge domain findings did surface reflective abilities when analyzing the
patient responses heard during service recovery telephone communication. Also, there were gaps
in their goal orientation in efficiently commanding service recovery practice, and their interest
level impacts their overall ability to ensure their engagement with patients yield positive patient
experiences. The study results also showed that organizational cultural models and setting have
a substantial influence on frontline manager performance ability. While the organization
invested resources, time a, and effort, it did not sustain employee engagement, feedback, and
metric sharing practices after implementation, resulting in practice drift, diminished priority for
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 131
the practice, and variation in overall commitment to the frontline managers. The frontline
managers at E4C command neither the knowledge nor motivation needed to manage the
intricacies of a comprehensive service recovery program and meet department expectations.
Also, the organization has not offered adequate practice tools to sustain service recovery from
neither an implementation nor a practice maintenance perspective. Inconsistent communication
practices, inadequate comprehensive training that includes rationale for practice, minimal
checking for learner understanding, review of departmental norms, and soliciting more feedback
will be addressed as components of the study recommendations.
Application of Findings to Research Question Three
The last research question solicits practice recommendations that will effectively close
these uncovered performance gaps. The overarching findings presented in Chapter Four will
serve as the foundation for the recommendations presented in Chapter Five. To ensure that the
recommendations are cogent and defensible, they are supported by empirical evidence related to
proven methods to address the performance deficiencies.
Summary of Validated Influences
The findings reported in this chapter facilitated the degree of validation of the assumed
KMO influences established in Chapter Two. These collective findings presented in this chapter
can answer the research questions initially introduced in Chapter One of this document. Table 16
summarizes the degree of finding validation of the assumed KMO influences, and the following
sections link the reported findings to each study research question.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 132
Table 16
Summary of Findings for Knowledge, Motivation, and Organizational Influences
KMO Influence Validation of Gap
Presence
Knowledge Influence 1: The frontline management team needs to know the
trigger points for service recovery procedures
Partially Validated
Knowledge Influence 2: The frontline management team needs to
understand the link between service recovery, patient engagement, and
patient satisfaction
Not Validated
Knowledge Influence 3: The frontline management team needs to know
how to engage patients during service recovery procedures
Partially Validated
Motivation Influence 1: Frontline staff managers should want to master
their responsibilities inclusive of probing engagements with patients as
opposed to only complying at the minimal expectation level when engaging
patients
Partially Validated
Motivation Influence 2: Frontline staff managers need to be interested in
the quality of their engagement with patients on patient satisfaction scores
and realize that their involvement makes a difference in patient care
perceptions
Partially Validated
Organizational Influence 1: The E4C organization needs to have an action-
oriented commitment to provide service recovery with urgency and
enthusiasm
Validated
Organizational Influence 2: The E4C organization needs to be committed
to providing adequate resources to ensure staff development, information
transfer and timely feedback to facilitate consistent service recovery
Validated
Conclusion
While there is value in assessing the findings of each study phase individually to
appreciate the results that will frame subsequent solutions, the collective review integrated varied
perspectives offering a more wholistic view practice challenges. The authors also noted that,
typically, qualitative reports feature an assortment of responses with virtually no a posteriori
interpretive staging. Melding of both thus surfaces a more encapsulating perspective of the
reviewed practice. While that melding introduces the need for greater rigor in methodology, the
result support the central reason for mixing methods and findings (Sandelowski, 2004). In the
case of this study, the quantitative and qualitative perspective more completely frames the
service recovery experience at E4C. While the service recovery was implemented and has
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 133
remined in place for over two years, the data reflects that the service recovery outcome
expectations have never been reached and, further, that there is dissatisfaction within the
stakeholder group that requires attention.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 134
CHAPTER FIVE: RECOMMENDATIONS FOR PRACTICE TO ADDRESS KMO
INFLUENCES
The purpose of this project was to evaluate the effectiveness of frontline management
staff members’ service recovery practices by exploring the quality of interventions designed to
enhance patient experiences. Results showed service recovery expectations have never been met,
and there is dissatisfaction within the stakeholder group that requires attention. This chapter
presents recommendations to close KMO gaps along with an evaluation plan to determine
whether improvements are taking place.
Knowledge Recommendations
Declarative and procedural knowledge of a practice domain provides detail to enable
employees to perform tasks as both designed and expected consistently (Krathwohl, 2002).
These knowledge influencers are based on assumed influences that surfaced during the literature
review as well as during initial data review. The information depicted in Table 17 demonstrates
two knowledge influences that were partially validated with final data assessment, meaning their
confirmation is highly probable. Principles and context-specific recommendations reflect the
relationship needed to address the performance gap to be verified, based on educational
principles.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 135
Table 17
Summary of Knowledge Influences and Recommendations
Assumed
Knowledge
Influence
Validated as
a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
The frontline
management
team needs to
know the trigger
points for service
recovery
procedures. (D)
HP Y It is important in carrying
out an operation to have
the ability to command a
basic understanding of a
domain or practice to
recognize operational
details and elements of
that practice, (Krathwohl,
2002)
Provide an information
sheet that includes an easy
to follow list and
definitions of the common
trigger points for service
recovery and their
observable signals and
signs.
The frontline
management
team needs to
know how to
engage patients
during service
recovery
procedures. (P)
HP Y To develop mastery,
individuals must acquire
component skills,
practice integrating them
and know when to apply
what they have learned
(Schraw & McCrudden,
2006).
Provide a job-aid that
provides practice-specific
scenarios that outline
appropriate patient
engagement techniques
which affect service
recovery practices.
Knowledge and Skill Solutions
Increasing the frontline management team ’s knowledge of the trigger points for
service recovery procedures. The triangulated quantitative results indicated that, while 11 of
the frontline managers professed command of the factual declarative knowledge of the trigger
points for service recovery procedures, there was lower confidence in their ability to perform it
and variation during the interviews articulating the same. A recommendation steeped in
information processing theory facilitates closing this declarative knowledge gap. Krathwohl
(2002) postulated the importance of the ability to command a basic understanding of a domain or
practice to recognize operational details and elements of that practice. Therefore, providing
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 136
learners with an informational definition list would facilitate perception, processing and
procedural recall. To support this theoretical position, the recommendation is to provide an
information sheet that includes an easy to follow list with definitions of the common trigger
points for service recovery and their observable signals and signs.
According to Ashill, Carruthers, and Krisjanous (2005), training hospital frontline staff to
deliver quality service and to handle customer complaints effectively drives service recovery
performance. The specific service recovery literature reported that employees who do not
demonstrate the appropriate job and interpersonal skills fail in provision of expected patient
engagement regarding service complaints (Bettencourt & Gwinner, 1996; Boshoff & Allen,
2000; Lewis & Gabrielsen, 1998). As such, the quality of the skills of the frontline managers
affect their learning potential. The suggested use of an information sheet that includes an easy to
follow list and definitions of the common trigger points for service recovery and their observable
signals and signs connects new information to similar information in long-term memory. This
sheet provides a learning tool that defines important process points and uses cognitive
architecture important to linking core information to practice (Rueda, 2011).
Increasing the frontline management team ’s knowledge of how to engage patients
during service recovery procedures. The findings confirmed that while, 11 of the frontline
managers believe they have procedural knowledge on know how to engage patients during
service recovery procedures, a gap exists that warrants intervention. These data prompt a
recommendation rooted in information processing theory that facilitates closing the confirmed
procedural knowledge gap. Schraw and McCrudden (2006) reported that, to develop mastery,
individuals must acquire component skills, practice integrating them and know when to apply
what they have learned. Thus, providing learners benefit job aids promotes the development of
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 137
operational skills and instructs on their integration into practice through direct application. In
this case, the recommendation is to provide a job-aid that provides practice-specific scenarios
that outline appropriate patient engagement techniques which affect service recovery practices.
Investment in ensuring effective instruction of service recovery by frontline managers to
employees offers increased potential to transfer knowledge and skill competency into the
workplace as this is often a point of failure (Grossman & Sala, 2011). Mayer (2011) supported
this by asserting that facilitating knowledge transfer promotes the learning process. As patients
will often judge their healthcare experience based on their interactions with hospital employees
(Ashill et al., 2005), management needs a commitment to service quality provided through the
process of training employees to deal with patient problems and situations as they arise (Boshoff
& Allen, 2000; Rod & Ashill, 2010). The recommended procedural job-aid offers a tangible
means of promoting the needed procedural learning. Clark and Estes (2008) noted any
procedurally focused job-aid should be based on the task analysis used to design the associated
training. The link between the expected procedure and the educational process offers reiteration
of expected process and builds solid information storing and recall (Rueda, 2011).
Motivation Recommendations
Clark and Estes (2008) described the cognitive link between the three components of
motivation, choice, persistence, and mental effort with learner development and capacity to
change behavior. With the finalized data assessment for this study, the motivation influences are
partially validated and there is high probability that the influences that surfaced during the
Chapter Two literature review are congruent with the data collected. The results of data analysis
show there may be a lack of service recovery mastery and interest within the group. The
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 138
information depicted in Table 18 offer context-specific recommendations that reflect the needed
connectivity to address the performance gap based on educational principles.
Table 18
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Goal Orientation –
Frontline managers
should want to master
their responsibilities
inclusive of probing
engagements with
patients as opposed to
only complying at the
minimal expectation
level when engaging
patients
HP Y Learners focused
on mastery are
persistent in
attempting to solve
problems,
displaying
characteristics of
being learning goal
oriented (Molden
& Dweck, 2000)
and
Focusing on
mastery,
individual’s
improvement,
learning, and
progress promotes
positive motivation
(Yough &
Anderman, 2006)
Provide frontline managers
praise for their persistent
efforts in attempting to solve
patient-reported problems
and pursuing their own self-
improvement as service
recovery content experts in
healthcare.
Interest - Frontline
managers need to be
interested in the
quality of their
engagement with
patients on patient
satisfaction scores
and realize that their
involvement makes a
difference in patient
care perceptions.
HP Y Activating and
building upon
personal interest
can increase
learning and
motivation
(Schraw &
Lehman, 2009)
Engage frontline managers
through educational training
dialogue designed to increase
their curiosity about service
recovery followed by
opportunities that encourages
frontline management staff
to reflect on their personal
joys and satisfaction
regarding the impact of their
engagement with patients
during service recovery.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 139
Motivation Solutions
Provide encouragement during self-improvement efforts. Quantitatively, the frontline
managers had a wider disbursement of agreement levels, but the qualitative results showed
inconsistency in command of the goal orientation platform of the influence, confirming they
would benefit from development in mastering probing engagements with patients when
performing service recovery. To address this operational need, goal orientation motivation
theory facilitates closing this measured motivational influence gap. Molden and Dweck (2000)
reported that learners focused on skill mastery are persistent in attempting to solve problems,
displaying characteristics of being learning goal oriented. Furthering this position, Yough and
Anderman (2006) confirmed that, when driven by attaining skill mastery, subsequent individual
improvement, learning, and progress promotes positive motivation. Collectively, this suggests
that providing learners with encouragement and acknowledgement of their efforts to improve
their service recovery practice would facilitate a greater desire to hone their skills. To support
this theoretical position, the recommendation is to provide frontline managers praise for their
persistent efforts in attempting to solve patient-reported problems and pursuing their own self-
improvement as service recovery content experts.
Learners often rely on personal reasons to motivate them toward behavior to achieve
tasks, establishing an intrinsic approach toward successful goal attainment and often leveraging a
mastery goal orientation to drive their desire to achieve higher levels of competence and
ultimately achieve satisfaction in commanding that goal (Pintrich, 2003; Rueda, 2011). In
looking at service recovery, Ashill et al. (2005) contended that successful service recovery may
not be related to extrinsic job satisfaction, attributing that finding to the need to know that they
are alleviating patient customer problems and their related distress. The drive for success and
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 140
personal satisfaction stems from mastering the skills required for task completion. Adriaenssens
De Gucht, and Maes (2015b) noted that the mastery approach goal orientation was strongly
related to an increase in work engagement. Thus, mastery orientations yield more high-quality
patient engagement outcomes. Famiglietti et al. (2013) and Toode et al. (2011) described how
high-quality patient engagement links to superior patient experience and satisfaction outcomes
through service. The internal drive to learn more, and command practice offers frontline
managers the opportunity to better prepare staff for satisfaction enhancement through service
recovery (Ashill et al., 2005). Summarily, offering praise and acknowledgement to the frontline
managers in their pursuit for self-improvement as service recovery experts furthers their drive to
succeed, deepening their understanding and developing their valued skill competence (Clark &
Estes, 2008; Rueda, 2011).
Leveraging curiosity and reflection to increase interest. Most of the frontline
management team agreed that their interest level impacts patient satisfaction scores and realize
that their involvement makes a difference in patient care perceptions. However, there was wide
distribution of being interested in service recovery meetings with staff, as some members of the
group did not engage in service promotive meetings and qualitatively demonstrated a wide range
of interest. This incongruence between quantitative and qualitative assessments suggests that
there is a need for intervention, albeit partially validated. A recommendation cemented in
interest theory facilitates closing this confirmed motivational gap. Schraw and Lehman (2009)
found activating and building upon personal interest can increase learning and motivation. Thus,
learner interest is highlighted when interactive engagements pique their curiosity. In this case,
the recommendation is to offer an educational training program designed to increase their
curiosity about service recovery, inclusive of encouraging the frontline management staff to
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 141
reflect on their personal joys and satisfaction regarding the impact of their engagement with
patients during service recovery.
To initiate and sustain a healthcare environment that focuses on quality patient service, an
environment must consistently offer a dedicated and stable infrastructure where service
orientation in integrated and reinforced; employees must have a service-oriented mindset
(Kenagy, Berwick, & Shore, 1999). Based on Maslow’s hierarchy of needs and Herzberg’s
theory of motivation to examine behavior, Lambrou et al. (2010) reported that, when leaders
have insight into employee motivational drivers, they can leverage staff needs and interests to
meet intended outcomes. Similarly, Renninger, and Hidi (2002) postulated interest develops
through triggered situational interest as related to a temporary change in stimulus environment of
information and that overall expression of interest extends through maintained situational interest
and well-developed individual interest. Thus, by offering educational opportunities that model
enthusiasm or interest, learning potential increases (Schraw & Lehman, 2009). Exposing
managers to interesting components of service recovery through training opportunities will
increase their intrinsic and situational interest levels, manifesting in the deeper embrace of
service recovery practice.
Organizational Recommendations
Even when learners demonstrate an abundance of knowledge, skills, and motivation in
their duties, inadequate resources or operational processes may still surface as performance gaps
(Clark & Estes, 2008). As noted in the knowledge and motivation influence sections, the data
assessment for this study is still being finalized, and the organizational influences are not yet
verified. However, there is high validity probability that the influences that surfaced in the
literature review are congruent with the data collected to date. Clark and Estes (2008) suggested
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 142
learner and organizational goals may not be achieved as designed due to a lack of resources and
unclear operational expectations. The key to achievement is seated in alignment between the
organization’s commitment to success and performance expectations. These manifest as the
organizational culture models and cultural settings that must be aligned if performance gaps are
to be addressed. As such, Table 19 offers organization-based recommendations that reflect the
needed connectivity to address the performance gap to be verified based on educational
principles.
Table 19
Summary of Organizational Influences and Recommendations
Assumed
Organizational
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Cultural Model
Influence –The E4C
organization needs to
have an action-
oriented commitment
to provide service
recovery with urgency
and enthusiasm.
V
Y
Organizations benefit
by consistently
measuring operational
success,
communicating the
importance of projects,
and swiftly influencing
employee direction
(Sirkin, Keenan, &
Jackson, 2005)
and
Instilling a sense of
urgency into important
operational projects as
projects that are
deemed important
perform better than
those seen as routine
(Pinto & Slevin, 1989)
Provide one-on-one
meeting opportunities
between frontline
managers and
organizational leadership
that communicates service
recovery importance and
encourages enthusiasm and
urgency for the practice.
and
Provide opportunities for
group discussion to inspire
frontline managers to
rethink their personal level
of enthusiasm and urgency
regarding service
recovery.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 143
Table 19, continued
Assumed
Organizational
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Cultural Setting
Influence – The E4C
organization needs to
be committed to
providing adequate
resources to ensure staff
development,
information transfer and
timely feedback to
facilitate consistent
service recovery.
V Y Insuring staff’s
resource needs are
being met is correlated
with increased learner
outcomes (Waters,
Marzano, & McNulty,
2003)
and
Effective change
efforts ensure that
everyone has the
resources (equipment,
personnel, time, etc.)
needed to do their job,
and if there are any
resource shortages,
then resources are
aligned with
organizational
priorities (Clark &
Estes, 2008).
Develop service recovery
resource benchmarks and
establish consistent
communication with
modeling reports
between managers to
ensure alignment of
available resources and
operational needs.
Organizational Solutions
Provide an action-oriented commitment to urgent and enthusiastic service. While
the quantitative findings yielded agreement with the organization’s professed commitment to
urgent and enthusiastic service, the level of agreement was disbursed over a broad range. This
variation combined with the qualitative expressions of feelings of defeat and need for more
training confirmed that E4C needs to more consistently promote the importance of an action-
oriented environment that demonstrates this commitment. To address this operational need,
assessment of the organization’s cultural modeling facilitates understanding the dynamic of this
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 144
organizational influence gap. Sirkin, Keenan, and Jackson (2005) reported that organizations
benefit by consistently measuring operational success, communicating the importance of
projects, and swiftly influencing employee direction. Supporting Sirkin et al.’s contention, Pinto
and Slevin (1989) postulated that, by instilling a sense of urgency into operational plans,
important tasks are performed better than those seen as routine. Subsequently, when leaders
provide consistent feedback on operational performance, they promote a sense of urgency into
task performance and reiterate the importance of the project. In support of this theoretical
position, two recommendations emerge: provide one-on-one meeting opportunities between
frontline managers and organizational leadership that communicates service recovery importance
and encourages enthusiasm and urgency for the practice, and provide opportunities for group
discussion to inspire frontline managers to rethink their personal level of enthusiasm and urgency
regarding service recovery.
Um and Lau (2018) described the relationships between job performance, patient
dissatisfaction, and actual behaviors in healthcare when service failure emerges and state there is
a need for action-oriented intervention to promote patient engagement and satisfaction. When
examining service recovery practice, an organization’s customer service orientation and
management commitment to service quality will positively impact the perception of service
quality (Ashill et al., 2005; Rod & Ashill, 2010). By placing importance on the process and
engaging in interventions promptly, the service recovery practice conveys a sense of urgency in
addressing dissatisfaction, actively influencing value fulfillment (McQuilken, Robertson, Abbas,
& Polonsky, 2018). Swift and thoughtful service recovery responses limit the potential for
dissatisfaction and minimize patients’ negative organization perceptions (Schweikhart et al.,
1993). Ashill et al. (2005) also noted management socialization of both new and existing staff
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 145
fosters swift issue resolution. Summarily, organizational management influences service
recovery potential by the promotion of swift, enthusiastic service recovery interventions
conveying a sense of importance and urgency to dissatisfied patients. Cultural models can either
promote or impede goal attainment, and it is imperative that organization leadership
communicates practice expectations to enable staff to be successful (Rueda, 2011).
Provide adequate resources to facilitate operations. While most of the frontline
management team agreed that E4C provides resources enough to perform service recovery, the
stakeholder group confirmed the need for a more significant commitment in this area,
particularly in the realms of additional performance feedback and greater training in managing
patient expectations of surprise and concern regarding engagement related to service
recovery. A recommendation regarding the organization’s cultural setting facilitates closing this
confirmed organizational gap. Waters, Marzano, and McNulty (2003) noted that meeting staff’s
resource needs results in increased learner outcomes. Furthering this position, Clark and Estes
(2008) noted effective change efforts ensure that everyone has the resources needed to do their
job, and, if there are any resource shortages, then resources require alignment with organizational
priorities. Actual performance outcomes improve when adequate resources are available to
support expectations, mainly through efficient staff development, timely feedback, and efficient
information transfer. Thus, the recommendation is to develop service recovery resource
benchmarks and establish consistent communication with modeling reports between managers to
ensure alignment of available resources and operational needs.
Kenagy, Berwick, and Shore (1999) stated that excellent healthcare service begins with
committed staff and supported employees, and leadership must ensure that the organization’s
allocation of resources and support systems are in alignment with the service mission. The
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 146
authors suggested a stable infrastructure supports excellent service that is integrated and
appropriately reinforced. Rod and Ashill (2010) stated that, to manage service quality and
service recovery commitment in hospitals, organizations need to adequately support their staff to
promote successful patient engagement. Thus, by committing to providing resources that
facilitate practical task completion, the potential for successful application increases (Clark &
Estes, 2008). By providing managers with the direction and tools that support service recovery,
organizations become better positioned to address patient needs when they share levels of service
dissatisfaction (Gutbezahl & Haan, 2006).
Integrated Implementation and Evaluation Framework and Plan
A well-designed training platform to integrate implementation and evaluation practices
that adequately address performance gaps will improve operations (Kirkpatrick & Kirkpatrick,
2016). The original Kirkpatrick Four-Level Model of Evaluation assesses reaction, learning,
behavior, and results, where each successive level of the model represents a more precise
measure of the effectiveness of a training program as determined by the participants (Kirkpatrick
& Kirkpatrick, 2006). The intent of the tool seeks to objectively analyze the impact of training,
to review team members learning and implementation, and to improve future learning
opportunities.
The essence of the revised New World Kirkpatrick Model extends beyond participant
satisfaction, using a top-down cascading sequence that assesses results, behaviors, learning, and
reactions (Kirkpatrick & Kirkpatrick, 2016). First, results reflect on the degree to which
expectations occur because of the learning and its associated reinforcement. The results should
be defined globally and not in small, niche areas. Next, behaviors look at the application of the
learning supported by critical behaviors, required drivers, and on-the-job reinforcement
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 147
(Kirkpatrick & Kirkpatrick, 2016). Thirdly, learning initially assessed knowledge, skills, and
attitude based on participation in the learning; the revised model also leverages an assessment of
confidence and commitment. Lastly, reactions reflect both learner satisfaction and the
engagement levels related to learning as well as the opportunity for learners to use the newly
learned skills on the job (Kirkpatrick & Kirkpatrick, 2016). The New World Kirkpatrick Model
emulates an operational order that follows professional training practice (Kirkpatrick &
Kirkpatrick, 2016). As such, the primary focus resides within results.
Organizational Purpose Need and Expectations
In the provision of radiation oncology services, E4C offers service recovery interventions
to patients who express dissatisfaction with the care they receive. To provide near real-time
interventions that will improve patient satisfaction through timely and consistent efforts to
address patient-reported challenges in meeting their expectations, E4C set goals to have 100% of
the Quality Reviews survey results of 1, 2, or 3 invoked within 24 hours of reporting. This study
reviewed the knowledge and skills, motivation, and organization challenges that limit the
attainment of that service recovery goal. The proposed solution, a comprehensive re-education
program that employs job aids and other support tools, effort recognition, curiosity promotion,
frequent metric review and related discussion, leverages the results obtained through the gap
analysis and should culminate in meeting the organizational goal.
Level 4: Results and Leading Indicators
Table 20 demonstrates the proposed Level 4 results and leading indicators framed in
outcomes, metrics, and methods for both external and internal expectations for E4C. When
internal outcomes meet the expectations resulting from the implemented education plan and
improved organizational support for the frontline managers, external outcomes should surface.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 148
Table 7
Outcomes, Metrics, and Methods of External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
1. Increased hospital
integration of Quality
Review tool for service
recovery
1. Number of external
departments using the
Quality Review tool
1. Quarterly review of reports on
departmental use of the tool
through hospital administration
2. Outside facilities
benchmarked their service
recovery practice against
E4C results
2. Number of external practices
referencing the E4C service
recovery outcome data
2. Quarterly comparative service
recovery reporting in
professional society committee
meetings
3. Increased publications of
service recovery practice in
peer-reviewed professional
journals
3. Number of scholarly
published peer-reviewed
articles on service recovery
in radiation oncology
3. Quarterly review of article
submission and publication
documentation by department
practitioners
Internal Outcomes
4. Improved overall
departmental patient
satisfaction management
4. Percentage scores of self-
reported patient satisfaction
on surveys
4. Quarterly review of Press
Ganey Patient Satisfaction and
Quality Reviews data reports
5. Improved compliance with
documented timely service
recovery practices
5. Percentage of service
recovery interventions
documented within 24 hours
of receipt
5. Quarterly review of Quality
Reviews service recovery
report
6. Increased service recovery-
specific refresher training
opportunities for frontline
managers
6. Frequency of service
recovery training in-service
programs for frontline
managers
6. Quarterly review of
documented departmental
service recovery training in-
service programs
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 149
Level 3: Behavior
Critical behaviors. The frontline managers are the gatekeepers to the service recovery
process, so attainment of organizational expectations reside with their ability to perform two
main operational behaviors. The first behavior is to correctly identify instances of reported
patient dissatisfaction. The second centers on complete and timely documentation of the service
recovery intervention to establish compliance with organizational expectations. Table 21 shows
the measured metrics, methodology, and timing for each noted outcome behavior.
Table 21
Critical Behaviors, Metrics, Methods, and Timing for Each Outcome
Critical Behavior Metric(s) Method(s) Timing
1. Correctly identify
instances of reported
patient dissatisfaction
into the service
recovery process
The number of
service recovery
instances that
needs action
The administrative team
will reconcile surveys
where patients have
scored an engagement
of “1, 2, or 3” on the
survey Likert scale in
the Quality Reviews
software
During the first 90
days of service
recovery training -
weekly.
Thereafter -
monthly, if
continued success
is observed.
2. Complete and timely
documentation of the
service recovery
intervention to
establish compliance
with organizational
expectations
The number of
completed
documentation
entries of patient
engagement that
accompanied
service recovery
intervention
2a. The administrative
team will review the
completeness of the
initial patient
engagement discussion
documentation for each
encounter needing
service recovery within
the Quality Reviews
system.
2a. During the first 90
days of service
recovery training -
weekly.
Thereafter - monthly,
if continued
success is
observed.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 150
Table 21, continued
Critical Behavior Metric(s) Method(s) Timing
2b. The administrative
team will review the
timeliness of the initial
patient engagement
discussion
documentation for
each encounter
needing service
recovery within the
Quality Reviews
system
2b. During the first 90
days of service
recovery training -
weekly.
Thereafter - monthly, if
continued success is
observed.
Required drivers. Frontline managers need the support of their leadership and the
organization to reinforce the behaviors learned in their education and training and prompt them
to apply them in a complete and timely manner. Encouragement and rewards should recognize
those achieving performance expectations as designed. Table 22 documents the required drivers
that support the critical behavior of the frontline managers.
Table 8
Required Drivers to Support Critical Behaviors
Method(s) Timing Critical Behaviors
Supported
Reinforcing
Provide a job-aid that provides practice-specific scenarios that
outline appropriate patient engagement techniques which affect
service recovery practices.
Ongoing 2
Provide an information sheet that includes an easy to follow list
and definitions of the common trigger points for service
recovery and their observable signals and signs.
Ongoing 1, 2
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 151
Table 22, continued
Method(s) Timing Critical Behaviors
Supported
Encouraging
Provide frontline managers praise for their persistent efforts in
attempting to solve patient-reported problems and pursuing
their self-improvement as service recovery content experts in
healthcare.
Ongoing 1, 2
Engage frontline managers through educational training
dialogue designed to increase their curiosity about service
recovery followed by opportunities that encourage frontline
management staff to reflect on their joys and satisfaction
regarding the impact of their engagement with patients during
service recovery.
Quarterly 1, 2
Rewarding
Provision of performance incentives to frontline managers
when service recovery compliance increases toward targeted
goals.
Quarterly 1, 2
Documented, public acknowledgment of improved service
recovery compliance through Blog entries, departmental quality
improvement maps, and senior leadership reporting.
Monthly 1, 2
Monitoring
Schedule consistent time for both individual and team meetings
for service recovery metric review and training.
Monthly 1, 2
Conduct department-wide meetings to communicate the
importance of service recovery and share team and individual
goals and accomplishments.
Bi-
annually
1, 2
Organizational support. Critical behaviors and their related drivers related to
organizational improvement require organizational support through the integrated
implementation of aligned recommendations (Kirkpatrick & Kirkpatrick, 2016). For the
frontline management team at E4C to fully realize the benefits related to the implementation
plan, the organization needs to provide resources that support their ability to perform at an
expected level. In this implementation plan, the following support systems will help ensure
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 152
success: job aids that stimulate attainment of service recovery knowledge and skills, leadership
and peer engagement opportunities that provide encouragement and recognition for
developmental efforts, provision of innovation platforms by encouraging curiosity, and creation
of reward systems that recognizes success and growth individually, departmentally, and
organizationally. Through these support initiatives and the commitment of leadership,
management, and staff, integrated implementation through required education and training
evaluation provides E4C with great success potential for the organization, staff, and the frontline
management team.
Level 2: Learning
Learning goals. Level 2 of the model assesses the degree to which participants gain
needed knowledge, skill, attitude, confidence and commitment based on their participation
during training (Kirkpatrick & Kirkpatrick, 2016). Integral to the processes, real-time feedback,
and formative learning must be evaluated through comparison of assessment information to
structured learning goals and predefined expectations (Dauphinee, Boulet, & Norcini, 2019).
Following the completion of the formal recommended solutions, E4C expectations require
frontline manager competency in service recovery by being able to
1. Summarize the features of the common operational trigger points that require service
recovery intervention, (Declarative factual)
2. Clarify the patient engagement process that occurs during service recovery,
(Procedural)
3. Integrate compliance expectations within the patient engagement aspects of the service
recovery process. (Procedural)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 153
4. Master their service recovery responsibilities of using probing engagements with
patients to solve their operational problems (Goal orientation)
5. Express interest in the quality of their service recovery engagements with patients
(Interest), and
6. Express interest in the difference-making impact of their engagements with patients
during service recovery. (Interest)
Program. The effectiveness and credibility of a training program requires the
components of the curricular experiences contribute to the intended learning process (Kirkpatrick
& Kirkpatrick, 2016). To realize the learning goals noted in the previous section, a training
program that probes the depth of functional and aspirational service recovery practice
components will facilitate expected outcomes within the frontline manager team. During the
training process, this stakeholder group will explore a broad range of topics that target effective
service recovery interventions designed to convert poor patient perceptions into more positive
overall experiences. The program blends one 60-minute introduction to service recovery
workshop to serve as an expectation setting primer. Three distinct 60-minute electronic learning
sessions follow with 60-minute in-person workshops after each to engage in the subject matter.
Then a final 60-minute workshop will be presented to finalize the overall learning. The entire
training program requires a commitment to eight learning sessions, spanning 480 minutes.
The blended, sandwiched design of the service recovery training offers both synchronous
and asynchronous engagement opportunities that will cover a synchronous overview to service
recovery, followed by asynchronous and synchronous couplings for each of the following: the
components of service recovery and when should it happen, engaging patients in the service
recovery process and how should it happen, and mastering the art of service recovery or the
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 154
value of improvement. These three groups of engagement will culminate with a final
synchronous session that will discuss what was learned and identify success and correction
opportunities and build sustainability. The initial synchronous in-person meeting formally
establishes the service recovery expectations history of E4C’s pathway to its use, recognition of
the efforts made to date, and provision of overarching objectives and intended outcomes to the
training program. By establishing intent and importance, the training program will benefit from
all stakeholders armed with expectations and tools for success.
Asynchronous electronic learning is steeped in constructivist theory that contends
leaning, and its associated meaning is built in learner’s minds through interactions with the
physical, social, and mental worlds they inhabit (Swan, 2005). The author noted that this
interplay of leading them to make sense of their experiences by building and adjusting such
internal knowledge structures allows the collection and organization of perceptions and
reflections on reality. During each asynchronous electronic learning sessions, the frontline
managers will engage curricular learning videos covering the full topic range for each session
title. They will be provided lists of key terms and charts that highlight the interconnectivity of
operational activities and service recovery operations. Also, operational flow charts depicting
the segment of training targeted in the session will allow for visualization of expectation during
service recovery practice learning. The video presentation will allow paced knowledge and the
ability to repeat sections that require reinforcement. The last sector of each asynchronous
session will offer practice opportunities via a series of multiple-choice questions and final open-
ended questions designed to review understanding of the content which facilitates instructor
review and feedback preparation. The formative assessment after each asynchronous session
feeds into the synchronous, in-person meetings that follow.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 155
Synchronous learning offers instruction where the student learns directly from the
instructor in real time in-person or online, and synchronous whole class meetings assist learners
to feel a stronger sense of connection to their peers and instructor and enhancing engagement
commitment with course activities (Yamagata-Lynch, 2014). During the synchronous in-person
engagements that follow each asynchronous lesson, the focus will be on the application of the
service recovery material learned by the frontline managers asynchronously to real-life service
recovery scenarios through role-play, discussions, learner challenges, and peer-to-peer learning
and reinforcement. This engagement also promotes staff synergy as they have opportunity to
connect with each other through peer-to-peer learning. The instructor team will offer their
personal experience on the sector of service recovery highlighted in each asynchronous platform
and prompt the learners to share their perspectives in real time facilitating further discussion.
Each presentation will offer discussion on the current state of service recovery, leading to team
strategy building on improving the practice. Real-time engagement will include opportunities to
broaden service recovery perspective with the frontline managers and openly acknowledge
collective and individual progress through review of departmental service recovery compliance
metrics.
By design, the synchronous learning will reinforce the asynchronous engagements,
allowing the team to develop their service recovery operational models and skills. Through these
two engagement venues, learners will experience meaningful learning (Yamagata-Lynch, 2014).
Evaluation of the components of learning. Kirkpatrick and Kirkpatrick (2016) noted
that “learning is simply a means to an end; we learn so that we can perform our jobs better and
ultimately contribute more to our organizations” (p. 43). Thus, the measure of success of a
formal training plan resides in the ability of the learner to acquire necessary knowledge and skills
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 156
for a task and effectively transfer that information to meet organizational performance
expectations. Formative in nature, Level 2 of model depends on both learning the knowledge,
skills, attitude, confidence, and commitment to reach the intended performance endpoint and
appropriate evaluation that guides relevant feedback, acknowledgment, adjustments, and praise.
The discipline used by Kirkpatrick and Kirkpatrick (2016) in The New World Kirkpatrick
Model uses different activities during the learning process to test knowledge level and movement
toward those associated competencies. Skill assessment requires demonstration of how the
knowledge is put into action and of the skill performed as intended. As for attitude, the caliber
of active engagement and questioning in performing or articulating the ability speaks to interest
in the process. The domain is rounded-out by assessment of confidence and commitment
through provision of opportunities to practice, ask clarifying questions, and discuss expectations
with instructors and peers (Kirkpatrick & Kirkpatrick, 2016). The authors noted the formative
nature of Level 2 evaluation needs to be immediate, during or after the training events.
Knowledge, skills, attitude, confidence, and commitment are key to service recovery
delivery. Table 23 lists the evaluation methodologies and timing for successful Level 2 learning.
Table 23
Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it. ”
Review and summarization of the components of service recovery and
the trigger points in its use through open-ended question segments in
the asynchronous learning sessions outlining the subject matter.
During the asynchronous
learning on service recovery
trigger points.
Review and summarization of the components of service recovery and
the trigger points in its use through peer-to-peer feedback session and
group discussion during the synchronous learning sessions.
During the synchronous
learning on service recovery
trigger points.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 157
Table 23, continued
Method(s) or Activity(ies) Timing
Procedural Skills “I can do it right now. ”
Review the ability to clarify the patient engagement process in
service recovery through written rationale and reasoning, where
the learner explains the asynchronous learning sessions.
During the asynchronous learning
engagements that review the patient
engagement process during service
recovery.
Review the ability to clarify the patient engagement process in
service recovery through group discussion where the learners
asked to diagnose what can go wrong during patient engagement
in the service recovery process during discussion sessions.
During the synchronous learning
engagements that discuss patient
engagement clarification.
Review the learner ability to integrate procedural knowledge of
E4C’s compliance expectations for service recovery timing
through group presentation and discussion and metric reviews on
current service recovery performance.
During the synchronous learning
engagements that service recovery
integration into practice.
Attitude “I believe this is worthwhile. ”
Instructor’s observation of participants’ statements and actions
demonstrating that they see the benefit of what they are being
asked to do regarding service recovery on the job.
During the synchronous, learning
engagements throughout the
training.
Discussions of the value of mastering the service recovery
process with personal examples of what they are being asked to
perform on the job.
During the final synchronous,
learning engagements in training.
Discussions on the frontline managers personal interest and
perceived challenges in the performance of service recovery that
they are expected to perform on the job.
During the final synchronous,
learning engagements in training.
Confidence “I think I can do it on the job. ”
Survey items using scaled items Following each session in the
asynchronous portions of the
course.
Discussions following practice and feedback.
During the synchronous, learning
engagements throughout the
training.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 158
Table 23, continued
Method(s) or Activity(ies) Timing
Commitment “I will do it on the job. ”
Detailed discussions following practice and
feedback.
During the synchronous, learning engagements
throughout the training.
Create an individual service recovery action
plan.
During the final synchronous learning engagement of
the training.
Level 1: Reaction
The New World Kirkpatrick Model culminates in the assessment of learner reactions to
the training they received (Kirkpatrick & Kirkpatrick, 2016). If the point of the model is to
transition the training process out of the realm and theory and into reality, the data and
evaluation offer the pathway to attaining program success. Focusing on learner perceptions of
the quality of their engagement in training, its relevance to practice, and their overall satisfaction,
Level 1offers formative, and summative evaluation measured immediately after the training
(Kirkpatrick & Kirkpatrick, 2016). The authors do caution there are limitations in the volume of
information available through participants moments after training conclusion and that waiting a
few days to weeks after training may offer a more objective program review. Table 24 lists the
methods and timing of Level 1 reactions assessment of the frontline managers at E4C.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 159
Table 24
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Direct instructor observation of participant engagement quality
with peers and instructors, active participation levels, and other
relevant participant behaviors.
Ongoing during asynchronous
learning sessions.
Completeness and timeliness of required asynchronous
assignments.
Ongoing during asynchronous
learning sessions.
Attendance in real-time live sessions. At the beginning of the
synchronous learning sessions
Course Evaluation Survey Scores. Two weeks after course
completion
Relevance
Brief pulse checks with learners during training after critical
component discussions.
Periodically during all
synchronous learning sessions.
Course Evaluation Survey Scores. Two weeks after course
completion
Customer Satisfaction
Brief pulse checks with learners during training after critical
component discussions.
Periodically during all
synchronous learning sessions.
Course Evaluation Survey Scores. Two weeks after course
completion.
Evaluation Tools
Immediately following the program implementation. Patton (1994) held to the
educational belief that formative assessment paved the path to summative evaluation. The author
noted that as summative evaluations assessed the extent of desired goals attainment, formative
evaluations help programs prepare for the summative assessment by improving program
processes and offering feedback about strengths and weaknesses that influence goal
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 160
attainment. An integral part of the E4C intervention evaluation process embraces this concept
through asynchronous and synchronous training.
Each component of the asynchronous training incorporates data collection regarding the
content of the modules by the frontline management stakeholders compared to the associated
timeline, which will indicate the Level 1 engagement with the asynchronous training
approach. All sessions will conclude with a post-training assessment, measuring the Level 1
interest and engagement with the section content. This assessment will surface perceptions on
content engagement, the relevance of the information to work accountabilities, and overall
satisfaction with the content and presentation, which will gather Level 1 engagement or interest
in the content, perception of the relevance of the course material to actual work, and satisfaction
with the online training experience. These same evaluations offer assessment of Level 2 learning
though evaluation of the applicability of the skills and tools learned to the work environment,
their attitudes regarding valuation of the information The post-training evaluations will also
measure participants’ learning by inquiring about new knowledge and skills, their perception of
mastery that resulted from the training, and their confidence and commitment to consistently
perform the skills during their actual job engagements. Formative assessments of Levels 1 and 2
training help learners assess competency to become better prepared for summative on-the-job
work demonstration of skills (Kirkpatrick & Kirkpatrick, 2016).
The opportunity for discussion is central to effective learning, and competent instructors
challenge learners to see the value of content offering blended discussion opportunities and
highlight how synchronous discussions augment asynchronous engagement (Han & Ellis, 2019).
During the synchronous training components, trainers will document participant attendance and
observe the extent of participation to assess engagement. Further, occasional checks for
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 161
understanding will be conducted by asking participants about the relevance of learning subject
matter and any associated challenges to learning and implementation that potentially affect their
satisfaction experience. Synchronous sessions will offer Level 2 learning assessments using
declarative and procedural assessments both during an in-person discussion and during activities
and post-training application assessments. Attitudes are an important component of Level 2
assessment, and trainers will employ participant observation of frontline managers during in-
person group and individual engagements to measure their valuation of learning concepts during
their verbal engagement and actions. Lastly, the confidence and commitment of the Level 2
engagement will be evaluated via discussion with participants following in-person activities and
detailed feedback. Further, frontline manager attitude, confidence, and commitment will be
assessed in a survey that follows the synchronous engagements. Appendix F depicts Level 1 and
2 rating items that will be included in surveys delivered after asynchronous and synchronous
sessions.
Delayed for a period after the program implementation. While the timing of delayed
assessment after training may vary based on the type of knowledge or skills being learned,
delaying evaluation facilitates review after the learning drivers are engaged and participants have
had the chance to apply to use their new tools in practice (Kirkpatrick & Kirkpatrick,
2016). E4C’s leadership will use a follow-up survey of frontline managers 10 weeks after
training completion and then again three months after training completion. Kirkpatrick and
Kirkpatrick (2016) offer a blended evaluation model that retrospectively assesses training
relevance and satisfaction (Level 1), participant attitude regarding learning content (Level 2),
application of training to the service recovery process (Level 3), and the ultimate measure of the
impact on deliverable actions pertaining to service recovery intervention as designed (Level
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 162
4). As such, this survey will contain 5-point Likert scaled questions and open-ended items to
meet the intended expectations. Appendix H demonstrates the blended evaluation items
addressing the four levels that link to the results, leading indicators, and the required drivers to
support frontline manager critical behaviors.
Data Analysis and Reporting
In a highly technical healthcare environment, the focus on results may overshadow the
process of reaching them. The relative emphasis that teams place on endpoints early in work may
lead team members to become outcome-focused or process-focused with consequences for
performance as a balance between the two required for success (Woolley, 2009). As such,
comprehensive evaluation tools employed in each learning section increase the potential for
obtaining expected results. Through formative and summative evaluations, the information
captured in the asynchronous service recovery learning opportunities. The networking and
instructor-guided engagements offered in the synchronous learning provide the platform for
improved service recovery outcomes and a well-circumscribed curriculum that provides
scalability and adjustment opportunities for future service recovery programming as well as a
template for other departmental and organizational projects.
Measurement and metrics are at the core of understanding whether a process, project, or
procedure is successful. The Hawthorne effect is often noted as an explanation for positive
results in intervention studies and implementation plan discussion. Stand (2000) pointed out that
a Hawthornesque explanation covers many phenomena where behavioral change is attributed to
a learner’s awareness of being observed, compliance with the instructor’s desires because of
increased attention received, or positive response to the stimulus being introduced. The author
also notes that, today, instead of referring to a disputable Hawthorne effect when evaluating
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 163
intervention effectiveness, researchers are well-served to assess any operational variables that
may have influenced any study not monitored during the project, along with the possible effect
on the observed results. Kirkpatrick and Kirkpatrick (2016) recommend researchers assess
appropriately defined metrics that measure outcomes and changes in behavior along with the
attainment of overall organizational practice expectations. When evaluating service recovery
intervention management offered by E4Cs frontline managers, metrics designed to measure the
specific learning goals will be reported. The data will be shared with all team members
consistently and discussions of practice and trends will take place among the frontline managers
and staff, departmental leadership, and executive-level leadership. This data sharing will inform
the practitioners expected to perform the tasks and cement the importance of the efforts as a
tangible means of improving overall patient experience.
The frontline managers’ learning goals evolved from the stakeholder goal of providing
timely service recovery interventions that offer near real-time opportunity to engage patients
regarding their self-reported poor experiences in radiation oncology. The metrics gathered using
the implementation plan directly link to declarative and procedural knowledge related service
recovery practice, frontline manager attitudes, confidence, relevance, and commitment towards
service recovery practice, results based on service recovery efforts, and overall satisfaction with
the implementation program. Levels 1 and 2 offer immediate feedback during and after each
asynchronous and synchronous learning sessions. The longer-term data gathering of Levels 1
through 4 offers two different methods for reporting pertinent information with all service
recovery stakeholders.
Detailed within the implementation plan that adheres to the New World Kirkpatrick
Model (Kirkpatrick & Kirkpatrick, 2016), E4C’s radiation oncology frontline managers will
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 164
attend alternating asynchronous learning sessions and synchronous networking and discussion
sessions spanning 8-consecutive weeks covering a wide range of service recovery practice
modules presented by content and operations experts from the parent organization and external
leaders in service recovery. Data will be captured following all engagement sessions through
exit evaluations targeted at the information presented for that session. Internet-based tools will
offer swift turnaround of the data for assessment and reporting. As noted, the assessment and
interpretation of the information will guide frontline managers and leadership opportunities for
course pivoting as needed. The data will provide insight into participant valuation of the
information and its role in developing them for better practice. All relevant data, both positive
and negative, will be shared with stakeholders, offering necessary transparency with the
expectation of promoting increased overall engagement and secondary capture of potential
solutions.
Level 4 and level 3 data reporting. Level 4 reporting reviews results that assess
conformality with organization expectations, and Level 3 determines the necessary behavioral
components necessary to ensure attainment of consistent results (Kirkpatrick & Kirkpatrick,
2016). From a long-term data assessment perspective, data will be collected and analyzed at the
end of 10 weeks and three months after the completion of the 8-week training program by way of
a survey administered through and facilitated by an online platform. Figure 6 depicts a graph of
the longitudinal performance of initial service recovery interventions that will communicate
compliance with the standard over time, satisfying Level 4 results reporting.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 165
Figure 6. E4C service recovery compliance.
Using the historical service recovery implementation performance metrics for this
reporting as a baseline and annotating the graph with collected data post-training, gains or losses
in reported output will provide a platform for reward or further intervention as needed. A similar
process will be used to assess behavioral changes defined in Level 3 of the model.
Appendix I provides an example of the metrics reporting the reporting of Level 3
behavioral data. The assessment of behavior modification is often minimized in implementation
planning. Behavioral assessment is key to cementing training skills into practice. Without effort
in this area, sustainable change is rarely seen (Kirkpatrick & Kirkpatrick, 2016). By using this
method of data sharing, all stakeholders can visually appreciate performance changes relevant to
service recovery practice. Further, frontline managers will have the opportunity to reflect and
comment via open-ended questions that query them about their service recovery experiences,
behavioral changes that were a direct result of focused learning presentations, and their results in
terms of personal and departmental service recovery identification, patient engagement, and
reporting efforts.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 166
Level 2 and level 1 data reporting. Infographic reporting will outline key Level 1 and 2
data for the week’s session, and relevant metrics will offer an important perspective on progress.
Each week, the data will build on the previous outcomes, providing an opportunity to praise and
encourage (Molden & Dweck, 2000). Again, the data shared in this infographic only represents
the Level 1 and 2 feedback provided by frontline managers following weekly learning
engagements. Appendix J offers a mock-up of an infographic report for formative Level 1 and 2
data captured during training.
Overall, the intent is to share the captured information consistently in an infographic and
scorecard format with all stakeholders of interest. To facilitate recognition and appreciation for
positive service recovery movement, data on service recovery will be coordinated with executive
institutional leadership and shared on institutional platforms, such as the employee website.
Frontline managers will also be encouraged to prepare a presentation for two venues. First, the
frontline manager team will be invited to submit an entry into the E4C quality improvement fair
where the rigor of training, the goal-focused engagement, and overall outcome improvement (if
that is the case) will be presented in an institutional competition, showcasing the stakeholder
growth. Secondly, the frontline manager team will be encouraged to build a 50-minute
presentation on the process to be submitted for presentation consideration at the radiation
oncology annual professional conference. In both platforms, sharing best practices will solidify
the service recovery platform and offer best practices which can be emulated. These sharing
opportunities positively address a broader chance to improve patient care.
Summary
An integrated, defensible implementation plan requires explicit and validated data
depicting where operational KMO performance gaps limit the attainment of stakeholder goals
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 167
(Kirkpatrick & Kirkpatrick, 2016). Using the Kirkpatrick New World Model (Kirkpatrick &
Kirkpatrick, 2016) offers an established platform to realize the extent of service recovery goal
compliance within the frontline manager stakeholder group. The assessment of secondary patient
satisfaction data and stakeholder surveys uncovered performance gaps that quantitatively
described the areas where service recovery expectations were not attained. Designed to
understand the dynamics of frontline manager practice, service recovery-related documents and
artifacts and stakeholder interviews reinforced the KMO operational gaps. Informed by the
literature and data-driven assertions, practice recommendations provided a foundation for
evaluation and interventions that facilitate goal attainment. Frontline managers were able to
effectively perform service recovery practices as designed when afforded clear expectations,
provided comprehensive education with cogent engagement opportunities with mentors as
models, equipped with relevant job aids/tools that outlined components of service recovery, and
were rewarded with acknowledgement and praise as appropriate. This enabled the development
of an intervention process espoused by the New World Kirkpatrick Model (Kirkpatrick &
Kirkpatrick, 2016).
Beginning with the ending practice assessment, the four tiers of the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) promote consistent operational expectation
achievement. Service recovery implementation metrics guided E4C frontline managers toward
successful practice to understand the components of service recovery and its relationship to
patient engagement and satisfaction. Needed behavioral changes were listed and served as a
focus of discussion and learning. With these frontline managers, desired behaviors included
increasing interest and desire to master the service recovery process, increasing core
understanding via the development of job enabling tools, and increased confidence in
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 168
performance and commitment to excellent service recovery practice. Through both formative
and summative measures, the service recovery training plan mostly benefitted from the provision
of clear expectations and exercises that promote increased valuation of the practice. Further,
relevance and appreciation were binding agents among practitioners, educators, and leadership.
Goal attainment equated to better patient experience and the central appeal associated with
helping others, a common theme of importance among the team.
Organizational support sustains attainment of operational goals (Clark & Estes, 2008).
Effective implementation of an integrated plan cannot be underestimated in addressing service
recovery practice while being sensitive to patient and practitioner needs. Sirkin et al. (2005) and
Pinto and Slevin (1989) both noted that project importance must be conveyed, demonstrated, and
measured to gain success through sustained performance. Frontline managers will be asked to
opine on the relevance and usefulness of the training, providing insight into plan effectiveness
and maintenance. The program provides increased value promotion as a fundamental design
pillar, thus addressing the need to provide patients with radiation oncology care that addresses
their disease management needs and their expectations of receiving quality care by swiftly
addressing any challenges. The use of the New World Kirkpatrick Model (Kirkpatrick &
Kirkpatrick, 2016) in this integrated service recovery plan promotes service excellence that can
be emulated in other patient-facing institutional initiatives designed to develop critical thinking
practitioners.
Strength and Weaknesses of the Research Approach
This study employed an explanatory sequential mixed-methods approach to collect and
analyze data pertinent to the problem of practice. E4C’s radiation oncology frontline managers’
knowledge and motivation were measured via a 19-question self-assessment, interviews, and a
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 169
document and artifact review. While the initial quantitative review offered information needed
to draw generalized conclusions, the qualitative phase provided detailed descriptions of why.
Specifically, the qualitative information offers stakeholder impressions, opinions, and views
leading to greater depth regarding their motivations, thinking, and attitudes, bringing depth of
understanding to your research questions. The integration of quantitative and qualitative data
offered greater interpretive outcomes by leveraging the strength of each method (Creswell &
Creswell, 2018; Greene et al., 1989). This was a natural approach that facilitated an accurate
depiction of frontline managers’ knowledge and motivation linked to service recovery and the
practice problem as well as with organizational influences that affect it.
Clark and Estes’ (2008) gap analysis methodology offered an assessment platform that
facilitated the identification of KMO influences that manifested as measurable performance gaps.
As performance gaps surfaced, the platform provided strategic pathways for recommendations to
minimize and potentially eliminate those gaps. While the abundance of information captured
through the secondary data, frontline manager survey, documents and artifacts, and frontline
manager interviews offered important points of triangulation for problem of practice analysis
beyond any single methodology, it did offer greater complexity in the data analysis. Considering
the strength of mixed-methods research with respect to understanding and explaining complex
organizational and social phenomena, that complexity introduces challenges in merging the
qualitative and quantitative data appropriately for assessment (Venkatesh, Brown, & Bala, 2013).
Ultimately, the benefits associated with the mixed-methods approach outweigh any challenge
related to the need for greater processing rigor.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 170
Limitations and Delimitations
This explanatory sequential mixed-methods study used secondary data, a survey, a
document and artifact assessment, and interviews to explore the problem of practice. As noted in
Chapter Three, the principal investigator holds an administrative role where the entirety of the
stakeholder group directly reports to him. As such, full consideration of that relationship
prompted the use of a CITI-certified qualitative researcher from a separate department to conduct
the interviews. Maxwell (2013) cautioned about specific validity threats that may influence the
collected data: bias, positionality, and reactivity. The team scrubbed the interview data of
identifying information before coding to ensure anonymity of responses.
Using outside data collection resources while addressing the direct influence of the
principal investigator on the frontline manager group impacted the study in two ways. First, the
data collection team did not have the benefit of the experiential value of the principal
investigator initially. While steeped in qualitative data collection, an initial time investment was
necessary to explain radiation oncology context and meaning to better frame the understanding
of the data for the data collector. This required verification of contextual transfer through
discussion and example sharing. Although this investment lessened the impact of practice
knowledge in the data collection team, the full breadth of over 30 years of experience and
reflection was likely not fully realized. Second, the anonymity of the findings limited direct
follow-up to address specific challenges an individual stakeholder may have articulated. As
such, a broader overarching approach had to be included in designing solutions to the problem of
practice. While this can be effective on a widespread basis and deeply rooted in individual and
group psychology, the strength of employee commitment to both the employer and role
improved through direct engagement and value sharing (Vance, 2006). Protecting the frontline
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 171
managers by ensuring anonymity and removing the principal investigator’s direct influence may
have also introduced a study limitation.
By design, the data collection was completed over two weeks for the surveys and three
weeks for the interviews and limited to frontline manager perspectives. These delimitations
maintain the integrity of the study design and ensure it was completed within the study’s
timelines. The views of frontline staff, administration, departmental leadership, and patients
likely would have surfaced varying perspectives on service recovery that were not included in
the study. Further, as the study was limited to review of an extensive, specialized radiation
oncology practice, the scalability and robustness of the method and solutions need to be
considered when attempting to adapt the solutions offered to other organizations.
Typically driven by researcher choice, objectives, questions, participants, and theoretical
framework may yield biases. In the case of this study, delimitation requires a review of each
decision made during study conceptualization with consideration to those areas that may not be
explicit. The participants were the frontline management team at one institution who direct staff
in engaging patients via different disciplines. Managers in different core disciplines may affect
service recovery as well as compliance with expectations.
Future Research
This study yields several opportunities for future research in terms of theory application
and concept validation. Additional research will refine and elaborate on the findings of this
study. Further exploration into service recovery in radiation oncology practice would add to the
body of knowledge, as current literature is limited. The first recommendation for consideration
is a longitudinal multivariate analysis study to discerns service recovery performance stratified
by service provider domain. While this study assessed service recovery across a broad domain
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 172
of practitioners, examination and comparison of practice domains offers insight on performance,
educational preparation, rigor of training, and service culture orientation. This type of follow-up
study builds on the foundation set in this explanatory assessment. It would offer multiple
perspectives on value of service recovery as well as any variation in practice maintenance across
functional groups. It would be interesting to understand what service recovery means to
frontline functional staff, assessing whether there is continuity of knowledge and motivation of
the groups directly engaging patients daily. The recommendations suggest investing in manager
understanding and consistently offering feedback on practices of service recovery that would
strengthen expected performance. Understanding the actual impact of the interventions requires
review of data on the effectiveness of increasing formative assessment on performance;
conventional thought proposes that formative assessment positively impacts student learning
(Black & William, 1998). Further study can test this position.
Second, conducting a follow-up mixed method improvement study of service recovery in
radiation oncology would be a natural progression on the explanatory service recovery study
reported in this dissertation. Review of the implementation of solutions would offer an
important assessment of the effectiveness of interventions. While the solutions identified herein
are supported by educational theory, a formal research approach would further validate them,
particularly if improvement is experienced. If improvement is not experienced, exploration of
reasons for that situation offers valuable perspectives that can be considered to refine solutions
and positively impact practice.
For final consideration, a follow-up correlative study that examines measured results of
the link between service recovery and overall patient satisfaction would solidify the value and
meaningfulness of the investment into service recovery. Chapter Two outlines the link between
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 173
patient engagement and patient satisfaction. As a form of patient engagement, service recovery
design seeks to improve the patient experience. Thus, assessing and linking service recovery
practice to patient satisfaction reports will add value and justify continued investment into the
practice. As E4C looks to offer an exceptional end-to-end patient experience, validation of
service recovery practice cements it as a best practice. The results from this type of study would
further benchmark platforms from an operational vantagepoint. As patients evolve on a
consumer front, greater value will be placed on their experience, frontline managers’ practice
improvement will be based on better-informed perceptions of patient care, and more
organizational resources will be earmarked to validate service recovery practice.
Conclusion
In the healthcare domain, desire to impact patient health through the mastery of
technological advances and transition of innovative care protocols from the benchtop to the
bedside reigns above all else. This focus on the process, at times, minimizes the importance of
offerings compassionate, individualized care to patients. With over 50% of the diagnosed cancer
population requiring radiation oncology intervention as a part of the care regimen, the need to
meld the technical with the caring needs of patients requires focused attention to meet health
outcome expectations and patient satisfaction expectations. E4C’s mission reflects that
importance. Yet, the radiation oncology department did not achieve patient satisfaction scores
reported by patients in benchmarked assessment. As such, there was need to review this problem
of practice to reverse the negative patient satisfaction trends. Service recovery was introduced to
address patient satisfaction through improved patient engagement and promote operational
changes that will yield better patient satisfaction outcomes.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 174
Selecting the frontline managers as the chosen stakeholder recognizes the influence that
this group has in guiding practice, as their choice of staff training and subsequent service
recovery interventions determines the success of the program. As it is not uncommon for
frontline radiation oncology managers to be selected for their roles because of their mastery of
treatment delivery and patient care skills, they are not adequately prepared for managerial
practice. These skills must be nurtured and developed through engagement, investment of time,
and training. Attaining the management competencies necessary to master the practice of service
recovery themselves and to develop their staff require preparation in service recovery component
skills with opportunity to integrate them into practice and knowing when to apply what they have
learned (Schraw & McCrudden, 2006). The role of the frontline manager is central to
programmatic success.
While the frontline managers play a pivotal role in ensuring service recovery practice
is invoked appropriately and in a timely fashion, they were found to be collectively inconsistent
in their command of knowledge and skills related to the practice. The frontline managers need
more organizational support and resources to ensure organizational expectations will be
achieved. Competing patient care responsibilities, limited performance feedback, and a lack of
continual comprehensive training and metric review limits the success of the program. Further,
with leadership expectations insisting on performance in the area, it is not difficult to see that the
managerial staff become frustrated. The overarching pressure to perform in this environment
directly impacts the management team’s effectiveness and clouds messaging to the frontline
staff. Greater leadership engagement is needed to reestablish service recovery as an important
platform to improve patient engagement and, ultimately, patient satisfaction. Time and resources
are required to ensure that appropriate service recovery skills, interest, and support to improve
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 175
the service recovery metric expectations to consistent success, a place the team has not reached
in two years. Without these efforts, the program will never meet its objectives.
E4C frontline managers shared their frustrations and challenges related to maintaining
service recovery practice. The cohort described understanding their expectations and that their
efforts are impactful on the patient experience, however, their factual and procedural knowledge
lacked cohesion Further, they expressed motivational challenges in the areas of task mastery and
interest levels pertaining to service recovery. Thus, participants might benefit from a program
that identifies value modeling and recognizes and rewards them for demonstrating the skills
needed for success. By constructing an environment that taps into both personal and situational
interest, and recognizing progress, behaviors toward tasks transform into successes that promote
desire and consistency in practice. The motivation of the frontline managers must be considered
in the formulation of a successful service recovery program.
E4C invested time and effort in developing the service recovery program. However, it
did not complete required ongoing training, performance sharing, and feedback loops with the
frontline manager team to cement the program as a programmatic anchor. Feedback must be
provided, recognition of accomplishments must be shared, and practice pivots performed
consistently if the expected outcomes will ever be realized. The results of the study surfaced six
areas needing practice reform if service recovery goals are to be met. Factual and procedural
knowledge must be addressed through focused training and practice opportunities. Stakeholder
motivation needs to be addressed to allow for goal orientation and interest to flourish. These two
areas need infusion of structured peer and expert discussion venues, acknowledgement and
recognition strategies, and platforms that spark their subject curiosity and offers personal
satisfaction in the process. By providing managers with this level of direction and tools that
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 176
support service recovery, the enterprise will become better positioned to address patient needs
when they share levels of service dissatisfaction (Gutbezahl & Haan, 2006). None of this will be
achievable without addressing the E4C cultural modeling and cultural practice setting. The
organization will benefit from professing that service recovery is a priority, and it will be
necessary to expend resources more consistently. Success cannot self-navigate and requires
planning, communication, and partnering between management and staff. The conceptual
framework of the study depicts the overarching influence that the organization has on practice.
As such, the transformation plan offers research-inspired interventions and strategies spanning
12 months.
The radiation oncology department at E4C requires service recovery practice reform.
The study design outlined a plan to assess and explain service recovery standard compliance and
the reasons for its performance through rigorous quantitative and qualitative methods. Patients
are focused on the caliber of their experience as it impacts their care satisfaction, and the days of
patients deferring to their doctors skills and habits alone are gone. Patients think more like
consumers of any other goods and services. Given the volume of patients at E4C and the
institution’s commitment to quality care provision across its entire continuum, reform is
necessary. The frontline managers and their leadership should be encouraged to offer the
comprehensive care quality that patients demand. While the effort to improve service recovery
practice falls to the E4C frontline managers and their support platform, the benefactors are the
patients. The patient ultimately drives the success of any healthcare organization. As Maya
Angelou noted “people will forget what you said, people will forget what you did, but people
will never forget how you made them feel.” The patients depend on the E4C frontline manager
team to care for their well-being holistically.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 177
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APPENDIX A
Dissertation-Specific Survey Questions and Categorizations
Research
Question/
Data Type
KMO
Construct
Survey Item
(question and
response)
Scale of
Measurement
Potential
Analyses
Visual
Presentation
Demographics –
Sample
Description
NA I am employed as
a:
Nurse Therapist
PSR Manager
Nominal Percentage,
Frequency
Table, Pie
chart
Demographics –
Sample
Description
NA I have worked for
E4C for ____
years in my
current capacity.
(0 -1, 2 - 3, 4 – 5,
6+)
Interval
Percentage,
Frequency,
Mode,
Median,
Mean,
Standard
Deviation,
Range
Table
Demographics –
Sample
Description
NA What is the
highest degree or
level of education
you have
completed?
(High school or
equivalent,
Bachelor’s,
Master’s,
Doctorate)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Bar
Chart
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(K-F) Service recovery
training has
prepared me to
address patients
when they are not
satisfied with their
care. (Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Stacked
bar chart
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 198
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(K-F) I am confident in
my ability to
identify the need
to use service
recovery
techniques when it
is appropriate.
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(K-C) Service recovery
is directly linked
to patient
engagement
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table
To what degree is
E4C’s radiation
oncology
department
meeting its goal
of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
(K-P) I can fully identify
the steps required
in the service
recovery
protocols.
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 199
hours of receipt
by Q4 2019?
Agree, Strongly
Agree)
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(M-GO) I hold ___ team
meetings each
month where I
reiterate the
importance of
improving the
patient
experience. (0 –
1, 2 – 3, 3 – 4, 5+)
Ratio Mean,
Standard
Deviation,
Range
Table
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(M-GO) To what degree do
you probe patients
with follow-up
questions in
assessing their
source of
dissatisfaction
during service
recovery? (Never,
Rarely,
Sometimes, Often,
Always)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
(M-I) I realize that the
quality of my
engagement can
impact the
effectiveness of
my service
recovery efforts.
(Strongly
Disagree,
Disagree,
Somewhat
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 200
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(O-CM) E4C promotes an
action-oriented
commitment to
gain expected
results by taking
on difficult
challenges with
urgency when
invoking service
recovery (Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Stacked
bar chart
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(O-CM) E4C promotes an
action-oriented
commitment to
gain expected
results by taking
on difficult
challenges with
enthusiasm when
invoking service
recovery (Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Stacked
bar chart
What are the
management
team’s
knowledge,
(O-CS) E4C provides
adequate
resources to
ensure staff
Ordinal Percentage,
Frequency,
Mode,
Table, Stacked
bar chart
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 201
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
development to
facilitate
consistent service
recovery delivery.
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Median,
Range
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(O-CS) E4C provides
adequate
resources to
ensure
information
transfer to
facilitate
consistent service
recovery delivery.
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Agree, Strongly
Agree)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Stacked
bar chart
What are the
management
team’s
knowledge,
motivation and
E4C’s radiation
oncology
department
influences related
to achieving its
goal of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
(O-CS) E4C provides
adequate
resources to
ensure timely
feedback to
facilitate
consistent service
recovery delivery.
(Strongly
Disagree,
Disagree,
Somewhat
Disagree, Neither
Agree nor
Disagree,
Somewhat Agree,
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Table, Stacked
bar chart
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 202
hours of receipt
by Q4 2019?
Agree, Strongly
Agree)
To what degree
is E4C’s
radiation
oncology
department
meeting its goal
of providing
100% of service
recovery for Q-
Review
®
scores
below the self-
reported score of
“3” within 24
hours of receipt
by Q4 2019?
(O-CS) We have ____
meetings a month
with leadership to
review and team
performance on
service recovery.
(0 – 1, 2 – 3, 3 –
4, 5+)
Ratio Mean,
Standard
Deviation,
Range
Table
K-F=Knowledge-Factual, K-C=Knowledge-Conceptual, L-P=Knowledge-Procedural,
M-GO=Goal Orientation, M-I=Interest, O-CM=Cultural Models, O-CS=Cultural Settings
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 203
APPENDIX B
Interview Protocol and Procedures
Start with a bit of small-talk with the interviewee to establish a rapport and build a trusting
relationship intended to place the subject at ease. With that lead-in, the interview can formally
begin.
Scripted narrative before the start of a formal interview:
Introduction
Good [morning/ afternoon]. My name is [NAME] and I’m a researcher at East Coast
Comprehensive Cancer Center working with Mr. Washington, the principal investigator for
this project. Thank you for speaking with me today! Our purpose today is to help us learn
more about the knowledge and skills, motivation, and organizational influences that you
experience as a staff manager in radiation oncology. Your input will help us understand how
we can improve service recovery for your patients that reported challenges in their care.
Ground Rules
Before we get started, I’m going to review some ground rules for this interview.
• You are the expert; we asked you here today so that we can learn from your
experiences. Please feel comfortable and free to share your unique point of view
during the discussion.
• Everything you share today will be helpful for us, and there aren’t any right
answers or wrong answers.
• Your participation today is entirely voluntary; you may stop at any time. You do
not need to answer any questions that you feel uncomfortable answering.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 204
• In today’s interview, we will cover topic areas such as knowledge, motivations, and
organizational influences that impact service recovery.
• Our interview today will last about one hour. If at any point I change the
discussion or move to the next topic, it is only because we have a lot of material to
cover today in a short amount of time. I understand that your time is valuable!
• Let me remind you that we will be audio-recording this discussion so that we can
accurately capture your feedback. I will also take notes. Please be assured that all
information you share will be kept private: no identifying information will be
included in my notes, the audio file, or the transcription of this interview. After the
audio recording is transcribed, the audio file will be deleted.
• All information will be kept strictly confidential and any information collected will
be securely retained in a locked file cabinet immediately after our discussions or a
password-protected file on my computer. All collected information (notes,
transcripts, and related information) will be destroyed, maintaining the integrity of
the information you provided.
• We will not use names when we write about our findings, and your comments
today will not be linked to you.
• Do you have any questions before we begin? You can stop me at any time for
clarification or to repeat the question.
• Thanks again! We will start the audio recording now.
To begin this interview, I would like to ask you some questions about your background and
experiences as a manager in radiation oncology.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 205
1. How long have you been practicing in your current management capacity? How long have
you been at E4C?
2. Before your current role, in what position were you working, either here or at another
institution?
3. What are your key responsibilities as a manager in radiation oncology?
4. It is common for managers to have a style preference for managing staff. Can you describe
a management style that you identify with? Follow-up: Can you describe a time when you
used this style to solve an operational problem.
Thank you very much for sharing. I would now like to ask you a series of questions specific to
the knowledge and motivation used in the service recovery process and your role as a manager.
5. What are your thoughts on the relationship between patient experience and satisfaction with
their care?
6. How would you define service recovery? Please share your thoughts on its role in patient
care. Follow-up: How would you define success with respect to service recovery? How do
you measure success?
7. What are the institution’s expectations for you and your staff regarding action-oriented
implementation of the service recovery process?
8. What are the departmental expectations for your role in service recovery? How were you
prepared/trained by your department to take an active part in service recovery?
9. What strategies do you use to prepare your staff to engage their patients to get the best
possible engagement outcomes? Follow-up: Think about a time when you needed to
provide some feedback or instruction on identifying a dissatisfied patient…how did you go
about it?
10. What do you look for in your staff to assess how well they link patient experience to their
satisfaction level?
11. Can you think of an example of when you gave any feedback to a staff member after
observing them working with a dissatisfied patient?
12. How would you describe your staff’s interest in service recovery? Follow-up: What do
you think contributes to their interest level in it?
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 206
13. Do you think that service recovery is important? Follow-up: Please share your thoughts on
the benefits seen compared to the time and effort used to perform service recovery.
14. What are your thoughts about the departmental service recovery strategy? Follow-up:
How do you feel when the service recovery process goes as planned? What factors
contribute to success? How about when it does not go as planned? What factors contribute
to it not going well? In those cases, what ideas do you have for explaining those factors?
What might work in making it better?
Thank you very much. I would like to end the line of service recovery questions with a couple
that explores any organizational influences on service recovery.
15. What are your thoughts on your success in managing the department’s service recovery
expectations? What criteria would you use to assess this? Follow-up: What has your
manager said about how you manage service recovery? Have you been given any
feedback on how you manage service recovery?
16. To what extent do you feel that your organization provides you with adequate resources to
successfully carry out the service recovery process? Follow-up: How would you rate the
current service recovery practice of your department?
17. Are there any additional resources or support that you need with service recovery?
18. Are there any core areas of service recovery that need to be improved in the department?
With the staff?
19. Do you have any thoughts on what you would like to be doing differently regarding
service recovery?
Before we end our interview, is there any additional information that you would like to
share about service recovery that we have not had a chance to discuss?
Again, thank you for taking the time to share your thoughts on service recovery. While I
do not think it would be necessary, I hope that I can call you if any clarification is needed as I
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 207
compile the information. At the completion of the project, I would be happy to share my
findings with you if you have a desire to see it. Thank you very much.
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 208
APPENDIX C
Document and Artifact Review Form
Type Code Descriptor
1 Policy
2 Procedure
3 Minutes/Notes
4 Publication/Handout
Coded
Document Type
Name of Document Date of Document Source of Document Authors of Document
For Whom was the
Document Intended
Was Document Peer-
reviewed
Any Bias Evident
Explanation of Document Bias
Observed (if applicable)
Identified Organization Strategies
for Service Recovery
What Resources/Materials
Are Needed?
Description of Strategies Comments
Document Type Key
Running head: SERVICE RECOVERY AND THE PATIENT EXPERIENCE 209
APPENDIX D
Frontline Manager Survey Results and Findings
Service recovery
training
has prepared me to
address patients
when they are not
satisfied with their
care.
I am confident in
my
ability to identify
the need to use
service recovery
techniques when it
is appropriate.
Service recovery is
directly linked to
patient engagement.
I can fully identify the
steps required in the
service recovery
protocols.
I hold ___ team
meetings
each month where
I reiterate the
importance of
improving the
patient
experience.
To what degree do
you probe
patients with follow-
up questions in
assessing their source
of dissatisfaction
during service
recovery?
I realize that the
quality
of my engagement
can impact the
effectiveness of my
service recovery
efforts.
E4C's Department of
Radiation Oncology
promotes an action-
oriented commitment to
gain expected results by
taking on difficult
challenges with urgency
when invoking service
recovery.
E4C's Department of
Radiation Oncology
promotes an action-
oriented commitment to
gain expected results by
taking on difficult
challenges with enthusiasm
when invoking service
recovery.
E4C's Department of
Radiation Oncology provides
adequate resources to
ensure staff development to
facilitate consistent service
recovery delivery.
E4C's Department of
Radiation Oncology
provides adequate
resources to ensure
information transfer to
facilitate consistent
service recovery delivery.
E4C's Department of
Radiation Oncology
provides adequate
resources to ensure
timely feedback to
facilitate consistent
service recovery delivery.
We have ____ meetings
a
month with leadership
to review team
performance on service
recovery.
Total n 12 12 12 12 12 12 12 12 12 12 12 12 12
Mean 2.5000 1.6667 1.4167 2.5833 1.7500 2.2500 1.0833 1.6667 1.7500 3.3333 2.5833 2.5833 1.5000
Standard Error 0.3989 0.2562 0.1486 0.3786 0.4459 0.3286 0.0833 0.2247 0.2176 0.4660 0.3128 0.4345 0.3371
Median 2.5 1.5 1 2.5 1 2 1 1.5 2 3 2 2 1
Mode 3 1 1 3 1 2 1 1 2 2 2 2 1
Standard Deviation 1.3817 0.8876 0.5149 1.3114 1.5448 1.1382 0.2887 0.7785 0.7538 1.6143 1.0836 1.5050 1.1677
Range 5 3 1 5 4 4 1 2 2 5 3 5 4
Minimum 1 1 1 1 1 1 1 1 1 1 2 1 1
Maximum 6 4 2 6 5 5 2 3 3 6 5 6 5
1: n=3 (25%)
[Strongly agee]
1: n=6 (50%)
[Strongly agree]
1: n=7 (58.3%)
[Strongly agree]
1: n=2 (16.7%)
[Strongly agree]
1: n=9 (75%) [1] 1: n=3 (25%) [Always]
1: n=11 (91.7%)
[Strongly agree)
1: n=6 (50%) [Strongly
agree)
1: n=5 (41.7%) [Strongly
agree]
1: n=2 (16.7%) [Extremely
adequte]
1: n=0 (0%) [Extremely
adequate]
1: n=2 (16.7%) [Extremely
adequte]
1: n=9 (75%) [1]
2: n=3 (25%) [Agree]
2: n=5 (41.7%)
[Agree]
2: n=5 (41.7%) [Agree] 2: n=4 (33.3%) [Agree] 2: n=1 (8.3%) [2-3] 2: n=5 (41.7%) [Often] 2: n=1 (8.3%) [Agree] 2: n=4 (33.3%) [Agree) 2: n=5 (41.7%) [Agree]
2: n=4 (33.3%) [Moderarely
adequate]
2: n=9 (75%) [Moderately
adequate]
2: n=6 (50%) [Moderately
adequate]
2: n=2 (16.7%) [2-3]
3: n=5 (41.7%)
[Somewhat agree]
3: n=0 (0%)
[Somewhat agree]
3: n=0 (0%)
[Somewhat agree]
3: n=5 (41.7%)
[Somewhat agree]
3: n=0 (0%) [4-5]
3: n=3 (25%)
[Sometimes]
3: n=0 (0%)
[Somewhat agree]
3: n=2 (16.7%)
[Somewhat agree]
3: n=2 (16.6%) [Somewhat
agree]
3: n=2 (16.7%) [Slightly
adequate]
3: n=0 (0%) [Slightly
adequate]
3: n=2 (16.7%) [Slightly
adequate]
3: n=0 (0%) [4-5]
4: n=0 (0%)
[Neither]
4 n=1 (8.3%)
[Neither]
4: n=0 (0%) [Neither] 4: n=0 (0%) [Neither] 4: n=0 (0%) [6+] 4: n=0 (0%) [Rarely] 4: n=0 (0%) [Neither] 4: n=0 (0%) [Neither] 4: n=0 (0%) [Neither] 4: n=1 (8.3%) [Neither] 4: n=2 (16.7%) [Neither] 4: n=0 (0%) [Neither] 4: n=0 (0%) [6+]
5: n=0 (0%)
[Somewhat
Disagree]
5: n=0 (0%)
[Somewhat
Disagree]
5: n=0 (0%)
[Somewhat Disagree]
5: n=0 (0%) [Somewhat
Disagree]
5: n=2 (16.7%)
[Never]
5: n=1 (8.3%) [Never]
5: n=0 (0%)
[Somewhat
Disagree]
5: n=0 (0%) [Somewhat
Disagree]
5: n=0 (0%) [Somewhat
Disagree]
5: n=2 (16.7%) [Slightly
inadequate]
5: n=1 (8.3%) [Slightly
inadequate]
5: n= 1 (8.3%) [Slightly
inadequate]
5: n=1 (8.3%) [Never]
6: n=1 (8.3%)
[Disagree]
6: n=0 (0%)
[Disagree]
6: n=0 (0%) [Disagree]
6: n=1 (8.3%)
[Disagree]
N/A N/A
6: n=0 (0%)
[Disagree]
6: n=0 (0%) [Disagree] 6: n=0 (0%) [Disagree]
6: n=1 (8.3%) [Moderately
inadequate]
6: n=0 (0%) [Moderately
inadequate]
6: n=1 (8.3%) [Moderately
inadequate]
N/A
7: n=0 (0%)
[Strongly Disagree]
7: n=0 (0%)
[Strongly Disagree]
7: n=0 (0%) [Strongly
Disagree]
7: n=0 (0%) [Strongly
Disagree]
N/A N/A
7: n=0 (0%) [Strongly
Disagree]
7: n=0 (0%) [Strongly
Disagree]
7: n=0 (0%) [Strongly
Disagree]
7: n=0 (0%) [Extremely
inadequate]
7: n=0 (0%) [Extremely
inadequate]
7: n=0 (0%) [Extremely
inadequate]
N/A
Answer options (n & %)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 210
APPENDIX E
Document and Artifact Codebook
Code Description
Item
reference
Example of supportive
quotations
Frequency
Expectations
Tasks and
procedures that
will facilitate
the success of
the project
1, 13
(1) “Respective
managers/supervisors will
follow up within their
respective areas. Service
recovery correspondence will
be made by 4PM same
(business) day of receiving an
unfavorable response. An
unfavorable response is any
questions with a score of 3 or
lower and/or an unfavorable
comment.
Manager/Supervisor
following up should make
sure they are assigned to the
response. “ (1) Document the
feedback on RateMyHospital
and change the status to
complete.
Meet patient’s requests
Offer alternate solution(s)
Unable to meet patient’s
request and explain
limitations (13) “Perform
timely
service recovery and reward
high-quality service”
3
Importance
Why the
project is
needed in the
department
13, 27
(13) “Give patients a voice -
let them know we care” (27)
“As a department, we are
excited to expand this pilot
as it will provide us with
great feedback of what we
are doing well and
opportunities for
improvement to better serve
our patients”
2
Outcomes
Overall result
of the project
1, 13, 27
(1) “Flag patients by placing
concern in comments to
ensure patient’s cancer are
3
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 211
met at next visit.” (27) “To
better serve our patients”
Rationale
Reasoning for
implementation
of project
1, 13, 20
(1) “Rate My Hospital is a
mobile and web-based
platform that captures real-
time, HIPAA-secure patient
feedback via text messaging.
Utilization of this tool allows
for immediate review of
patient feedback and
intervention for unfavorable
experiences. “ (20) “The
dashboard and mobile
feedback tool allows a faster
and more accurate way than
traditional surveying
methods for medical
facilities to gather and
analyze patient feedback.
The data collection and
analytics tools provide
healthcare administrators
and providers the answers
and insights needed to
improve the patient’s
experience in real time.”
3
Vision
Overall goal of
the project
1, 13, 20
(13) “Measure
improvements in patient
satisfaction in real-time.”
(20) “Staff engagement in
clinical practice is important
to understand the patient
perception of care.”
3
Discussion
Collaboration
regarding pilot
and launch of
project
14, 22,
30, 6
(14) “Scheduled: weekly
check in call will be
Mondays at 11AM” (30)
“Do you have a short
paragraph or description
about Rate My Hospital that
I can share with my team
just introducing the system
to them prior to the meeting
next week?”
4
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 212
Policy and
Procedure
Development
Creation of
formal
document of
how to conduct
service
recovery
1, 6
(1) “This policy will provide
guidance on handling Rate
My Hospital (RMH)
Surveys. “
2
Process
Development
Thoughts and
ways of how to
engage others
in service
recovery
1, 15, 18,
19, 3
(1) “PSR will inform/explain
to patients upon checking
into their new visit
appointment and confirm the
mobile number.” (18) Need
text message wording
5
Staff Challenges
Barriers to
expectations
27, 8
(8) “ PSR fear of explaining
survey to pt
3
Staff feedback
Ways to
improve
engagement
and results
2, 11
(11) “3 Question for 3
different visits”
3
Staff Training
Preparing
frontline staff
for launch of
project
12, 14,
17, 18,
22, 23, 25
(12) “Work with
RateMyHospital to schedule
introductory demos and
training of frontline staff
prior to launch date “ (14)
“RateMyHospital dashboard
training for Chris
Choudhury, Mari Rodriguez,
and Charles Washington
scheduled for Thursday
5/11/17 at 1PM” (18)
“Frontline staff introductory
demo completed on 5.25.17
and 5.26.17”
8
Communication
Sharing of
updates,
thoughts, or
procedures
16, 20,
22, 25,
28, 29
(16) Provide ongoing
support via biweekly
webinars during pilot. (25)
Thanks Mari. I shared with
the Westchester team.
6
Discussion
Collaboration
of improving
project
20, 27
(20) Departmental
management team will
implement additional ways
to improve response rate
2
Engagement
Facilitating
communication
and connection
20, 6, 9
(20) POA staff to engage
NVs the next business day
after visit (6) Schedule
biweekly mtg. w/ regionals
5
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 213
throughout all
staff and sites
Main
stakeholder
feedback
Feedback from
frontline staff
about updates
and needed
20, 32, 7,
8
(20) “Expanded questions to
solicit feedback on all
additional aspects of RO
practice (physician and
administrative engagement,
courtesy, scheduling, and
how likely to recommend
practice to others)” (7) NA if
question is not applicable
5
Other
stakeholder
feedback
Feedback from
others
(physicians or
patients) about
updates and
needs
20, 7, 8, 9
(20) “During service
recovery, patients very
appreciative (and surprised)
of the call” (9) “Knowing of
rate my hospital - refusing to
see difficult pt”
5
Pilot Launch
Phase I of
project roll out
12, 14,
16, 20
(12) “Identify stakeholders
and “go to people” at each
pilot location” (20) “Go-live
6/5 beginning with NVs for
pilot group” (20) “Late June
– expanded to all clinic MD
visit types within pilot
group”
5
Metrics
Types of data
that can be
created
4, 8
(8) “Turnaround time for
recovery” (4) “Analytics/
Reports: score trends, scores
by location, dept ranks”
2
Onboarding
New Staff
Training for
additional staff
after launch
33
(33) “(excuse XXX because
she was not shown the
spreadsheet I just questioned
her today about it however
she does call the patients as
assigned as I get her
completions)”
1
Reporting
Sharing of
metrics
31,10, 11,
5
(31) “Im seeing lots of
negative feedback without
service recovery notes - are
we still calling patients,
informing physicians, etc. I
have not seen emails about
any of these patients and
there are no notes in RMH.”
5
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 214
(10) “XXX would like to
give each attending the
feedback”
Retraining
Re-establishing
understanding
of procedures
and policies
33
(33) “Either the managers
just don’t use it or are just
not calling patients back and
it is time-consuming .The
assignment pool is pretty
slim due to vacations, staff
no longer here and cc
training.”
1
Staff Meetings
Staff check ins
about project
32, 9
(32) “Can you please share
the managers that will be on
the rotation list to call pts for
Manhattan? When will this
be in”
2
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 215
APPENDIX F
Sample Post-Training Survey Items Measuring Kirkpatrick Levels 1 and 2
1. This service recovery training held my interest. (Level 1: Engagement)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
2. This service recovery training was relevant to the expectations of my position. (Level 1:
Relevance)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
3. I am satisfied with my training experience today. (Level 1: Customer Satisfaction)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
4. From the list below, choose the one that is NOT a trigger for service recovery intervention:
(Level 2: Declarative Knowledge)
a Patient visibly upset while waiting for care.
b. Patient that rated a service experience with a “1” on the service recovery survey but
did not offer any comments.
c. Patient that rated a service experience with a “3” on the service recovery survey.
d. Patient that rated a service experience with a “5” on the service recovery survey.
5. I understand the link between service recovery and patient engagement and patient
satisfaction. (Level 2: Declarative Knowledge)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 216
6. Which of the following is essential to patient engagement during service recovery? (Level
2: Procedural Knowledge)
I. Create and communicate the same customer service message to all staff
II. Attentively listen to what the patient is saying during your engagement
III. Provide training only to new staff that has not ever done service recovery
a. I and II
b. I and III
c. II and III
d. I, II, and III
7. Understanding how to read and interpret service recovery compliance reports is valuable
to my work. (Level 2: Attitude)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
8. I feel confident I can read and accurately interpret next month’s service recovery report.
(Level 2: Confidence)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
9. I am fully committed to applying my knowledge of using the service recovery reports each
month going forward to improve my practice. (Level 2: Commitment)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 217
APPENDIX G
Frontline Manager Interview Domains, Codes, Descriptions, and Frequencies
Domain Code/ Concept Distribution across
transcripts n(%)
Knowledge Definition of service recovery
(centered on “patient experience”/
“patient voice”/ “feeling heard)
10 (90.9)
Lack of clarity on data use
5 (45.5)
Organizational Influence Feasibility of meeting 24-hour time
expectation
6 (54.5)
Feedback on 3-star threshold
(expectation impacts call volume)
9 (81.2)
Feedback on specific survey items
(expectation impacts call volume,
e.g. “wait times”)
5 (45.5)
High Expectations (coded as:
“Expectations” and “Importance”)
7 (63.6)
Motivation Internal Motivations (job
satisfaction)
7 (63.6)
External Motivations (department
improvement)
4 (36.4)
Training and Needs Need for Support (to perform SR/
meet SR expectations/ staffing
needs)
9 (81.2)
Training (“no formal training”/
training needs)
8 (72.7)
Patient Response Patient reaction to call- positive/
surprise
6 (54.5)
Patient fear of retaliation/ changes
tone
4 (36.4)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 218
APPENDIX H
Sample Blended Evaluation Items Measuring Kirkpatrick Levels 1–4
1. The training information has been applicable to my recent service recovery work. (Level
1: Relevance)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
2. What information was most relevant to your service recovery practice? (Level 1:
Relevance)
3. What information was least relevant to your service recovery practice? (Level 1: Relevance)
4. What information should be added to this training in the future to increase its relevance to
frontline managers? (Level 1: Relevance)
5. What information, if any, do you feel was missing from training? (Level 2: Knowledge,
Skills)
6. How has your confidence using what you learned changed since the training? (Level 2:
Confidence)
7. I have successfully applied what I learned in training for my service recovery work. (Level
3: Transfer)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
8. If you selected Strongly Disagree or Disagree for #7 above, please indicate the reasons
(check all the apply): (Level 3 Transfer)
a. What I learned is not relevant to my work.
b. I do not have the necessary knowledge and skills.
c. I do not feel confident in applying what I learned to my work.
d. I do not have the resources I need to apply what I learned to my work.
e. I do not believe applying what I learned will make a difference.
f. No one is tracking what I am or am not doing anyway.
g. Other (please explain):
9. What else, if anything, do you need to apply what you learned successfully? (Level 3
Transfer)
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 219
10. I have received praise for my leadership, recognizing my efforts in attempting to solve
patient-reported problems, and pursuing my self-improvement as a service recovery
provider. (Required Drivers: Encouraging)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
11. I have been able to reflect on my joys and satisfaction regarding the impact of my
engagement with patients during service recovery with my leadership. (Required Drivers:
Encouraging)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
12. I am incentivized to apply what I learned. (Required Drivers: Rewarding)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
13. I have been or will be rewarded for successfully applying what I learned. (Required
Drivers: Rewarding)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
14. My leadership has scheduled a consistent time for both individual and team meetings for
service recovery metric review and training. (Required Drivers: Reinforcing, Monitoring)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
15. I consistently hold meetings to communicate the importance of service recovery and share
team and individual goals and accomplishments. (Required Drivers: Reinforcing,
Monitoring)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 220
16. I am held accountable for applying what I learned and making progress. (Required Drivers:
Monitoring)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
17. I already see positive results from applying what I learned. (Level 4: Results)
a. Strongly Disagree
b. Disagree
c. Agree
d. Strongly Agree
18. I see a positive impact in the following areas as a result of applying what I learned (check
all that apply): (Level 4: Results)
a. Increased compliance with service recovery expectations of my staff
b. Increased engagement and satisfaction among my staff
c. Decreased need for a remedial service recovery training
d. Increased feeling of organization support for service recovery
e. Increased ability to focus on other business priorities aside from service recovery
f. Increased patient engagement and satisfaction scores
19. Please provide one or more examples of positive outcomes from applying this training:
(Level 4: Results)
20. Please share any suggestions you have for improving this training:
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 221
APPENDIX I
Example of Metric Reporting of Level 3 Behavioral Data
SERVICE RECOVERY AND THE PATIENT EXPERIENCE 222
APPENDIX J
Mock-Up of Infographic for Formative Level 1 & 2 Data
Abstract (if available)
Abstract
The subject of providing service recovery in radiation oncology has not been researched at length. At present, the relationships among patient satisfaction, care compliance, and treatment outcomes suggest patients who report dissatisfaction with their care perceive receipt of suboptimal care. Patient satisfaction also plays a role in defining the quality of care received, potentially affecting institutional reimbursement and reputation capital. This study explored frontline management’s role in effective service recovery, the process of actively addressing identified instances of patient dissatisfaction directly to improve the overall patient experience through patient engagement and finding solutions to challenges early using an explanatory sequential mixed methodology approach. Secondary data conveying patient perceptions of care, survey of frontline managers to quantify the knowledge, motivation, and organization influencers on intervention protocols, review of service recovery documents and artifacts, and probing interviews triangulate the problem of practice and offers insights and solutions for consideration. This dissertation broadly examines patient and institutional benefits of proactively addressing patient engagement and solution-finding through service recovery, converting poor perceptions of quality of care toward an appreciative engagement between radiation patients/consumers and care providers.
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Asset Metadata
Creator
Washington, Charles Michael
(author)
Core Title
Addressing service recovery with radiation oncology frontline managers to improve the patient experience: an evaluation study
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Publication Date
11/06/2019
Defense Date
10/02/2019
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
OAI-PMH Harvest,patient experience,patient satisfaction,radiation oncology,service recovery
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Tobey, Patricia Elaine (
committee chair
), Malloy, Courtney (
committee member
), Robles, Darline (
committee member
)
Creator Email
charleswashington12@yahoo.com,cmwashin@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-229536
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Document Type
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Washington, Charles Michael
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(contributing entity),
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(collection)
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Tags
patient experience
patient satisfaction
radiation oncology
service recovery