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Reducing gaps in healthcare delivery quality on American Indian reservations and Alaska Native communities: an improvement study

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Reducing gaps in healthcare delivery quality on American Indian reservations and Alaska Native communities: an improvement study

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Reducing Gaps in Healthcare Delivery Quality on American Indian Reservations and Alaska
Native Communities: An Improvement Study
By
Carlton Underwood

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

May 2022

Copyright 2022 Carlton Underwood
ii

Acknowledgements
I made a promise to myself and my family as a high school student living on the Wind
River Indian Reservation that I would one day graduate with my doctorate degree. This process
of earning that doctorate degree was arduous, strenuous, and downright demanding. However, I
did not accomplish this goal alone. First and foremost, I need to thank my mother, Amelia
Underwood, for being my strength and belief system as well as encouraging me to always do my
best. Without my mother’s constant support, I strongly believe that I would not be as successful
in completing my academic goals.
In addition, I would like to thank my siblings (Russell Underwood and Vincent Tony
Underwood, Jr.) for always being there for me and supporting their little brother throughout all
of my academic endeavors. My big brothers are truly humble Arapaho men, but they are not
afraid to show their pride for everything I have been able to accomplish this far in life. I cannot
thank them enough for all that they do for me and I share this diploma with my brothers.
I cannot express my deepest and sincerest gratitude enough to my dissertation committee,
Dr. Bryant Adibe, Dr. Mary Andres, and Dr. John Ronquillo, who have been a part of this study
from its inception. The expert knowledge and tutelage these amazing people have provided me
has made the challenge of writing academically all the more possible to finish this research
project. I would like to extend a very special thank you to Dr. Bryant Adibe, my dissertation
committee chair, for his patience, guidance, and unwavering support throughout this study.
In closing, as I reflect on my accomplishment, I would like to thank my late father,
Vincent Underwood, Sr. for providing me with the influence to be the strong, respectful, and
humble man I have become. This rural, country, Arapaho boy is now a USC doctoral graduate.
Fight on!
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Table of Contents
Acknowledgements………………………………………………………………………………..ii
List of Tables……………………………………………………………………………………viii
List of Figures…………………………………………………………………………………….ix
Abstract……………………………………………………………………………………………x
CHAPTER 1: INTRODUCTION ................................................................................................... 1
Introduction of the Problem of Practice .......................................................................................... 1
Organizational Context and Mission .............................................................................................. 2
Organizational Performance Status ................................................................................................. 3
Related Literature............................................................................................................................ 3
Importance of Addressing the Problem .......................................................................................... 5
Organizational Performance Goal ................................................................................................... 7
Description of Stakeholder Groups ................................................................................................. 8
Stakeholder Group for the Study .................................................................................................... 8
Purpose of the Project and Questions ........................................................................................... 10
Methodological Framework .......................................................................................................... 11
Definitions..................................................................................................................................... 12
Organization of the Project ........................................................................................................... 12
CHAPTER TWO: REVIEW OF THE LITERATURE ................................................................ 13
Influence of the Gaps in Healthcare Delivery Quality .................................................................. 13
Health Outcomes of American Indian Reservation and Alaska Native Community
Populations ................................................................................................................................ 14
Existing Access to Healthcare on American Indian Reservations and Alaska Native
Communities ............................................................................................................................. 15
Lack of Current Research ......................................................................................................... 17
Developing Proficient Healthcare Compliance Programs ............................................................ 18
The Importance of Compliance Programs to Healthcare Organizations .................................. 18
Types of Health Care Crimes and Ramifications ..................................................................... 20
Health Care Compliance: Goals ................................................................................................ 21
Health Care Compliance: Barriers ............................................................................................ 22
Role of Stakeholder Group of Focus ............................................................................................ 24
Clark and Estes Gap Analytic Conceptual Framework ................................................................ 24
Clinical Department Chairpersons Knowledge, Motivation, and Organizational Influences .. 25
Knowledge and Skills ............................................................................................................... 26
Clinical Department Chairpersons Need to Understand the Importance of a Compliance
Program ................................................................................................................................. 28
Clinical Department Chairpersons Need to Know their Ethical Responsibility to Report
iv

any Compliance Issue ........................................................................................................... 28
Clinical Department Chairpersons Need to Know How Work Performance Influences
Overall Compliance of the Organization .............................................................................. 29
Motivation Influences ............................................................................................................... 32
Clinical Department Chairpersons Need Adaptive Attributions .......................................... 32
Clinical Department Chairpersons Need Self-Efficacy Theory............................................ 33
Organizational Influences ......................................................................................................... 35
The Organization Needs a Culture of Continual Improvement ............................................ 35
The Organization Needs Regular and Periodic Training Programs ...................................... 36
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context ........................................................................................................... 37
Conclusion .................................................................................................................................... 40

CHAPTER THREE: METHODS ................................................................................................. 42
Research Questions ....................................................................................................................... 42
Participating Stakeholders ............................................................................................................ 42
Interview Sampling Criteria and Rationale................................................................................... 43
Criterion 1. Participating stakeholders in the interview process of this study agreed to a
confidential interview to discuss knowledge and skills and motivation influences. ................ 43
Criterion 2. Participating stakeholders in the interview process of the study agreed to a
confidential interview to discuss organizational influences. .................................................... 44
Interview Sampling (Recruitment) Strategy and Rationale .......................................................... 45
Data Collection and Instrumentation ............................................................................................ 46
Interviews .................................................................................................................................. 47
Documents and Artifacts........................................................................................................... 48
Data Analysis ................................................................................................................................ 49
Credibility and Trustworthiness .................................................................................................... 50
Ethics............................................................................................................................................. 50

CHAPTER FOUR: RESULTS AND FINDINGS ........................................................................ 53
Participating Stakeholders ............................................................................................................ 54
Determination of Assets and Needs .............................................................................................. 55
Results and Findings for Knowledge Causes................................................................................ 56
Declarative Knowledge ............................................................................................................. 57
Influence 1. Clinical department chairpersons need to understand the importance of a
compliance program.............................................................................................................. 57
Procedural Knowledge .............................................................................................................. 61
Influence 1. Clinical department chairpersons need to know their ethical responsibility
to report any compliance issue .............................................................................................. 61
Metacognitive Knowledge ........................................................................................................ 66
v

Influence 1. Clinical department chairpersons need to know how work performance
influences overall compliance of the organization ............................................................... 66
Results and Findings for Motivation Causes ................................................................................ 74
Attributions Theory ................................................................................................................... 75
Influence 1. The clinical department chairpersons need Attributions Theory. ..................... 75
Self-Efficacy ............................................................................................................................. 81
Influence 1. The clinical department chairpersons need Self-efficacy Theory. ................... 81
Results and Findings for Organization Causes ............................................................................. 89
Cultural Models ........................................................................................................................ 90
Influence 1. The organization needs a culture of continual improvement. ........................... 90
Cultural Settings........................................................................................................................ 96
Influence 1. The organization needs regular and periodic training programs. ..................... 96

CHAPTER FIVE: RECOMMENDATIONS .............................................................................. 107
Introduction and Overview ......................................................................................................... 107
Recommendations for Practice to Address KMO Influences ..................................................... 107
Knowledge Recommendations ............................................................................................... 108
Increase procedural knowledge of clinical department chairpersons’ ethical
responsibility to report any compliance issue. .................................................................... 110
Organization Recommendations ............................................................................................. 111
Create a culture of continual improvement of the organization. ........................................ 113
Create regular and periodic training programs for the organization. .................................. 114
Integrated Implementation and Evaluation Plan ......................................................................... 115
Implementation and Evaluation Framework ........................................................................... 115
Organizational Purpose, Need and Expectations ........................................................................ 116
Level 4: Results and Leading Indicators ................................................................................. 117
Level 3: Behavior .................................................................................................................... 119
Critical Behaviors ............................................................................................................... 119
Required Drivers ................................................................................................................. 119
Organizational Support ....................................................................................................... 121
Level 2: Learning .................................................................................................................... 122
Learning Goals .................................................................................................................... 122
Program ............................................................................................................................... 122
Evaluation of the Components of Learning ........................................................................ 123
Level 1: Reaction .................................................................................................................... 124
Evaluation Tools ......................................................................................................................... 125
Immediately Following the Program Implementation ............................................................ 125
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Delayed for a Period after the Program Implementation ........................................................ 126
Data Analysis and Reporting .................................................................................................. 127
Summary ..................................................................................................................................... 128
Limitations and Delimitations ..................................................................................................... 129
Future Research .......................................................................................................................... 130
Conclusion .................................................................................................................................. 132

References ................................................................................................................................... 135

Appendix A ................................................................................................................................. 140

Appendix B ................................................................................................................................. 144

vii

List of Tables
Table 1. Organizational Mission, Organizational Goal, and Stakeholder Performance Goal…….9
Table 2. Description of Knowledge Influences, Knowledge Types, and Assessment
Methods………………………………………………………………………………....30
Table 3. Motivation Influences and Motivational Influence Assessments……………………....34
Table 4. Description of Assumed Organizational Influences……………………………………36
Table 5. Demographic Information on Participants……………………………………………...54
Table 6. Knowledge Assets or Needs as Determine by the Data………………………………...56
Table 7. Participants Common Comments Related to the Assumed Declarative, Procedural,
And Metacognitive Knowledge Influences…………………………………………….71
Table 8. Motivational Assets or Needs as Determine by the Data………………………………72
Table 9. Participants Common Comments Related to the Assumed Attributions Theory
And Self-efficacy Motivation Influences……………………………………………….86
Table 10. Organizational Assets or Needs as Determine by the Data………………………….. 87
Table 11. Participants Common Comments Related to the Assumed Cultural Models
And Settings Organization Influences……………………………………………….102
Table 12. Summary of Knowledge Influences and Recommendations………………………...105
Table 13. Summary of Organization Influences and Recommendations………………………108
Table 14. Outcomes, Metrics, and Methods for External and Internal Outcomes…………......114
Table 15. Critical Behaviors, Metrics, Methods, and Timing for Evaluation………………….115
Table 16. Required Drivers to Support Critical Behaviors......................................................... 116
Table 17. Evaluation of the Components of Learning for the Program………………………...119
Table 18. Components to Measure Reactions to the Program………………………………….120

viii

List of Figures
Figure 1. Conceptual Framework for this Improvement Study………………………………….39
Figure 2. Sample dashboard to report progress in achieving the stakeholder goal…………….123

ix

Abstract
The research study addressed the problem of reducing the gaps in healthcare delivery
quality on American Indian reservations and Alaska Native communities. A qualitative research
design was used to collect data using online virtual interviews of the identified stakeholders to
assess their assumed knowledge, motivation, and organizational influences to achieve the
organizational and stakeholder goals as well as an analysis of regulatory documents and artifacts
provided by the organization identified for this study. Two assumed knowledge and two assumed
motivation influences were found to be assets while one assumed knowledge and two assumed
organizational influences were found to be needs, or gaps, in this study. The findings within this
study help provide recommendations that propose to close the knowledge and organization gaps
that affect the stakeholders and organization’s ability in achieving the organizational and
stakeholder goals of this study.
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CHAPTER 1: INTRODUCTION
Introduction of the Problem of Practice
This research study addressed the problem of reducing the gaps in healthcare delivery
quality on American Indian reservations and Alaska Native (AI/AN) communities. In a study by
the Agency for Healthcare Research & Quality (AHRQ, 2019), the authors found that AI/ANs
have the lowest access to healthcare by about 40% of the standardized access measures as
compared to the White population. Also, the quality of care was better for Whites than for
AI/ANs on about 40% of the quality measures, which demonstrates that this is a problem (Drago,
2016; Agency for Healthcare Research & Quality [AHRQ], 2019). Of the total AI/AN
population of the United States (US), approximately 40% live in rural communities,
predominantly on reservations, while only 17% of the total US population resides in rural
communities across the country. People who reside in rural residence face disabilities, diseases,
various factors associated with lower health outcomes, and access to health care services at a
disproportionate level compared to urban areas. These factors are compounded when rural
residence and minority status intersect, especially when poverty status and education are
considered (Towne et al., 2015).
Due to the inequality of access to and quality of healthcare, the evidence highlights that
the majority of AI/ANs who live in rural reservations and communities face the reality of living
with disproportionate health disparities, including diabetes, cardiovascular disease, alcoholism,
and tuberculosis (Kruse et al., 2016; Purtzer & Thomas, 2019). The problem of reducing the gaps
in healthcare delivery quality on AI/AN reservations and communities is important to address
because it is essential to reduce the health disparities that exist among the AI/AN population of
this country by providing high-quality, comprehensive healthcare that focuses on the patient, is
2

affordable, and safe (Pardue, 2015). Also, the administrators and providers of healthcare
facilities that exist on the AI/AN reservations and communities need to work together to improve
healthcare for these communities by expanding access and enhancing the quality of care (AHRQ,
2018). The reduction of gaps in healthcare delivery quality can also happen by recognizing the
various cultural values, beliefs, and aspects that exist among the AI/AN reservations and
communities, which can provide for an increase in positive health behavior among these AI/AN
societies (Scarton et al., 2019).
Organizational Context and Mission
The Indian Tribe of the Northern Rockies (ITNR, a pseudonym) is located on an Indian
reservation in the northern Rocky Mountains. The healthcare organization included in this study
is Native Traditions Health Care (NTHC, a pseudonym). The organization is owned and operated
by ITNR and provides healthcare services to an enrolled member or descendant of a federally
recognized Indian tribe who lives within the exterior boundaries of the reservation (R. Brannan,
personal communication, July 30, 2019).
The mission of NTHC, as documented in their policies and procedures manual, is "to
provide primary care, traditional healing, preventative care, and wellness promotion to all
members of the community, as intended by the Creator" (NTHC, 2017, p.1). NTHC provides
clinical services in the following areas: dental, medical, optometry, nursing, pharmacy,
behavioral health, and public health education. The overall goal of NTHC is to become a
“medical center of excellence that provides high-quality, comprehensive, and integrated health
care and wellness services” (NTHC, 2017, p.1). NTHC employs many individuals to assist in
providing these healthcare services. Those employees that helped in this research study included
3

the Chief Executive Officer, Human Resources Officer, Chief Operations Officer, and the
Clinical Compliance Officer (R. Brannan, personal communication, July 30, 2019).
Organizational Performance Status
NTHC began operations on January 1, 2016 when ownership transferred from the Indian
Health Service (IHS) to the ITNR. The resources available on January 1, 2016 included
approximately 50 employees and only five primary care providers. That number increased to
approximately 200 employees and 13 primary care providers since ITNR assumed operations.
Also, NTHC expanded services by opening two new clinical facilities in August and October of
2019. One of those facilities is located in an area of the reservation that did not have access to
health care previously while the other facility is located off the reservation in an urban township
that borders the reservation and serves AI/AN members (R. Brannan, personal communication,
July 30, 2019).
Studies have shown that the AI/AN population served by the IHS in the states of
Wyoming and Montana experience a lower life expectancy and more considerable health
disparities by approximately 8% than the total AI/AN population of the US (Anderson et al.,
2005). The improvements of NTHC demonstrates the commitment of the organization to succeed
in accomplishing its mission and overall goal by expanding healthcare services to provide the
appropriate care that the reservation communities need and deserve.
Related Literature
The literature related to the problem of practice demonstrates that a gap exists in the
delivery quality of healthcare on AI/AN reservations and communities. Drago (2016) states that
despite the U.S. government's allocation of over four billion dollars in 2014 to provide healthcare
to over two million AI/ANs, severe health disparities continue to persist among this population.
4

Skinner (2016) posits that early interactions between the U.S. government and AI/AN tribal
nation leaders developed treaties aimed to enhance the standard of living and social well-being of
AI/AN communities that were comparable to the non-Indian society. However, in exchange for
the land, protection by the federal government, and for peace and friendship, the AI/AN
population did not receive, and continue to struggle for, access to quality healthcare (Skinner,
2016).
The history of the interactions between the U.S. government and the AI/AN population
has created a lack of adequate healthcare due to the nature of the removal and reservation
policies that determined how and where the U.S. government placed the AI/AN people once they
became a conquered nation of the government (Drago, 2016). Approximately 40% of the total
AI/AN population living in rural areas of this country lack adequate access to health care that is
otherwise readily available in other parts of the US, which can lead to more severe health
disparities within the AI/AN population (Towne et al., 2015; Kruse et al., 2016). Also, lack of
access to healthcare can have other adverse effects for the AI/AN communities, such as lower
access to healthcare providers and greater distances to healthcare facilities (Towne et al., 2015).
Furthermore, the issues of living in rural areas and the inadequate access to healthcare
can lead to AI/AN community members relocating from rural reservation communities to the
larger urban cities of the country (Castor et al., 2006). However, when this relocation is
completed by the AI/AN community member access to healthcare provided by the IHS is lost as
is the identity as AI/AN community members due to the lack of recognition of tribal diversity
within these urban settings (Castor et al., 2006).
Also, the issue of cultural ignorance, or insensitivity, by non-minority health care
providers creates communication barriers to adequate provision of care that AI/AN community
5

members need (Sanchez et al., 1996). For example, the AI/AN individual can develop serious
communication and behavioral issues when interacting with healthcare providers who display an
approach to care that does not align with the core beliefs held by AI/AN individuals. These
communication and behavioral issues possibly leads the AI/AN person to delay the important
care that is needed and only seek the care after much consideration or when the health issue is so
severe that no other choice exists. To provide better quality of care to the AI/AN reservations
and communities, non-minority healthcare providers need to not only understand and respect the
values of AI/AN culture but also demonstrate cultural sensitivity to help the healthcare
interactions be more acceptable by the AI/AN community members (Sanchez et al., 1996).
In an effort to protect resources to continue to provide healthcare and improve regulatory
compliance rates, organizations implement healthcare regulatory compliance programs that are
designed to affect the behaviors of healthcare employees to be more ethical (Silverman, 2000).
This emphasis on ethics is due to healthcare organizations’ need to continuously improve the
healthcare systems to be efficient, effective, affordable, and work to protect the patients they
serve (Pardue, 2015, Silverman, 2000). Benefits of implementing a robust regulatory compliance
program include preventing illegal behavior from employees, fostering an atmosphere that
promotes critical thinking, and improving crucial areas of care (Guinn, 2000; Silverman, 2000).
Importance of Addressing the Problem
The problem of reducing gaps in healthcare delivery quality on AI/AN reservations and
communities is vital to solve for a variety of reasons. First, the varieties of health disparities that
exist within the AI/AN reservations and communities include diabetes, cardiovascular disease,
alcoholism, and tuberculosis. These disparities continue to negatively affect the AI/AN
reservations and communities despite billions of dollars being allocated from the federal
6

government to the IHS in an effort to address these health concerns (Kruse et al., 2016; Purtzer
& Thomas, 2019; Drago, 2016). Second, AI/AN reservations and communities are located in
rural areas of the country, which adds a level of difficulty to the access of healthcare providers
needed by AI/AN community members in helping to address healthcare issues (Towne et al.,
2015).
A third reason concerns non-minority healthcare providers’ tendency to view cultural
insensitivity not as discrimination, but as an issue that is either too political or too difficult to
resolve (Purtzer & Thomas, 2019). Consequently, non-minority healthcare providers may not
consider health disparities that affect AI/AN reservations and communities as nothing more than
less personal intimidating factors, such as cultural or language challenges from the AI/AN
community members or low health literacy among the AI/AN communities overall. Therefore,
the relationship between the patient and healthcare provider needs a culturally competent
approach as understanding the lack of access to and the poor quality of healthcare, and how these
factors relate to the health disparities within AI/AN reservations and communities, is inherent to
providing quality healthcare (Purtzer & Thomas, 2019).
Given the age of NTHC, the literature on the problem of practice, and the mission of the
organization, NTHC has the potential to address these issues of healthcare related to AI
reservation and AN community members by providing a different outlook on improving the
severe health disparities that AI/AN reservations and communities face. One strong initiative that
NTHC can take in addressing the problem of reducing gaps of healthcare delivery quality on
AI/AN reservations and communities, as well as addressing the health disparities, is to monitor
organizational compliance with healthcare regulations in an effort to improve its regulatory
compliance rate. By improving the regulatory compliance rate, NTHC will demonstrate effort in
7

protecting all resources to provide the healthcare that the AI reservations and AN communities
need and accomplish the organizational performance goal.
Organizational Performance Goal
The organizational performance goal of NTHC is that, by 2025, NTHC will improve its
regulatory compliance rate by 30%. This goal comes from the mission statement and the overall
goal of the organization. The Chief Executive Officer (CEO) and the administrative team
recognized that for the organization to become a healthcare facility of excellence that provides
high-quality, comprehensive, and integrated healthcare to the members of the community,
protection of the financial resources available to the organization is paramount. To initiate this
protection, NTHC will need to focus on improving its regulatory compliance rate. Together, the
Chief Executive Officer (CEO) and the Chief Compliance Officer (CCO) set the date of 2025 for
this goal in mid-2019. The CEO, recognizing that the organization needs to have a firm
adherence to compliance efforts to increase the organization's ability to provide the high-quality
healthcare the reservation communities deserve, contributed to determining the standard of the
goal.
To maintain progress towards the organizational goal training on healthcare regulatory
compliance issues occurs on an annual basis for the entire staff of the organization. Since the
organization began the delivery of healthcare to the reservation communities, services have
expanded in the areas of primary care, dental, optometry, behavioral health, risk management,
and regulatory compliance. To fully accomplish the organizational goal, NTHC needs to
continue to recognize the importance of the delivery of high-quality, comprehensive, and
integrated healthcare depends on the organization's ability to improve the regulatory compliance
rate.
8

Description of Stakeholder Groups
A stakeholder group is a group of individuals who directly contribute to and benefit from
the achievement of the organization’s goal. For NTHC, the stakeholders include three groups of
individuals who benefit directly from the organization's performance and completion of the goal.
These groups include the patients who receive the healthcare, the administrative team of NTHC,
and the clinical department chairpersons. Each of these stakeholder groups will assist in the
achievement of the organizational performance goal by participating in regular random
evaluations of the organization's ability to implement a regulatory compliance program.
Stakeholder Group for the Study
Although a complete analysis would involve all stakeholder groups, which include the
clinical department chairpersons of NTHC, the administrative team, and the patients of the
organization, for practical purposes of this improvement study, only the clinical department
chairpersons will be the focus. The clinical department chairpersons include Chief Medical
Officer, Head Clinical Nurse, Head Counselor of Behavioral Health, Chief Dental Officer, Head
Optometrist, Chief Laboratory Technician, Billing and Coding Manager, and Chief Pharmacist.
The identification of this stakeholder group as the focus of this study is due to the importance of
the stakeholder’s knowledge, motivation, and organizational influences that impact the
achievement of the organizational goal.
The identified stakeholder goal is by 2025, clinical department chairpersons of NTHC
will implement the healthcare compliance program with at least a 90% consistency as measured
by regular random evaluations. These regular random evaluations will determine the
stakeholder’s ability to successfully implement the regulatory compliance program. This critical
measurable level of achievement came from the high level of importance of the stakeholders to
9

accomplish the stakeholder goal. The determination of the stakeholder goal came from the author
of this study and the chairperson of the author’s dissertation committee.
The performance goal of NTHC is to improve its regulatory compliance rate by 30%, and
the importance of the stakeholders achieving the goal is paramount to not only reduce the
healthcare delivery gaps on the reservation but to implement a robust regulatory compliance
program for the organization. Should the stakeholders fail to achieve the organizational
performance goal, NTHC becomes more vulnerable of violating healthcare regulations, even if
the violations are unintentional. If the organization is found liable for any violations, the ability
to bill for healthcare services, apply for federal funding, and, most importantly, provide the
healthcare services that the AI reservation and AN communities need and deserve will have a
negative effect to NTHC and ITNR.
Table one provides the organization’s mission, the organizational goal, and the
stakeholder goal for this study.

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Table 1
Organizational Mission, Organizational Goal, and Stakeholder Performance Goal
Organizational Mission

To provide primary care, traditional healing, preventative care, and wellness promotion to all
members of the community, as intended by the Creator.
____________________________________________________________________________
Organizational Performance Goal

By 2025, NTHC will improve its regulatory compliance rate by 30%.
____________________________________________________________________________
Stakeholder Goal

By 2025, clinical department chairpersons of NTHC will implement the healthcare compliance
program with at least a 90% consistency as measured by regular random evaluations.

Purpose of the Project and Questions
The goal of this project is to study NTHC's performance related to reducing gaps of
healthcare delivery quality to AI/AN reservations and communities. While a complete study
would focus on all stakeholders, for practical purposes, the stakeholder group to be focused on in
this analysis is the clinical department chairpersons of NTHC. This improvement study will
include a review of the stakeholders' knowledge and skills, motivation, and organizational
influences necessary to reach the organizational and stakeholder goals.
The following questions will be used to guide this study:
1. What knowledge, motivation, and organizational needs must be met to enable the clinical
department chairpersons to improve the healthcare organization’s regulatory compliance
rate?
11

2. What is the interaction between organizational culture and context and the clinical
department chairpersons' knowledge and motivation?
3. What are the knowledge, motivation, and organizational solutions to facilitate the
abilities of the clinical department chairpersons to implement the regulatory compliance
program?
Methodological Framework
Clark and Estes (2008) argue that research of the knowledge, motivation, and
organizational influences of an organization provides the means to analyze performance gaps.
This improvement study includes an analysis of the Clark and Estes framework to assist in
identifying what problems exist within the knowledge, motivation, and organizational factors of
NTHC that cause gaps between current performance and the organizational and stakeholder
goals. A literature review will establish a list of relevant knowledge, motivation, and
organizational influences as they relate to the clinical department chairpersons of NTHC.
The methodological approach for this study used an ethnography qualitative design.
Creswell and Creswell (2018) suggest that using a qualitative approach to research allows the
researcher to explore and understand why individuals, or groups of people, adapt to a social or
human problem. Furthermore, researchers who utilize the qualitative approach honor an
inductive style of research, support a focus on personal meaning, and realize how important it is
to report on the intricacy of a situation. Ethnography, according to Creswell and Creswell (2018),
comes from the anthropological and sociological realms where the researcher studies certain
behaviors, language, and actions of a group of individuals who work together in a close setting
over a specified period. Interviews, observations, and documents analysis are the primary options
of data collection with the ethnography design of inquiry.
12

The ethnography qualitative research design was appropriate for this study as this
approach provided for a greater understanding of how the clinical department chairpersons
contribute to the implementation of the healthcare regulatory compliance program at NTHC. The
knowledge and skills, motivation, and organizational influences were highlighted with the
interviews of the clinical department chairpersons as they worked towards achieving the
organizational goal of increasing the regulatory compliance rate of NTHC.
Definitions
American Indian/Alaska Native: A person having origins in any of the original peoples of
North and South America (including Central America) and who maintain tribal affiliation or
community attachment (Jones & Norris, 2010; Office of Minority Health, 2017).
Indian Health Service: An agency within the Department of Health and Human Services that is
responsible for providing federal health services to AI/AN (Indian Health Service, 2019).
Indian Tribe of the Northern Rockies: A pseudonym of the Indian tribe used in this study.
Native Traditions Health Care: A pseudonym for the health care organization used in this study.
Organization of the Project
Chapter one of this dissertation provides the problem of practice, the organization to be
studied, the organizational goal, the stakeholders to be analyzed, the stakeholder goal and the
methodological framework. Chapter two provides a review of the literature concerning the
problem of practice, the knowledge, motivation, and organizational influences the stakeholders
need to accomplish the organizational and stakeholder goals, and the conceptual framework of
this research study. Chapter three discusses the methods used in the research study. Chapter four
includes the collection of data and the analysis of the data. Chapter five provides a discussion of
the findings and results of the research and best practices.
13

CHAPTER TWO: REVIEW OF THE LITERATURE
This chapter reviews the literature on reducing gaps in healthcare delivery quality on
AI/AN reservations and communities. The initial review of the literature focuses on the various
health disparities concerning AI/AN populations, access to healthcare quality on AI/AN
reservations and communities, and the lack of research concerning this subject material. A
review of the literature on the impact of healthcare compliance programs, how compliance
affects the operations of healthcare organizations, and the goals and barriers to achieving
compliance for AI/AN communities follows the initial review, where both sections help inform
the problem of practice.
It is essential to study the problem of reducing gaps in healthcare delivery quality on
AI/AN reservations and communities because of the limited access to healthcare that the AI/AN
population experience as well as the quality gaps in healthcare delivery that exist. The chapter
then explains the Clark and Estes’ (2008) knowledge, motivation, and organizational (KMO)
influence lens used in this improvement study. In this section, the chapter defines the types of
knowledge, motivation, and organizational influences examined and the clinical department
chairpersons’ knowledge, motivation, and organizational influences on performance. The chapter
concludes with a presentation on the conceptual framework guiding this study.
Influence of the Gaps in Healthcare Delivery Quality
The initial literature review is presented in three portions with the first portion discussing
the various health disparities facing the AI/AN population of this country. A review of the
existing access to healthcare quality by the AI/AN population follows in the second portion
providing insight on how this access influences the gaps in healthcare delivery quality on AI/AN
14

reservations and communities. The third portion includes a discussion on the lack of current
research concerning the AI/AN population and healthcare related issues.
Health Outcomes of American Indian Reservation and Alaska Native Community
Populations
AI/AN populations include both federally and state-recognized tribes with a majority
residing on reservations and communities located in rural areas of the country. Among these
tribes, the AI/AN individuals have poverty rates that are double that of the national average and
struggle with cultural barriers, geographic isolation, and discrimination (Scarton et al., 2019).
Although the U.S. government has allocated an abundance of funding ($4 billion in 2014), health
disparities continue to plague the AI/AN population that affect various aspects of daily life
(Drago, 2016).
Compared to other racial or ethnic groups of the US, AI/AN populations suffer the most
from type two diabetes and experience the highest prevalence of this disease, and have a
disproportionate problem of diabetes complications (Scarton et al., 2019). Also, the mortality
rate is 66.0% in 2010 from diabetes mellitus for AI/AN individuals, which is more than three
times that of the overall population of the US at 20.3% (Drago, 2016; Indian Health Service
(IHS), 2019). Additionally, in comparison to all racial groups of the US, AI/AN people are more
likely to die from alcoholism and chronic liver disease, or cirrhosis, with a mortality rate of six
and four times higher, respectively (IHS, 2019). The life expectancy of AI/AN people is 4.1
years fewer than the average life expectancy of the overall U.S. population with studies of
AI/AN health disparities pointing to various causes for this disparity (Drago, 2016).
Within AI/AN communities, an emphasis on caring for the elderly (age 55 and older) has
always been a common trait. Unfortunately, two other leading causes of death for AI/ANs in this
15

age group are heart disease and cancer. These types of chronic diseases continue to negatively
affect the health status and quality of life for the AI/AN elders and may worsen as this group of
AI/AN people is expected to grow over time (Denny et al., 2005).
A factor that compounds health disparities that negatively affect the AI/AN communities
is the spending that the federal government initiates for the AI/AN populations versus other
groups in the country. In 2016, the federal government spent $2,843 per patient within the Indian
Health Service (IHS) as compared to $8,602 on federal inmates per capita. Also, the IHS spent
$3,332 per patient in 2017 as compared to $12,829 spent by Medicare and $7,789 spent by
Medicaid per patient that same year (Walker, 2019). These healthcare spending trends are only
one contributing factor to the health care disparities affecting the AI/AN populations. Another
major contributing factor is the current access that AI/AN people have to healthcare.
Existing Access to Healthcare on American Indian Reservations and Alaska Native
Communities
AI/AN populations live in the most rural areas of the United States, and that increases the
difficulty to have access to the medical providers the AI/AN people need to help address primary
health concerns. Towne et al. (2015) estimate that of the total population of the US, 17% live in
rural areas across the country. However, of the total AI/AN population of the country, 40% live
in rural areas predominantly on reservations and communities where the access to healthcare
includes a greater distance to, or the lower availability of, healthcare providers. Also, as
previously mentioned, the AI/AN population is faced with higher rates of chronic diseases,
higher morbidity rates associated with those diseases, and are at a higher risk of either being
underinsured or uninsured, which makes the access to healthcare even more critical (Towne et
al., 2015).
16

The federal government helps address the issues of health disparities by providing a
system of hospitals and clinics managed by the IHS, and more recently, by AI/AN tribes.
Primary care services are the majority of services offered by the IHS facilities, with some limited
specialty services provided by contracted private providers. However, services vary significantly
across all AI/AN tribes, and not every tribe has access to a hospital on their reservation or in
their community. Instead, small clinics with limited services are the primary access to healthcare
for most tribes. Access to specialized care depends on the availability of funding to the IHS
(Zuckerman et al., 2004).
Limited access to healthcare causes some AI/AN people to relocate from these rural
communities to the urban areas of the country, but this action by the AI/AN individuals can have
an increased negative affect when it comes to issues of healthcare. Castor et al. (2006) found that
the number of AI/AN individuals who relocated into urban centers rose from 38% to 61% over
three decades (1970 to 2000). Although the urban centers offer more in certain areas of life,
access to healthcare decreases a great deal for AI/AN people, mostly due to the loss of access to
the IHS facilities located on the rural reservations and communities. Instead, the AI/AN people
can visit smaller facilities known as urban Indian health organizations that receive funding from
the IHS. Still, little knowledge exists about the health status of these AI/AN people. Relative to
the overall population of the country, the small numbers of AI/AN people in the urban centers
makes it difficult to target and track this population group (Castor et al., 2006). Even with the
most current studies available that focus on the AI/AN population of this country, it is still
necessary to understand the amount of research available when it comes to healthcare.

17

Lack of Current Research
The amount of data available regarding the AI/AN population, adequate access to
healthcare, and the various health disparities are very minimal, which makes this area of research
both inadequate and obstructive. The majority of research conducted on the disparities of health
among the AI/AN population of this country has come from the adult age group (18 – 54)
making the availability of research for the elderly and children quite scarce (Sarche & Spicer,
2008). Sarche and Spicer (2008) disclose that the literature they found on children, specifically,
is somewhat outdated, relatively small, and generalized to selective smaller studies of
environmental samples.
Moy et al. (2006) discovered that not all healthcare information is available on the AI/AN
population, and this contributes to significant gaps in the data and precludes a complete valuation
of disparities faced by the AI/AN population. The data gaps were more significant for the AI/AN
population than for any other racial and ethnic groups when studying the National Healthcare
Disparities Report, which is an annual report provided by the Agency for Healthcare Research
and Quality. Moy et al. (2006) contributed to the severe limitation in the ability to assess the
disparities faced by the AI/AN population to the incredible lack of data concerning this ethnic
population.
Furthermore, Leston et al. (2019) found that when conducting a research project, which
centered on a community-based study to reduce health disparities with AI/AN people, literature
was non-existent when it came to this subject matter. Via the study by Leston et al. (2019), the
researchers communicated that a community-based participatory research method was a
framework that AI/AN populations could support as this research approach engages AI/AN tribal
members in the process of policy changes at various levels of government. This type of
18

participatory study is important as it researches the effects of a community-based approach at
reducing the health disparities and provides a direction to the AI/AN population in making
changes to promote health equity (Leston et al., 2019). However, this type of study appears to be
an original, which points to the lack of research concerning the AI/AN communities to be quite
significant.
Developing Proficient Healthcare Compliance Programs
Discussing the importance of including a compliance program within healthcare
organizations is found in the first portion of this next section of the literature review. The
following portion includes a discussion of the types of crimes facing the healthcare industry,
such as fraudulent actions by individuals who work in the healthcare field and the abuse of
medical and business practices. This section concludes with a discussion on the goals of
establishing a healthcare compliance program for AI/AN communities and the barriers to
achieving those compliance goals.
The Importance of Compliance Programs to Healthcare Organizations
Healthcare regulatory compliance programs influence the performance of healthcare
organizations across the country. More and more, administrators of healthcare organizations are
faced with ethical issues related to patient welfare as the funding dynamics, and the delivery of
healthcare, of the organizations compete with patient welfare when making decisions affecting
the financial solvency of the organization (Silverman, 2000). Also, the transformation of
healthcare in the country gives way to new and advanced methods of healthcare delivery, how
payment occurs for healthcare, and a new focus on the quality of care that would help transform
the way healthcare is measured (Pardue, 2015). Although constant change positively affects the
healthcare system, an emphasis on ethical standards need to be in effect within healthcare
19

organizations to enhance the system to not only be efficient, affordable, and effective but works
to provide sufficient safeguards to patients (Silverman, 2000; Pardue, 2015).
Since the early 1990s, compliance programs have increased in numbers in the healthcare
industry and address the investigation and prosecution of fraud and abuse situations that affect
healthcare organizations (Guinn, 2000). Over time, the Joint Commission on Accreditation of
Health Care Organizations, and the United States Sentencing Commission, developed and
introduced compliance standards. These standards are to support healthcare organizations to
enhance their ethical practices, ensure that clinical and administrative decisions do not include
any financial pressure, and help prevent illegal activity (Silverman, 2000). The idea behind
integrating compliance programs into healthcare organizations is to facilitate improvement in
three crucial areas of healthcare: efficiency, affordability, and quality of care. Striving to comply
with the compliance standards or federal regulations help protect against fraudulent or wasteful
spending by healthcare organizations, thereby promoting efficiency and affordability. Also,
compliance helps to reduce medical malpractice, improve patient privacy, and streamline
management and payment systems, which improves the quality of care (Pardue, 2015).
Compliance programs are essential to the healthcare industry more than just to address
preventing illegal behavior and improving crucial areas of care. Compliance needs to provide a
shift in the thinking of all healthcare personnel that relates to an overall ethical mindset for the
organization (Guinn, 2000). By providing an organizational ethics concept, the healthcare
organization can foster a critical thinking climate that allows individuals to think about what they
should do when faced with ethical issues versus what they cannot do based on a legal perspective
(Silverman, 2000). Also, compliance programs need to provide the effort to lessen fears about
potential violations and promote an atmosphere of cooperation between the federal regulations
20

and the healthcare organization's activity (Pardue, 2015). Therefore, compliance programs need
to provide for an organizational ethics approach that focuses more on the ethical behaviors of
individuals, which leads to the strengthening of faulty organizational processes and system
structures (Silverman, 2000).
Types of Health Care Crimes and Ramifications
Fraud and abuse affecting the healthcare industry has different variations and can cause
adverse effects on the provider, the healthcare organization, the federal government, and the
American taxpayer. Fraud is the behavior of an individual, or individuals, who knowingly and
willfully devise and execute a plan that defrauds, or obtains by negative pretenses, benefits from
any healthcare program. The definition of abuse is the acts of an individual, or individuals that
are inconsistent with appropriate medical or business practice (Rudman et al., 2009). For a
federal auditor, the signs of fraud and abuse come in many forms, such as specific terminology
used in billing practices or submission of bills without proper signatures, documentation, or
appropriate medical codes (Cascardo, 2015).
Types of fraud and abuse activities encompass a wide range of actions. The most
common include submitting false claims to the federal Medicare program, billing for medically
unnecessary services or tests, misrepresenting the quality of care provided, and the most
egregious act, upcoding (Cascardo, 2015; Rudman et al., 2009). Upcoding is defined as the act of
medical providers or healthcare organizations, submitting bills for a more expensive service than
the one that the patient actually received. One example of upcoding would be submitting a
medical claim for a 30-minute office visit when the actual visit was only 10 minutes (Bauder et
al., 2017). A majority of individuals who commit fraudulent activity are prosecuted and
21

sentenced with fines and restitution to pay and required months or years of incarceration
(Rudman et al., 2009).
Furthermore, when it comes to the providers and healthcare organizations committing
fraud and abuse there is a significant effect on what the cost is to the federal government and the
American taxpayer. The Government Accountability Office estimates the cost of health care
fraud to be nearly $50 billion in 2013. Also, the Federal Bureau of Investigation estimates the
cost of fraudulent billings to be in the range from $18 to $61 billion for the same year (Bauder et
al., 2017). The discussions of how to combat the ethical issue of fraudulent activity within the
health care industry include health care organizations taking a moral and ethical stand against
fraudulent behavior. Unfortunately, even though the federal government works diligently to
prosecute those who commit fraud, the estimate on loss recovery from the fraudulent activity is
only at 5 percent (Rudman et al., 2017). Given the seriousness of illegal activity within the
healthcare industry, a discussion on how to incorporate a proficient compliance program in
healthcare organizations of the AI/AN communities is needed.
Health Care Compliance: Goals
There is an essential need to develop an effective compliance program to protect the
access to healthcare of the AI/AN population. To reiterate, the AI/AN population of this country
predominantly live in rural areas of the country on reservations and suffer various health
disparities associated with inadequate access to and quality of care. This insufficient quality of
healthcare, and correlated disparities, is often associated with racial/ethnic prejudice of
healthcare professionals and related discrimination. An essential approach to making the
patient/provider relationship more effective is to take the culturally competent method as this is a
crucial step to prepare the healthcare workforce in delivering quality healthcare to the AI/AN
22

population (Purtzer & Thomas, 2019). Bridging this effort with the active development of a
compliance program for the healthcare organizations is noteworthy as these compliance
programs stand on the foundation of ethics.
Heller (1999) asserts that when looking at the protection of the healthcare organization
against any fraud or abuse activities, most organizations look to create healthcare compliance
programs using an ethical organizational culture. This type of organizational culture draws into
focus the organizational conditions that contribute to the actions of and the development of
characters of employees over time. Also, with an ethical organizational culture, and should fraud
occur, there is less chance that the activity will go unreported or tolerated by the employees or
leaders of the organization (Heller, 1999).
Trevino et al. (1999) found that utilizing a values-based approach in developing the
compliance program is more effective due to this approach being rooted in personal self-
governance and motivates employees to adhere to shared values. More importantly, a values-
based approach can positively enhance an alignment toward satisfying patients, and the
community, by holding employees to a decent standard regarding behavior and actions through
monitoring and disciplinary structures (Trevino et al., 1999). Although incorporating cultural
competence into the development of an effective compliance program for the healthcare
organization is the right approach, a discussion on the barriers to this effort needs to occur.
Health Care Compliance: Barriers
Aspects of healthcare and how it interacts with the AI/AN population can create some
barriers in establishing a proficient compliance program. One such aspect is the relationship that
exists between the AI/AN tribes and the federal government. AI/AN tribes have a unique and
historically complex relationship with both state and federal governments. Because of these
23

unique and complex relationships, the healthcare system of the AI/AN population is clearly
separate but fundamentally attached to the overall healthcare system of the US (Frerichs et al.,
2019).
One major factor stemming from this relationship is the Public Law No. 93-638, the
Indian Self-determination and Education Assistance Act. This federal act, which appeared in
1975, allows for direct agreements with, and direct funding from, the federal government to
AI/AN tribes and emphasizes activities to gauge self-determination that is meaningful to AI/AN
social and economic well-being (Skinner, 2016). Through Public Law No. 93-638, as well as
other numerous treaties, executive orders, and federal legislation, a trust responsibility exists that
requires the U.S. government to provide healthcare to the AI/AN tribes of the country (Frerichs
et al., 2019). The barrier coming from this aspect is that since the federal government is
responsible for providing healthcare to the AI/AN populations of this country, the need for a
regulatory compliance program may not be a prevalent part of providing healthcare to the AI/AN
communities.
Another barrier comes from vulnerabilities and breakdowns in organizational
infrastructure by the AI/AN tribes who work with the federal government. The Council of the
Inspectors General on Integrity and Efficiency (CIGIE, 2017) discovered a wide array of issues
facing the successful administration of federal funding received by the AI/AN tribes. These
vulnerabilities include a lack of internal controls, lack of monitoring and reviews, poor
recordkeeping and documentation, staffing challenges, and a lack of established policies and
procedures. The CIGIE (2017) attributes breakdowns in operations by the AI/AN tribes as
follows: improper expenditures, loss of federal or tribal resources, unsafe working conditions,
conflicts of interest, and poor service quality. These vulnerabilities and resulting breakdowns
24

make it very difficult for the AI/AN tribes to succeed in providing the services their reservations
and communities need. By not maintaining strong organizational infrastructure, organizational
conditions that make fraud and abuse more likely will emerge, thus creating a barrier to create
and implement a regulatory compliance program for the healthcare organization (CIGIE, 2017).
Role of Stakeholder Group of Focus
Clinical department chairpersons play a central role in the development of healthcare
compliance programs in healthcare organizations. Treviño et al. (1999) describe the approach
that healthcare employees should take when implementing a robust healthcare regulatory
compliance program into healthcare organizations. Not only should healthcare employees
understand how healthcare compliance issues negatively affect the organization, they should take
a values-based approach to implement a healthcare regulatory compliance program that helps
meet their compliance goals. Clinical department chairpersons need to make time to build this
influential ethical culture among the healthcare organization employees to demonstrate the
importance of achieving and maintaining compliance with healthcare regulatory issues (Treviño
et al., 1999). Considering the challenges that face the clinical department chairpersons, an
analysis of the knowledge, motivation, and organizational influences will help bridge the
relationship between the development and implementation of a robust healthcare compliance
program.
Clark and Estes Gap Analytic Conceptual Framework
Clark and Estes (2008) explain what research can show on the performance gaps of the
knowledge, motivation, and organizational influences, as well as help identify what problems
exist within these influences that cause the gaps between current performance and goals. For the
performance goals of an organization to be realized, the process must begin with the proper
25

knowledge and skill enhancement of the members, or employees, of the organization (Clark &
Estes, 2008). Krathwohl (2002) explains there are four different types of knowledge that include
factual, conceptual, procedural, and metacognitive. For this study, only three types of knowledge
will be included in the following order; declarative (conceptual), procedural, and metacognitive.
Motivation influences relate to an individual’s ability to want to do something and are the
influences that keep an individual going, and the level of effort one should put into completing
tasks (Krathwohl, 2002; Clark & Estes, 2008). Rueda (2011) points out that there are variables
that impact motivation that include self-efficacy, adaptive attributions, values, and goals. Finally,
organizational influences that affect the performance goals include work process, material
resources, and value chains and streams (Clark & Estes, 2008).
The knowledge influences affecting the clinical department chairpersons in achieving the
organizational and stakeholder goals are the focus in the following three sections. First, each
knowledge influence will have a category of one of the three knowledge types previously
mentioned. The second section will focus on adaptive attributions and self-efficacy as these
variables are critical in evaluating the clinical department chairpersons’ motivation in achieving
the organizational and stakeholder goals. The third section will discuss the assumed
organizational influences on the organizational and stakeholder goals. Further discussion on each
of the stakeholder knowledge, motivation, and organizational influences will appear in the
methodology section of chapter 3.
Clinical Department Chairpersons Knowledge, Motivation, and Organizational Influences
This review of literature focuses on the knowledge, motivation, and organizational
influences of what the clinical department chairpersons at NTHC need to understand to achieve
the organizational and stakeholder goals. The organizational goal is, by 2025, NTHC will
26

improve its regulatory compliance rate by 30%. The stakeholder goal is by 2025, clinical
department chairpersons of NTHC will implement the healthcare compliance program with at
least a 90% consistency as measured by regular random evaluations.
Knowledge and Skills
Influences related to knowledge are essential to the clinical department chairpersons at
NTHC in achieving the organizational and stakeholder goals. Clark and Estes (2008) argue that
for performance goals of an organization to be achieved, a gap analysis is necessary to evaluate
if employees know how to achieve the performance goals. Currently, NTHC does not have an
evaluation protocol in place to effectively ascertain the knowledge and skill level of all
employees. As a result, further enhancements of knowledge and skills may require additional
attention as the clinical department chairpersons may not know how to accomplish the
organizational or stakeholder goals, and future performance may require extra problem solving
(Clark & Estes, 2008).
The clinical department chairpersons will require various job aids to help the employees
perform job tasks as well as specific job training to accurately assess the employees’ job
knowledge and skills while providing feedback to help meet the organizational and stakeholder
goals (Clark & Estes, 2008). Krathwohl (2002) provides a well-articulated summary about goals
stating that for goals to be accomplished, employees should have a complete understanding of
the expectations of duties as discussed with the hierarchy of leadership. When considering future
challenges and problems, Clark and Estes (2008) suggest that continuing education is how
employees gain the knowledge and skills necessary to help address these future challenges as
challenges are often unexpected and different.
27

Clinical department chairpersons of NTHC need to comprehend knowledge as it relates
to regulatory compliance issues affecting the healthcare organization. To this end, Krathwohl
(2002) explains there are four different types of knowledge that include factual, conceptual,
procedural, and metacognitive. For this study, only three types of knowledge will be analyzed
and begins with declarative or conceptual knowledge. Conceptual knowledge includes the
categories, classifications, principles, and models that an individual needs to know to aid in
understanding the issues affecting the job duties (Krathwohl, 2002). Procedural knowledge is the
third type of knowledge and refers to the understanding by an individual of how to do something,
such as a healthcare employee properly documenting patient procedures for medical
reimbursement or employees in the accounting department to accurately code these procedures
for the correct amount to be reimbursed (Rueda, 2011). The fourth knowledge type,
metacognitive knowledge, refers to the awareness an individual has of self-cognitive processes
and allows for reflection on contextual factors to engage in practical problem solving (Rueda,
2011).
The knowledge influences affecting clinical department chairpersons at NTHC in
achieving the organizational and stakeholder goals are the emphasis in the following sections.
Each knowledge influence will have a category of one of the four knowledge types previously
discussed. It is essential to categorize the knowledge influences to determine the most effective
manner in assessing the clinical department chairpersons’ progress towards achieving the
organizational and stakeholder goals.

28

Clinical Department Chairpersons Need to Understand the Importance of a Compliance
Program
The first knowledge influence is conceptual knowledge and focuses on the clinical
department chairpersons’ ability to identify key concepts and apply them to the job functions. In
the late 1990’s the Office of Inspector General (OIG) issued a compliance plan to be used by
hospitals due to the increase in criminal and civil investigations and prosecutions regarding fraud
and abuse in the healthcare industry (Silverman, 2000; Guinn, 2000). Since this compliance plan
was issued, healthcare organizations have implemented compliance programs requiring
employees to understand organizational standards, various Federal and state laws, audit
practices, and the corresponding disciplinary actions to those who violate these laws (Silverman,
2000).
Furthermore, employees of healthcare organizations should understand that compliance
programs exist for two reasons. One reason is to prevent and detect criminal conduct and,
second, to emphasize an atmosphere of what an employee should do when faced with a
compliance issue rather than focus on what an employee can not do while performing job duties
(Silverman, 2000; Guinn, 2000). The clinical department chairpersons' ability to understand the
need for a compliance program can influence the behavior of the organization to achieve the
organizational and stakeholder goals and address the problem of reducing gaps in healthcare
delivery quality on AI/AN reservations and communities.
Clinical Department Chairpersons Need to Know their Ethical Responsibility to Report any
Compliance Issue
The second knowledge influence the clinical department chairpersons need is procedural
knowledge as this knowledge influence relates to how to do something. For example, how an
29

employee utilizes information to provide a complaint through the correct compliance procedure
established within the organization. When faced with a regulatory compliance issue in the
workplace, most employees come across an ethical quandary called a morally conflicted choice,
which means that within this experience comes inner turmoil or confusion when faced with
reporting a compliance issue (Heller, 1999). In general, individuals have the ability to do the
right thing when faced with a morally conflicted choice. However, when an individual is placed
in a situation that challenges that ability the right choice may not always be obvious to the
individual. This indecisive mindset places the responsibility of having open discussions on ethics
and values on leaders of the organization to aid the individual when faced with a morally
conflicted choice (Heller, 1999; Trevino et al., 1999).
Additionally, employees of healthcare organizations do not possess knowledge of all laws
and regulations that relate to healthcare compliance. However, if employees have some
awareness of ethical and legal issues relevant to the organization the employees are more likely
to do the right thing when faced with appropriately reporting compliance issues affecting the
organization (Trevino et al., 1999). By understanding that reporting compliance issues through
the proper sources within the organization, NTHC can work to protect the organization's ability
to address the problem of reducing gaps in healthcare delivery quality on AI/AN reservations and
communities and achieve the organizational and stakeholder goals.
Clinical Department Chairpersons Need to Know How Work Performance Influences Overall
Compliance of the Organization
The third knowledge influence the clinical department chairpersons need to have is
metacognitive knowledge as it relates to the ability to think about job duties versus actions on the
job and how this activity relates to overall compliance of the healthcare organization. Healthcare
30

employees should have a familiarity with what constitutes a violation of statutes, rules, and
regulations of Medicare, third party insurance companies, and the healthcare organization
(Cascardo, 2015). However, some instances exist that involve employees unknowingly
committing a violation by not filing a medical claim appropriately or not filing one at all due to
various factors within the organization (Cascardo, 2015).
Conversely, there are occurrences of criminal violations that include conspiracy,
healthcare fraud, embezzlement, and drug diversion and trafficking by healthcare employees that
all result in criminal convictions and place a negative connotation on the healthcare organization
(In Critical Condition: The Urgent Need, 2010). In any instance, these violations have far-
reaching impacts not only for the employees and the healthcare organizations, but for the
government agencies issuing the reimbursement payments and the American taxpayers as well
(Bauder et al., 2017). NTHC needs access to various resources, especially financial resources, to
address the problem of reducing gaps in healthcare delivery quality on AI/AN reservations and
communities and achieve the organizational and stakeholder goals. Clinical department
chairpersons can ensure the protection of these resources by influencing the behavior of the
organization to maintain a high level of regulatory compliance while performing job duties.
Table two categorizes the four knowledge influences by knowledge type and describes
the assessment methods of each. The table also gives the organizational mission of Native
Traditions Health Care as well as the organizational and stakeholder goals.

31

Table 2
Description of Knowledge Influences, Knowledge Types, and Assessment Methods
Organizational Mission
The mission of the health care organization of the Indian Tribe of the Northern Rockies is
to provide primary care, traditional healing, preventative care, and wellness promotion to
all members of the community, as intended by the Creator.

Organizational Global Goal
By 2025, Native Traditions Health Care will improve its regulatory compliance rate by
30%.

Stakeholder Goal
By 2025, clinical department chairpersons of Native Traditions Health Care will implement
the healthcare compliance program with at least a 90% consistency as measured by regular
random evaluations.

Knowledge Influence Knowledge Type Knowledge Influence
Assessment
Clinical Department
Chairpersons need to
understand the importance of a
compliance program.

Conceptual Using interviews, ask
questions to gauge knowledge
of how important a healthcare
compliance program is to the
organization.

Clinical Department
Chairpersons need to know
ethical responsibility to report
any compliance issue.

Procedural Using interviews, ask
stakeholders to describe the
appropriate procedure
available when reporting a
compliance issue to ascertain
the stakeholders’ knowledge.

Clinical Department
Chairpersons need to know
how work performance
influences overall compliance
of the organization.

Metacognitive Using interviews, ask
stakeholders to describe the
thought process when
completing work duties and
the ensuing reflection on
efforts to keep the healthcare
organization in compliance
with regulations.

32

Motivation Influences
Influences related to motivation are essential to the clinical department chairpersons at
NTHC in achieving the organizational and stakeholder goals. Rueda (2011) explains that
motivation relates to an individual’s ability to want to do something or willingness to do
something. Motivation includes both instigation and sustainment of goal-directed activities that
are influenced by both internal and external factors (Rueda, 2011). Clark and Estes (2008) define
motivation as the influence of what keeps an individual going and the level of effort one should
put into completing tasks. Motivation consists of three factors: active choice, persistence, and
effort. The first factor, active choice, is when an individual decides to pursue a goal actively.
Persistence, the second factor, refers to the level of commitment from the individual to complete
the goal. The third factor, effort, refers to the mental ability of the individual to increase
knowledge and learning while completing the goal (Rueda, 2011; Clark & Estes, 2008).
Rueda (2011) points out that there are variables that impact motivation that include self-
efficacy, adaptive attributions, values, and goals. The following sections will focus on adaptive
attributions and self-efficacy as these variables are critical in evaluating the clinical department
chairpersons’ motivation at NTHC in achieving the organizational and stakeholder goals and
addressing the problem of reducing gaps in healthcare delivery quality on AI/AN reservations
and communities.
Clinical Department Chairpersons Need Adaptive Attributions
The first motivation influence the clinical department chairpersons at NTHC need to
achieve the organizational and stakeholder goals is adaptive attributions, or attributions theory.
Rueda (2011) refers to attributions as the beliefs that an individual has about why success or
failure occurs while completing an activity or task and just how much control the individual has
33

in that success or failure. Also, when the individual views the success or failure as a result of the
efforts put forth, the more likely the individual is to try harder to succeed at completing the tasks
or activities (Mayer, 2011). Within attribution theory, Rueda (2011) explains that individuals
always want to make sense of the aspects of any surroundings, and this often leads to questions
regarding success or failures at tasks and how improvement might lead to better or continued
success.
The clinical department chairpersons at NTHC need to have this mentality the most as the
responsibility for educating healthcare employees on healthcare regulatory compliance issues
will contribute to the success of the compliance program implementation. Surrounding the
organization with the belief that maintaining a high level of compliance can help the clinical
department chairpersons achieve the organizational and stakeholder goals and address the
problem of reducing gaps in healthcare delivery quality on AI/AN reservations and communities.
Clinical Department Chairpersons Need Self-Efficacy Theory
The second motivation influence the clinical department chairpersons need to achieve the
organizational and stakeholder goals is self-efficacy. Parajes (1996) asserts that self-efficacy is
the inner belief an individual has regarding efficient capabilities to complete tasks, or perform
functions, at a desired level. The primary motivational belief is the higher the self-efficacy, or the
more the individual believes in inner competence and expectations for positive outcomes, the
higher the motivation will be to complete the task or activity with more engagement, persistence,
and hard work (Rueda, 2011). Also, history shows that AI/AN tribal nations who take over the
delivery of healthcare to their reservation communities have seen an improvement in the health
outcomes of the community members (Walker, 2019). The clinical department chairpersons of
NTHC need to have confidence in their job performance to help achieve the organizational and
34

stakeholder goals and address the problem of reducing gaps in healthcare delivery quality on
AI/AN reservations and communities.
Table three describes the two motivation influences identified to assess the employees of
Native Traditions Health Care and provides the assessment methods of each. The table also
gives the organizational mission of Native Traditions Health Care and the organizational goal.
Table 3
Motivation Influences and Motivational Influence Assessments
Organizational Mission
The mission of the health care organization of the Indian Tribe of the Northern Rockies is
to provide primary care, traditional healing, preventative care, and wellness promotion to
all members of the community, as intended by the Creator.

Organizational Global Goal
By 2025, Native Traditions Health Care will improve its regulatory compliance rate by
30%.

Stakeholder Goal
By 2025, clinical department chairpersons of Native Traditions Health Care will implement
the Underwood compliance program with at least a 90% consistency as measured by
regular random evaluations.

Assumed Motivation Influences

Motivational Influence Assessment

Attributions – Clinical department
chairpersons at NTHC need to have
attributions theory the most as they are
responsible for educating organizational
employees on healthcare regulatory
compliance issues.

Interview item: “What are some of the causes
of healthcare successfully understanding
health care compliance issues?”

Self-efficacy – Clinical department
chairpersons of NTHC need to have the
confidence in their job performance to help
achieve the organizational and stakeholder
goals.

Interview item: “Describe your impact on, or
contributions to, the organizational compliance
rate.”

35

Organizational Influences
Clark and Estes (2008) discuss organizational influences and the impact these influences
have on the performance of the organization. According to Gallimore and Goldenberg (2001),
cultural models are defined as a common understanding of how things should, or ought, to work.
Cultural settings include the collective efforts put forth to accomplish something by two
individuals, or a group of individuals, over time. Both cultural models and cultural settings
define the overall culture of an organization due to these influences being enabled and confined
to that organization (Gallimore & Goldenberg, 2001). This section will explore how NTHC
ensures a culture of continual improvement (cultural model) within the organization that
promotes the competency of healthcare regulatory compliance as well as provides regular and
periodic training programs (cultural settings) for the improvement of the organizational
compliance rate. Organizational influences are essential to the clinical department chairpersons
of NTHC in achieving the organization and stakeholder goals as well as addressing the problem
of reducing gaps in healthcare delivery quality on AI/AN reservations and communities.
The Organization Needs a Culture of Continual Improvement
When considering the cultural model of NTHC, the organization needs a culture of
continual improvement. Clark and Estes (2008) state that any organization’s culture should align
with all essential policies, procedures, and communication within the organization. Also, should
the organization’s culture fail to align with these three factors and the goals of the organization
expect problems with performance to exist. Furthermore, due to the legal authority that oversees
the proper handling of fraud and abuse, as well as protecting the available resources to the
healthcare organization, NTHC should take the time to ensure that the organization continues to
improve to remain in compliance with all applicable laws (Shuren, 2001). Furthermore, NTHC is
36

in a rural area, which makes the organization more susceptible to having considerable distances
or lower availability to healthcare providers and can affect the delivery of healthcare quality
(Towne et al., 2015). NTHC needs to align its culture to continuously improve the clinical
department chairpersons’ ability to achieve the organizational and stakeholder goals and address
the problem of reducing gaps in the delivery of healthcare quality on AI/AN reservations and
communities.
The Organization Needs Regular and Periodic Training Programs
When considering the cultural setting of NTHC, the organization needs regular and
periodic training programs. When organizations institute a change process, training is typical in
teamwork and process analysis as well as looks at specific content, such as techniques, to build
trust among team members based on the separate skills of each team member (Clark & Estes,
2008). Also, health disparities are often related to a racial divide that exists between patient and
provider, where the provider does not make an effort to understand the cultural aspects of the
patient to provide proper care (Purtzer & Thomas, 2019). The clinical department chairpersons
of NTHC need to recognize that regular and periodic training programs would help the
organization deliver the highest quality of care to the communities of the reservation. The
cultural model and setting determined will help the clinical department chairpersons achieve the
organizational and stakeholder goals and address the problem of reducing gaps in healthcare
delivery quality on AI/AN reservations and communities.
Table four categorizes the assumed organizational influences and the assessment to
analyze each influence. Also, the table provides the organizational mission of Native Traditions
Health Care, the organizational goal, and the stakeholder goal.

37

Table 4
Description of Assumed Organizational Influences
Organizational Mission
The mission of the health care organization of the Indian Tribe of the Northern Rockies is
to provide primary care, traditional healing, preventative care, and wellness promotion to
all members of the community, as intended by the Creator.

Organizational Global Goal
By 2025, Native Traditions Health Care will improve its regulatory compliance rate by
30%.

Stakeholder Goal
By 2025, clinical department chairpersons of Native Traditions Health Care will implement
the Underwood compliance program with at least a 90% consistency as measured by
regular random evaluations.

Assumed Organizational Influences Organization Influence Assessment

(Cultural Models)
The organization needs a culture of continual
improvement.

Using interviews: ask questions concerning the
culture of continual improvement the
stakeholders experience from the organization.

(Cultural Settings)
The organization needs regular and periodic
training programs.

Using interviews: ask questions concerning the
amount of training the stakeholders receive.

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
Maxwell (2013) explains that the conceptual framework is an important part of the
research study and provides a visual rendition of the items to be studied: the key factors,
concepts, or variables. The conceptual framework can be in either written or visual form and
should explain the presumed relationships between those items that are to be studied (Maxwell,
2013). Furthermore, Merriam and Tisdell (2016) describe the conceptual framework as the
38

structure that underlines the study and comes from the stance that the researcher applies to the
research study.
It is important to remember that although the knowledge, motivation, and organizational
influences present as independent factors, they will not necessarily be studied separately from
each other. All the factors identified have some variance of dependence on each other within the
study. For example, and as previously mentioned, clinical department chairpersons of the
healthcare organization should understand that compliance programs exist for two reasons. One,
to prevent and detect criminal conduct and, two, emphasize what an employee should do when
faced with a compliance issue rather than what an employee should not do while performing job
duties (Silverman, 2000; Guinn, 2000).
Concerning the motivational influence of self-efficacy, Rueda (2011) argues that the
more the individual believes in inner competence and expectations for positive outcomes, the
higher the motivation will be to complete the task or activity with more engagement, persistence,
and hard work. NTHC should contribute to this belief by creating a culture of continual
improvement and by providing for regular and periodic training programs.
These are just two examples of how the knowledge and skills and motivation influences
are reliant on the organizational influences. The conceptual framework will provide a visual
representation of how the knowledge, motivation, and organizational influences are relative to
each other within the research study. Figure one provides the conceptual framework for this
improvement study.

39

Figure 1
Conceptual Framework for this Improvement Study

Regulatory compliance within NTHC is a crucial factor when addressing the problem of
reducing the gaps in healthcare delivery quality to the reservations and communities. The clinical
department chairpersons of NTHC are the identified stakeholders of this research study. The
stakeholders have the knowledge and motivation influences that depend on the organizational
influences to accomplish the stakeholder goal. The double arrow between the two circles points
to the organization and the stakeholders primarily to emphasize the dependency that exists
Clinical Department
Chairpersons
(Stakeholders)
Knowledge influences:
conceptual, procedural,
metacognitive
Motivational influences:
self-efficacy and
attributions theory
Native Traditions
Healthcare (Organization)
Cultural settings:
continual improvement
Cultural model:
training programs
Stakeholder goal
By 2025, clinical department chairpersons of
Native Traditions Health Care will implement
the healthcare compliance program with at
least a 90% consistency as measured by
regular random evaluations.
40

among the knowledge, motivation, and organizational influences. The arrow pointing to the
stakeholder goal is the point where the stakeholders want to be by the targeted date and can get
there by acquiring those knowledge and motivation influences with the help from the
organization.
This conceptual framework aspires to demonstrate the needs of the stakeholders to
accomplish the stakeholder goal. Not only do the stakeholders need knowledge on healthcare
regulatory compliance issues, there is also a need to motivate the stakeholders to acquire that
knowledge. The organization can provide that motivation by creating a culture of continuous
improvement with regular and periodic training programs. To establish a robust healthcare
regulatory compliance program, the stakeholders will rely on the organization to see it become a
reality.
Conclusion
This improvement study sought to determine how to reduce the gap in healthcare delivery
quality on American Indian reservations and Alaska Native communities. The organizational
goal is that by 2025, Native Traditions Health Care will improve its regulatory compliance rate
by 30%. Also, the stakeholder goal is that by 2025, clinical department chairpersons of Native
Traditions Health Care will implement the healthcare compliance program with at least a 90%
consistency as measured by regular random evaluations. The literature review component
explored the access to healthcare that members of AI/AN reservations and communities typically
experience as well as the numerous health care disparities that face these communities and the
factors behind the disparities. Also, the literature review explored the goals and barriers to
establishing a robust healthcare regulatory compliance program within a healthcare organization.
The knowledge, motivation, and organizational (KMO) influences the conceptual framework
41

used in this study to learn what the stakeholders, the clinical department chairpersons, of NTHC
need to possess, and what the organizational culture and context need to be, to accomplish the
organizational and stakeholder goals. In chapter three, an emphasis on the methodological
approach of this study appears in detail.

42

CHAPTER THREE: METHODS
The purpose of this improvement study was to analyze the clinical department
chairpersons’ knowledge and skills, motivation, and organizational influences to address the
problem of reducing gaps in healthcare delivery quality on AI/AN reservations and communities.
The first section of this chapter includes a revisit of the research questions that guided this study,
a discussion of the research design, and a discussion on the methods of the data collection and
analysis. The second section of this chapter discusses the data collection and instruments utilized
in the qualitative approach of the research. This chapter concludes with a discussion of the data
analysis approach utilized in the study.
Research Questions
The following questions will guide this study:
1. What knowledge, motivation, and organizational needs must be met to enable the clinical
department chairpersons to improve the healthcare organization’s regulatory compliance
rate?
2. What is the interaction between organizational culture and context and the clinical
department chairpersons' knowledge and motivation?
3. What are the knowledge, motivation, and organizational solutions to facilitate the
abilities of the clinical department chairpersons to implement the regulatory compliance
program?
Participating Stakeholders
The identified stakeholders for this study were the clinical department chairpersons of
NTHC. The stakeholders to be analyzed in this study did not include any members of the
management team because they worked closely with the researcher, and any data collected from
43

these individuals may have had a sense of bias towards the research questions. All participating
stakeholders were identified as clinical department chairpersons who were employed with the
organization for a minimum of one year and understood the mission and overall goal of the
organization.
Interview Sampling Criteria and Rationale
Criterion 1. Participating stakeholders in the interview process of this study agreed to a
confidential interview to discuss knowledge and skills and motivation influences.
This research study sought to determine the knowledge and motivation influences most
needed by the clinical department chairpersons to accomplish the organizational and stakeholder
goals and address the problem of reducing gaps in healthcare delivery quality on AI/AN
reservations and communities. Interviews are an effective data collection tool that helps provide
an understanding of what is in and on the minds of the interviewee. Additionally, interviews
provide meaningful information on factors of an individual such as behavior, feelings, and
interpretations of surroundings that cannot be otherwise observed (Merriam & Tisdell, 2016).
Johnson and Christensen (2014) state that the interview is an interpersonal encounter with
friendly connotations, and the researcher must clarify that the interview process is confidential to
help build trust between the researcher and the interview participant. Building trust encourages
complete and honest responses and discourages interview participants from providing biased
information (Johnson & Christensen, 2014).
The researcher of this study engaged stakeholders with an invitation to participate in a
confidential interview. However, with the recent discovery of the coronavirus disease (COVID-
19) and ensuing pandemic that has affected the entire world community; the researcher had to
modify the manner in which the confidential interviews were conducted. Health officials
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established several protocols to help minimize the spread of COVID-19, which included
avoiding close contact with other people, maintaining a six feet distance between individuals
from different households, and covering the mouth and nose with a mask (Centers for Disease
Control and Prevention [CDC], 2020). Due to these requirements from the CDC, the interviews
could not be conducted in-person. Rather, the researcher used an online forum, such as the
website Zoom.us, to create a virtual meeting room to complete the interview process for each
participant.
The interviews offered an ideal manner for the clinical department chairpersons to answer
questions regarding knowledge and skills and motivation influences in relation to successfully
implementing a regulatory compliance program for and improving the regulatory compliance
rate of NTHC. Also, the interviews provided meaningful data that revealed the abilities of the
clinical department chairpersons in addressing the problem of reducing gaps in healthcare
delivery quality on AI/AN reservations and communities.
Criterion 2. Participating stakeholders in the interview process of the study agreed to a
confidential interview to discuss organizational influences.
Organizational influences are available and exist to support or enhance the knowledge
and motivation efforts of the clinical department chairpersons. Again, interviews provide
meaningful data from stakeholders regarding what is in and on an individual’s mind as well as
factors that are not always observable (Merriam & Tisdell, 2016). An important factor within the
interview process is that the researcher will be certain to fully explain that the responses of the
participant will be confidential or anonymous to gather as much meaningful data as possible.
Also, the researcher must inform each interview participant that their responses in the interviews
provide integrity to the study and that the participants are a vital part of the research study.
45

The researcher of this study conducted confidential interviews of the clinical department
chairpersons to gauge the organizational influences available to assist in accomplishing the
organizational and stakeholder goals. It was important for the researcher to discuss value of
confidentiality and the importance of the clinical department chairpersons’ participation in the
study as both enhance the collection of data. These actions by the researcher helped to determine
the clinical department chairpersons’ abilities in addressing the problem of reducing gaps in
healthcare delivery quality on AI/AN reservations and communities. Additionally, due to the
safety protocols regarding COVID-19, the interviews were not be conducted in-person. The
researcher used an online virtual meeting room on the Zoom website to complete the interview
process. An incentive plan was provided to each participant to stimulate support for the
interviews of this study.
Interview Sampling (Recruitment) Strategy and Rationale
The researcher used a purposeful sampling strategy to select the sample to analyze in this
study. More specifically, a typical sampling method acquired the data needed for this qualitative
research study that is typical, normal, and average of clinical department chairpersons’ ability to
accomplish the organizational and stakeholder goals. Also, due to the confidentiality of the
interview and the importance of honest answers from the participants, the researcher stressed to
the clinical department chairpersons the significance of participating in the interviews and the
overall goals of the research study to gain the most accurate data possible.
The researcher invited eight clinical department chairpersons to participate in the
interview process in an effort to learn as much as possible about the knowledge and skills,
motivation, and organizational influences to accomplish the organizational and stakeholder
goals. Seven of the chairpersons participated in an interview. Additionally, the data collection
46

captured information about the ability of the clinical department chairpersons to address the
problem of reducing gaps in healthcare delivery quality on AI/AN reservations. All interviews
were conducted using an online virtual meeting room on the Zoom website. One clinical
department chairperson was unavailable to complete the interview. The researcher attempted to
schedule an interview with the next individual in command of the department but was
unsuccessful.
Data Collection and Instrumentation
Merriam and Tisdell (2016) suggest that qualitative data comes from an individual’s
experiences and knowledge through interviews, observations of behaviors and actions, and
excerpts and quotations from documents. To this end, data collection for this study used a two-
sided approach: conducting online virtual interviews to gather data concerning behaviors and
actions of the clinical department chairpersons and collecting healthcare regulatory documents
from NTHC and other Native American agencies. The research questions for the study guided
the approach to the data collection process and the development of the instruments for the study.
The researcher sought to gain an understanding of the clinical department chairpersons’
level of knowledge and motivation influences in achieving the organizational and stakeholder
goals as well as addressing the problem of reducing gaps in healthcare delivery quality on AI/AN
reservations and communities. Utilizing the interview process helped the researcher achieve this
understanding. Also, gathering and analyzing public records, such as staff meeting agendas and
minutes, organization policies and procedures, and regulatory compliance manuals specific to
healthcare organizations, assisted the researcher in assessing the organizational influence needs
to help the clinical department chairpersons achieve the organizational and stakeholder goals.

47

Interviews
The interview protocol the researcher used in this study was a semi-structured interview.
Using semi-structured interviews allowed the researcher to respond to the clinical department
chairpersons as information on the interview topic emerged or new ideas developed as the
interview was conducted (Merriam & Tisdell 2016). The types of questions included in the
interviews focused on healthcare regulatory compliance programs and the importance of
improving the organization’s regulatory compliance rate. These interviews provided data to
assess the knowledge and skills, motivation, and organizational influences that affect the clinical
department chairpersons’ ability to achieve the organizational and stakeholder goals. The
decision to use interviews to focus on the knowledge and skills, motivational, and organizational
influences of this study is grounded in Patton’s (2002) assertion that interviews gain the
perspective of the participants on the issue and how meaningful that perspective is in
understanding the influences under analysis.
The interviews occurred within a fourteen-day timeframe before the researcher collected
and analyzed additional documents. The interviews focused on establishing the level of
knowledge and skill and motivation influence levels of each clinical department chairpersons in
relation to achieving the organizational and stakeholder goals. The interviews also focused on the
organizational influences available to the clinical department chairpersons to enhance their
knowledge and motivation in achieving the organizational and stakeholder goals. The researcher,
via proxy, conducted seven confidential, one-time interviews of each clinical department
chairperson with each interview lasting approximately twenty-five to thirty-five minutes. The
total time across all participants was approximately four hours.
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All interviews were both formal and informal as all interviews included predetermined
questions as well as a predetermined order of the questions to be asked. Also, the proxy
approached each interview with the effort of allowing each clinical department chairperson to
develop new ideas concerning the successful implementation of a healthcare regulatory
compliance program and improving the compliance rate of NTHC. The interviews occurred
online using the Zoom website and during an agreed upon time to allow for each clinical
department chairperson to tend to other daily responsibilities within the healthcare organization
should any unforeseen circumstances arise. To capture the data from the interviews, the proxy
used the video recording option in the Zoom platform and note taking.
Documents and Artifacts
Bowen (2009) posits that document analysis serves as a means to validate or corroborate
other data, such as interviews, within a research study. The documents for analysis in this study
were the agendas and minutes of meetings that concerned the clinical department chairpersons,
policies and procedure manuals of NTHC, and health care regulatory compliance manuals.
Requests for the staff meeting agendas and minutes from the administrative team of NTHC were
completed with a written form that included a signature line for the approval of the request.
Approving signatures from the Chief Executive Officer served as the affirmative authorization to
use the documents in this study. The policies and procedures manuals followed a similar
approving protocol. NTHC’s meeting agendas and minutes provided data for analysis of the
organizational influences that help the clinical department chairpersons achieve the
organizational and stakeholder goals.
Access to healthcare regulatory compliance manuals was attained through the websites of
federal government organizations such as the Department of Health and Human Services and the
49

Office of Inspector General. These documents are often referred to as “Federal Registers” and
are free to the public for review. The manuals assisted the researcher in comprehending federal
regulations that concern healthcare organizations and address the implementation of regulatory
healthcare compliance programs. Understanding the rules and regulations helped the researcher
effectively mine data from policies and procedures of NTHC and from healthcare compliance
manuals that support the implementation of a regulatory healthcare compliance program.
Additionally, American Indian organizations such as the First Nations Development
Institute, American Indian College Fund, and the Native American Rights Fund produce various
policy papers, white papers, and professional reports that include health care issues. These
documents are considered applied research and, therefore, peer reviewed. Including these
documents in the data analysis to help inform the problem of practice and how NTHC can
integrate them into their implementation of a regulatory compliance program was an added
benefit to the study. Overall, analyzing all aforementioned documents assisted the researcher in
tracking the levels of the knowledge and skills, motivation, and organizational influences in
addressing the problem of reducing gaps in healthcare delivery quality on AI/AN reservations
and communities.
Data Analysis
For the interview process, data analysis began during the data collection phase. The
researcher drafted analytic memos after reviewing the transcript from each interview.
Additionally, the researcher documented document all thoughts, concerns, and initial conclusions
about the data with respect to the conceptual framework and research questions of this study.
Once the researcher had reviewed all of the interview transcripts, transcription and coding of the
interviews occurred. In the first phase of analysis, the researcher used open coding, looking for
50

empirical codes and applying a priori codes from the conceptual framework. The second phase
of analysis included the aggregating the empirical and a priori codes into analytic/axial codes. In
the third phase of data analysis, the researcher identified pattern codes and themes that emerged
concerning the conceptual framework and research questions. The researcher then analyzed
documents and artifacts for evidence consistent with the concepts in the conceptual framework.
Credibility and Trustworthiness
According to Merriam and Tisdell (2016), the researcher of any research study has the
responsibility to conduct the research in a valid and trustworthy manner. Also, the researcher
should use language and implement research strategies that ensure the credibility of the results of
the study, thereby making the analysis trustworthy (Maxwell, 2013). The strategies used in this
study to ensure credibility and trustworthiness included a triangulation of two data sources,
respondent validation, and adequate engagement of data collection (Merriam & Tisdell, 2016).
The interview process of the clinical department chairpersons allowed the researcher to ascertain
the knowledge and skill, motivation, and organizational influence level of achieving the
organizational and stakeholder goals. Analyzing documents related to the organizational
influences available to the clinical department chairpersons to enhance the knowledge and skills
and motivational influences to achieve the organizational and stakeholder goals immediately
followed the completion of the interviews.
Ethics
The study utilized qualitative methods to help answer the research questions. As such,
data gathering used data mining of documents and artifacts as well as interviews with the clinical
department chairpersons of NTHC. The importance to conduct this study most ethically is due to
the collection of data that involved personal conversations, i.e., interviews. To this end, all
51

participants were given informed consent forms at the beginning of this study prior to being
asked to participate in and give consent for the utilization of video recordings the interviews.
According to Rubin and Rubin (2012), informed consent is necessary to ensure the participants
comprehend the nature of the research, understand the risks involved, and are fully aware that
participation is completely voluntary. The researcher received approval from the Institutional
Review Board (IRB) at the University of Southern California before initiating this research.
Additionally, the researcher followed all rules and regulations to ensure the successful
completion of this research project.
The researcher provided to each clinical department chairperson an informed consent
form prior to the interview. At the beginning of each interview, the proxy confirmed that the
participant had received an informed consent form, explained that participation was completely
voluntary, and verified that all identities would be kept confidential. Also, due to the sensitive
environment in where the clinical department chairpersons complete daily job functions, the
proxy reassured the participants that confidentiality would be of utmost importance for this
study. The proxy also explained that the researcher would honor the wishes of any clinical
department chairperson to exit the study at any time. Prior to all interviews, the proxy gained
permission to record the interviews through audio and video means.
Merriam and Tisdell (2016) state that in any research study special attention must be
given to the relational category of ethical issues and the researcher must disclose any
relationships to the participants included in the study. As such, the researcher of this study must
disclose the unique relationship that exists between the researcher and the organization included
in this study. As a member of the tribal nation, the researcher has the opportunity to receive
healthcare from NTHC. Furthermore, the researcher is employed with the tribal nation as the
52

Chief Compliance Officer (CCO). However, this position is supervised by the tribal nation
governmental unit and not by the CEO of NTHC. The job duties of the CCO require the
completion of internal audits on all sections of NTHC as well as provide training on healthcare
compliance issues to the employees of the organization. As CCO, the researcher will not lead the
interviews as this relationship with the clinical department chairpersons may influence answers
provided in a manner that is biased toward positive compliance efforts. Therefore, the researcher
will appoint a proxy who has fulfilled all the requirements of the IRB to take the lead in
conducting the interviews. Further, the proxy will provide the researcher a transcript of each
interview and will assign random participant numbers to the transcribed responses so that the
participants’ identities remain anonymous to the researcher.
Glesne (2011) argues that one role the researcher has the potential to assume during the
research project is the intervener/reformer. As such, the researcher may want to perceive the
right to be wrong and condemn all that is unjust when gathering the data (Glesne, 2011). Given
the role of the researcher with NTHC, combined with the experiences receiving healthcare
provided, the judgement of the researcher may have influenced the analysis of the levels of
knowledge and skills, motivation, and organizational influences affecting the clinical department
chairpersons in maintaining compliance with healthcare issues affecting NTHC and the
regulatory compliance rate.

53

CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of this improvement study is to analyze the clinical department
chairpersons’ knowledge and skills, motivation, and organizational influences to reduce gaps in
healthcare delivery quality on AI reservations and AN communities. This analysis will help
support accomplishing the suggested organizational goal of NTHC improving its regulatory
healthcare compliance rate by 30% by 2025. Also, this analysis will help address the stakeholder
goal of, by 2025, clinical department chairpersons of NTHC will implement the healthcare
compliance program with at least 90% consistency as measured by regular random evaluations.
The exploration of assumed causes was through a gap analysis of the knowledge, motivation, and
organizational influences impacting the clinical department chairpersons at NTHC.
The findings of this analysis are categorized using these assumed causes of knowledge,
motivation, and organization, each providing a section discussing the results. Qualitative data
were collected using two methods: online virtual interviews and document and artifact data. The
data provides an understanding of the knowledge, motivation, and organizational challenges the
clinical department chairpersons encounter at NTHC while implementing the healthcare
compliance program and increasing the organization’s compliance rate. The first method used is
the interview protocol followed by document and artifact analysis to help substantiate the data
collected from the interviews.
The following questions guide this study:
1. What knowledge, motivation, and organizational needs must be met to enable the clinical
department chairpersons to improve the healthcare organization’s regulatory compliance
rate?
54

2. What is the interaction between organizational culture and context and the clinical
department chairpersons' knowledge and motivation?
3. What are the knowledge, motivation, and organizational solutions to facilitate the
abilities of the clinical department chairpersons to implement the regulatory compliance
program?
Participating Stakeholders
A total of eight clinical department chairpersons agreed to participate in this
improvement study. However, only seven completed the interview process. All seven clinical
department chairpersons have experience of more than nine years in the healthcare industry and
at least four years working with American Indian or Alaska Native healthcare organizations. The
clinical department chairpersons range from mid-thirties to seventy in age, which provides a
broad perspective on regulatory healthcare compliance. Table five provides the demographic
information on each clinical department chairperson.

55

Table 5
Demographic Information on Participants
Participant
#
Years of
Service in
Healthcare
Years of
Service in
Native
American
Healthcare

Approximate
Age
Race Gender
1 52 10 70+ White Male

2 15 4 40-45 White Male

3 12 12 40-45 White Male

4 32 32 65-70 White Male

5 45 4 65-70 White Female

6 10 4 36-40 White Male

7 9 7 30-35 Native American Female

8 28 5 60-65 White Female

Determination of Assets and Needs
The two primary sources of qualitative data for this improvement study were virtual
online interviews of the clinical department chairpersons and documents and artifacts on
regulatory healthcare compliance from NTHC. The researcher analyzed the interviews first to
gain an understanding of the knowledge, motivation, and organization influences, which were
then corroborated with the analysis of the documents and artifacts. The interviews were
conducted using a set of 12 questions that focused on the knowledge, motivation, and
organizational influences of the clinical department chairpersons as they relate to their daily
operations. Also, the researcher was considered a peer to the participants of this improvement
56

study, and therefore used a proxy to complete all of the interviews. The researcher reached
saturation by ensuring all interview questions were asked of each participant and stopped all
interviews when each participant completed the interview process.
In addition, the researcher determined and applied criteria in determining an influence as
an asset or a need based on the size of the organization, the commonality of answers from the
participants in the interviews, and the number of similar characteristics found in the healthcare
regulatory document. Therefore, data that provides for a finding of the clinical department
chairpersons or the organization meeting the influence at a rate of 51% or better is considered an
asset and any finding of 50% or lower as a need.
Results and Findings for Knowledge Causes
Several interview questions were asked to assess the knowledge influences affecting the
clinical department chairpersons’ ability to implement the healthcare compliance program and
improve the organizations healthcare compliance rate. The results and findings are reported
using the categories of declarative, procedural, and metacognitive knowledge and the assumed
causes are included in each category. Table six shows the knowledge influences for this study
and their determination as an asset or need.

57

Table 6
Knowledge Assets or Needs as Determine by the Data
Assumed Knowledge Influence

Asset or Need
Declarative

Clinical Department Chairpersons need to
understand the importance of a compliance
program

Asset - 57%, four out of seven, clinical
department chairpersons demonstrate they
meet the knowledge influence
Procedural

Clinical Department Chairpersons need to
know ethical responsibility to report any
compliance issue

Need - 43%, three out of seven, clinical
department chairpersons demonstrate they
meet the knowledge influence
Metacognitive

Clinical Department Chairpersons need to
know how work performance influences
overall compliance of the organization

Asset - 57%, four out of seven, clinical
department chairpersons demonstrate they
meet the knowledge influence

Declarative Knowledge
Influence 1. Clinical department chairpersons need to understand the importance of a
compliance program
Interview findings. Declarative knowledge focuses on the ability of the clinical
department chairpersons to identify key characteristics of a robust healthcare compliance
program. Declarative knowledge is described as the categories, classifications, principles, and
models that an individual needs to know to aid in understanding the issues affecting the job
duties (Krathwohl, 2002). The literature references a compliance plan that the Office of Inspector
General (OIG) issued in the early 1990’s that required healthcare organizations to implement
compliance programs requiring employees to understand organizational standards, various
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Federal and state laws, audit practices, and the corresponding disciplinary actions to those who
violate these laws (Silverman, 2000; Guinn, 2000).
The clinical department chairpersons were asked, from their respective positions, what
the characteristics include that make up a robust healthcare compliance program. The data
reflects that 57%, or 4 out of 7, of the clinical department chairpersons were able to describe the
characteristics of a robust compliance program in a healthcare organization aligning with the
literature. Participant one demonstrated the knowledge of various requirements provided from
different regulatory agencies that have oversight of healthcare organizations saying, “First of all,
understanding what the requirements are and understanding that there are various agencies and
oversight that have to be met in a timely fashion.” This clinical department chairperson showed
that they were aware of the regulations and that meeting these requirements should be completed
in a respectable amount of time.
Participant three provided a great process of self-reflection by a team of employees of the
healthcare organization as a big characteristic of a robust compliance program adding, “I think
the characteristics would be a dedicated team that meets regularly to look at where compliance is
either lacking or failing. I think it really comes down to risk management or just culture.” Here,
the clinical department chairperson stressed the need for an organizational team to take it upon
themselves to learn what compliance is, the current state of compliance of the organization, and
how to make it work in the best interest of the organization.
Two of the clinical department chairpersons commented on the importance of
understanding rules and regulations as well as having the right personnel in place to help
strengthen the compliance efforts of the organization. Participant five pointed out in their
interview that, “The big thing (is) policies and procedures. You can have all the policies and
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procedures you want, but when you get multiple clinical departments making multiple
procedures about the same thing that's where you run into problems with compliance.” Here, the
clinical department chairperson suggested that far fewer issues and problems would arise should
the rules of the organization be more universal rather than struggling to understand what each
clinical department has in place when a compliance issues surfaces. Furthermore, the clinical
department chairperson discussed the importance of not only having strong policies and
procedures, but having the appropriate personnel in place in the organization to enforce those
rules. Participant five stressed, “That's why they try to have a quality person oversee everything”
again suggesting that these two characteristics, of having strong policies and procedures as well
as having an individual on staff with a strong background in compliance, are quite important for
a robust compliance program.
Similarly, participant four showed an understanding of the importance of following
policies and procedures when discussing the characteristics of a robust healthcare compliance
program adding, “We have a whole set of rules that we follow and review. We have, you know,
outcomes compliance. To me, oftentimes means compliance with the billing sort of ends of
things.” Here, this clinical department chairperson referred to rules that need to be followed and
reviewed and discussed an example of proper billing protocol within their department.
According to participant four, “Reviewing how people are doing certain things, how they're
putting in their notes, what they're billing for (with) certain kinds of visits, and do those visits
meet the criteria for that billing code.” This participant suggested that when the organization
provides for a review of steps within the process, they are adding to the validity of the protocols
and, thereby, strengthening compliance efforts. This participant was able to provide an
understanding of a robust healthcare compliance program.
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Three of the seven clinical department chairpersons could not provide a characteristic of
a robust healthcare compliance program when asked do so in the interview process. Participant
two guessed at a possible characteristic saying, “Going to say probably communication with the
officers of the health care facility.” Participant six guessed at what they think should be involved
with the compliance program adding, “I mean, I would guess having roles that everyone knows.
Probably training on those roles oversight to make sure people are following the rules.” Here, the
clinical department chairperson struggles to provide a proper characteristic of a robust healthcare
compliance program. Lastly, participant eight gave a very simple answer saying, “Having
processes in place and adhere to them along with policies and procedures.” Given the limited
answers these clinical department chairpersons provided, it is difficult to assess their complete
declarative knowledge on the characteristics of a robust healthcare compliance program. Overall,
the clinical department chairpersons were able to discuss that rules, policies, and procedures are
a part of a healthcare compliance program. They were also able to describe the characteristics of
what makes the compliance program a robust and reliable system.
Document analysis. NTHC uses a Compliance Plan that they adopted to guide the
organization on compliance procedures and uses this plan as a basis for their compliance
training. This Compliance Plan along with training documents were used in this section of the
analysis of the declarative knowledge influence of clinical department chairpersons need to
understand the importance of a compliance program.
According to the Compliance Plan, NTHC expects all employees of the organization to
support the mission of the organization and to “provide the absolute highest level of care to our
patients” (“NTHC Compliance Plan,” 2017, p. 11). The Compliance Plan continues to explain
that all medical care provided must be medically necessary and be provided by qualified
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individuals. Also, the documentation of the care must meet all laws and regulations, payer
requirements, and professional standards (“NTHC Compliance Plan,” 2017). These stipulations
within the Compliance Plan state the importance of certain compliance measures to the
employees of NTHC on what is expected from them during their employment. This section of
the Compliance Plan clearly helps the understanding of the clinical department chairpersons on
the importance of a compliance program.
In summary, the interview process of the clinical department chairpersons concerning the
declarative knowledge influence provides the finding that over half of these participants (57%)
aligned with the literature on the conceptual knowledge influence. For example, four of the seven
participants provided characteristics of a robust compliance program in a healthcare organization
when asked. Three of the seven participants could not provide true characteristics within their
answers, and their answers were very short.
After reviewing of the Compliance Plan from NTHC, it is clear that all employees are
required to follow all applicable laws and regulations, payer requirements, and professional
standards when providing the medical care to patients. This section of the Compliance Plan
supports the clinical department chairpersons need to understand the importance of a compliance
program. Given these findings, the declarative knowledge influence is determined to be an asset
in this study.
Procedural Knowledge
Influence 1. Clinical department chairpersons need to know their ethical responsibility to
report any compliance issue
Interview findings. Procedural is the second knowledge influence and refers to an
individual possessing specific skills, techniques, or particular methodologies in accomplishing
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specific actions. According to Rueda (2011), procedural knowledge is the “knowing how to do
something” (p. 28). The literature states that, although healthcare employees will not know all
laws and regulations that relate to overall healthcare compliance, they should have some
awareness of ethical and legal issues relevant to their respective healthcare organization. Having
this awareness enhances the likelihood that employees will do the right thing when faced with
appropriately reporting compliance issues affecting the organization (Trevino et al., 1999).
The clinical department chairpersons where asked to describe the current process
available within their organization in utilizing services supplied by the organization’s
compliance program. The data shows three out of seven of the clinical department chairpersons,
or 43%, have this ability, which does not align with the literature. The best description came
from participant three based on their knowledge of how the process is established. This clinical
department chairperson explains, “Typically we have a compliance committee that meets fairly
regularly or every couple of months, but Covid has kind of made that much more difficult. It
used to be in person, which I think is a little more efficient.” The participant also referred to how
departmental protocols should be given a random review by the organization’s healthcare
compliance officer to strengthen employee’s perception of compliance. Participant three
concluded that, “If there's some kind of systemic problem then we will take it back to the med
staff as a whole or we also have dental and pharmacy and behavioral health and all those
departments as well.” With this response, the clinical department chairperson demonstrated that
they possess a small understanding of the steps involved in reporting and responding to a
compliance issue. The next two responses from participants did not provide as much knowledge
on this procedural influence, but they did describe the current process available.
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Participant three explained the current process available in utilizing services supplied by
the organization’s compliance program saying, “We have an incident reporting system (that)
goes to our compliance officer and then it goes up for review whenever they go to meetings,
obviously (COVID) has made that difficult, but I think that that's our basic process.” Here, the
clinical department chairperson understood the process and was able to describe how it works by
mentioning an incident reporting system. They continued to mention the use of a compliance
officer and the role they play in the compliance process. The answer they provided shows that
they are aware of the services available and how to use them if a reason arises when it comes to
compliance issues.
Furthermore, participant one gave an answer that suggested that they were aware of the
current process available in utilizing services supplied by the organization’s compliance
program. This clinical department chairperson says, “We have a compliance officer who
monitors activities and a fairly robust credentialing department (that) makes sure everyone is
properly credentialed in their particular field. We do have a chain of command that involves
various reporting to one's supervisor.” The answer provided here acknowledges that a
compliance officer exists in the organization and that the officer plays a part in the process of
reporting compliance issues. Also, the clinical department chairperson mentioned the chain of
command an individual can follow when faced with reporting compliance issues within the
organization. The participant did not mention any steps involved in the process of reporting
compliance issues, however, and did not say how the process begins or ends.
Not aligning with the literature, four out of seven, or 57%, of the clinical department
chairpersons were not able to provide a description of the current process available in utilizing
services supplied by the organization’s compliance program. Participant two demonstrates they
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have an understanding of the current process available saying, “I don't know that I have a great
understanding of how we do it. But as far as I know, we send an email to our compliance officer
with any (compliance) issues and then it just snowballs from there.” Here, the participant issues a
caveat admitting they do not possess a great deal of understanding of the process available in
reporting any compliance issues. They did mention the compliance officer and the role they play
in the process. With this admission of their limited knowledge of the current reporting process
available from the organization, this clinical department chairperson revealed their inability to
possess the procedural knowledge in reporting compliance issues.
In addition, participant eight did not provide any details of the current process available
in utilizing services supplied by the organization’s compliance program saying, “Currently we
have the HIPPA training and policies and procedures written but not completely approved. We
also have a compliance officer and a compliance team.” This response was rather short and only
mentions a compliance officer and compliance team, but they did not provide details of how
either are used in reporting compliance issues.
Furthermore, participant six states, “Okay, yeah. I mean, there's a compliance officer and there's
a compliance training every year and there's mostly policies and procedures, and you know,
there's people that that look over all their different areas.” Here, the clinical department
chairperson only mentioned a compliance training, but failed to provide details on how to use the
process available in ensuring the compliance of the organization.
Lastly, participant five provided a response that did not offer a description of the current
process available in utilizing services supplied by the organization’s compliance program.
Instead, the participant discussed the gaps that exist within the compliance efforts of the
organization saying, “We don't have somebody who's fully in charge of compliance. There's the
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overall compliance plan that we all had to sign and read and it talks about maintaining standards.
But like most organizations there are holes where things aren't completed.” Although this
response provided good thoughts on what gaps exist within the current compliance program, the
clinical department chairperson did not describe the current process available in reporting
compliance issues. The participant, however, mentioned the compliance plan that discusses
maintaining standards, which suggests they understand that a process does exist. Without any
further discussion from the clinical department chairperson on the current process available, it
seemed as if they do not possess the procedural knowledge to utilize the services supplied by the
organization’s compliance plan.
Document analysis. NTHC adopted a Compliance Plan that is used to guide the
organization on compliance procedures. NTHC uses this plan as the basis for their compliance
training and is used in this section of the analysis of the procedural knowledge influence of
clinical department chairpersons need to know their ethical responsibility to report any
compliance issue.
The Compliance Plan includes a section titled, “How to Report Alleged Violations of the
Compliance Plan,” and includes the following language, “Any supervisor or other management
personnel who receives a report of known or suspected non-compliant conduct shall forward the
information directly to the Compliance Officer(s) for review and follow-up” (“NTHC
Compliance Plan,” 2017, p.25). This section of the Compliance Plan provides details how to
report any compliance issues utilizing various reporting formats and what to do if the employee
prefers not to report the compliance issue to their supervisor for various reasons. The steps
within this section of how to report compliance issues also describes what will happen if any
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employee fails to report such issues as well as the disciplinary actions against personnel who
commit these reporting failures (“NTHC Compliance Plan,” 2017).
In summary, the interview data shows that 43%, or three out of seven, of the clinical
department chairpersons were able to describe portions of the current process available within
their organization in utilizing the services supplied by the organization’s compliance program.
With less than half of the participants aligning with the literature on the procedural knowledge
influence demonstrates that a need exists among the clinical department chairpersons.
Furthermore, although the remaining four participants were able to address in some form the
current process available in utilizing the services supplied by the organization’s compliance
program, they were not able to provide an accurate description of the entire process.
The Compliance Plan from NTHC provides a detailed description of the steps involved in
reporting any compliance issue and what is expected of all employees with respect to
maintaining compliance within the organization. This section of the Compliance Plan provides
critical support to the clinical department chairpersons’ need to know their ethical responsibility
to report any compliance issue. The data indicates that a need exists within the procedural
knowledge influence due to the inability of four out of seven (57%) clinical department
chairpersons to describe the current process available in utilizing services provided by the
organization’s compliance program.
Metacognitive Knowledge
Influence 1. Clinical department chairpersons need to know how work performance
influences overall compliance of the organization
Interview findings. Rueda (2011) posits that metacognitive knowledge is an individual’s
awareness of their own cognition and particular thought processes. Metacognitive knowledge is
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considered a key feature of strategic behavior in problem solving as well as allows an individual
to contemplate contextual and provisional characteristics of a given activity or problem (Rueda,
2011). According to the literature, there can be some instances where healthcare employees
unknowingly commit a violation of certain healthcare rules and regulations, such as not filing a
medical claim appropriately (Debra Cascardo, 2015). However, there are occurrences of criminal
violations, such as healthcare fraud, embezzlement, and drug diversion that result in criminal
convictions and place the organization in a negative light (In Critical Condition: The Urgent
Need, 2010). Whatever the violation, healthcare employees should have familiarity of both types
of violations and the implications they pose to the healthcare organization (Cascardo, 2015).
During the interview process the clinical department chairpersons were asked what
abilities they have that would help the organization achieve a high level of compliance with
healthcare regulations. The data shows that 57%, or four out of seven, of the clinical department
chairpersons possessed the knowledge to know how work performance influences overall
compliance of the organization, which aligns with the literature. Participant three discussed the
importance for healthcare employees to make time to talk about compliance issues saying, “I
think if we're always in a reactive mode and not able to put time away to plan and discuss
compliance issues or other issues, then we can never get ahead and solve our compliance issues.”
Here, the clinical department chairperson was thinking about the benefit of discussing
compliance and using this time for employees to realize the importance of stopping compliance
issues before they start. In answering the question of what abilities they have to help the
organization achieve a high level compliance with healthcare regulations the participant stated
that they allow for time to be afforded to the employees they supervise to help educate them on
the benefits of maintaining compliance.
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Both participants one and four discussed their past experiences working in a private
practice healthcare organization that provided for their abilities in helping the organization
achieve a high level of compliance with healthcare regulations. According to participant one, “I
have 35 years of experience working as a private practitioner in a private specialty practice. I
was the designated Wyoming Department of Health staff dentist who would oversee Medicaid
issues relating to dentistry, recruiting, and credentialing of new dentists.” Participant one
proclaimed that their experience made them very aware of compliance issues, which suggests
that they know how work performance influences overall compliance of the organization.
Having the experience of being in charge of various important activities for previous healthcare
organizations that required maintaining compliance gave this clinical department chairperson the
knowledge of how work performance affects the organizations compliance rate.
Participant four discussed their past experience working in private practice and how this
experience contributed to their abilities to help the organization achieve a high level of
compliance with healthcare regulations. Participant four says, “I think one of the problems in a
government program like this is that you're not in a private practice, so you're not doing the
billing or coding for the organization.” An example the participant provided describes a situation
where the organization divides the billing and coding job duties between two different
departments, but there is no oversight of those duties. Not having an employee designated to
review both billing and coding activities could lead to a major compliance issue for the
organization, according to this clinical department chairperson. With this response, the clinical
department chairperson demonstrated they have the knowledge of how work performance
influences overall compliance of the healthcare organization.
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Participant five relied on their experiences working with regulations that come from
various Federal agencies, such as the Centers for Medicare and Medicaid Services (CMS) and
the Federal Drug Administration (FDA), to answer the question of what abilities they have that
would help the organization achieve a high level of compliance with healthcare regulations. This
clinical department chairperson understood that each clinical department has differences when it
comes to regulations saying, “(The policy is) different for pharmacy, lab, or radiology. That's
why when you (have) multiple policies that is supposed to cover a whole organization you have
to include sub sections so that all regulations are included.” Here, the clinical department
chairperson is well aware that each department is faced with adhering to specific regulations and
stressed that the organization needs to be aware of and help each department work to maintain
compliance with these regulations to help support overall organization compliance. The answer
from this clinical department chairperson showed they know how work performance influences
overall compliance of the organization.
Forty-three percent, or three out of seven, of the clinical department chairpersons could
not fully demonstrate they possessed the knowledge of how work performance influences overall
compliance of the organization. Participant six admitted they struggle to understand what
abilities they have that would help the organization achieve a high level of compliance with
healthcare regulations saying, “I know most of the rules that have to do with my department. I
don't know. I do chart reviews and edits to make sure services meet certain standards but, yeah, I
don't know.” This clinical department chairperson continued to admit they do not have the
awareness of compliance since they do not think about compliance on a continual basis.
Although participant two and eight provided answers that suggest they are aware of some
components of compliance, they did not describe what abilities they have that would help the
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organization achieve a high level of compliance with healthcare regulations. For example,
participant two claimed they have a strong ability to communicate with the providers and staff of
the organization saying, “Um, I think I have a fairly good working relationship with our
providers and with the staff in the in the facility. So, so I can certainly help with
communication.” However, while strong communication can be considered a skill that positively
affects overall compliance, this response from the participant did not describe what other abilities
they possess to help the organization achieve a high level of compliance.
Also, participant eight provided a short answer that suggested they have an ability that
would help the organization achieve a high level of compliance saying, “To conduct internal
audits within the Business/Billing Office and share the findings with my staff and the
organization and if there are problems then come up with a quality improvement plan.” Here, the
clinical department chairperson provided a component of compliance of how to use the results of
a performance audit for productive use. However, they did not further articulate how this audit
applies to the overall organization and how this will help the organization improve its
compliance rate. This short response makes it difficult to say that the participant knows how
work performance influences overall compliance of the organization.
Document analysis. The Compliance Plan document, and related training documents that
NTHC provides to the employees of the organization were analyzed for this section of the study.
Metacognitive knowledge relates to the clinical department chairpersons’ need to know how
work performance influences overall compliance of the organization.
The organization’s Compliance Plan provides for an upfront expectation of employees on
honoring their ethical responsibility by describing the Code of Conduct, which appears at the
front of the document. Under this Code of Conduct section of the Compliance Plan a section
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titled, “Policy of Ethical Practices,” appears and clearly states that the organization is committed
to using the highest ethical and moral standards while providing healthcare to the community. As
such, NTHC expects all employees of the organization to “be knowledgeable of all applicable
Federal and State laws and regulations that apply to and impact upon the organization’s
documentation, coding, billing, medical and business practices, as well as the day-to-day
activities” (“NTHC Compliance Plan,” 2017, p.10). This part of the document provides specific
detail to help the clinical department chairpersons maintain compliance while performing their
work duties by including the language of daily activities.
This section of the Compliance Plan document also encourages the employees to seek
assistance when they are not familiar with all Federal and State requirements by asking a
knowledgeable officer of the organization or reading outside compliance resources. With this
statement, the organization encourages the clinical department chairpersons to fully understand
the purpose of the Code of Conduct and how to maintain compliance with all regulations and
requirements.
In summary, the interview data for this portion of the study indicates that 57%, or four
out of seven, of the clinical department chairpersons possess the knowledge of how work
performance influences overall compliance of the organization. However, only 43%, or three out
of seven, of the clinical department chairpersons did not possess this same knowledge. The
literature is clear that healthcare employees should have an awareness of healthcare compliance
issues and how these issues can affect the day-to-day operations of a healthcare organization.
The data shows that the clinical department chairpersons reached the 51% threshold, which
makes this influence an asset for the organization in this study.
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Furthermore, the organization supplies a Compliance Plan that requires all employees to
fully know and understand the Federal and State laws and regulations that apply to their
operations. The organization encourages their employees to seek help when they do not fully
understand these regulations to better help them maintain compliance in their daily work
routines. Overall, despite all participants not being able to provide what they bring to the
organization to help the organization achieve a high level of compliance, the clinical department
chairpersons understand what the compliance program means for the organization. Table seven
identifies common comments from the participants regarding the assumed declarative,
procedural, and metacognitive knowledge influences.

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Table 7
Participants Common Comments Related to the Assumed Declarative, Procedural, and
Metacognitive Knowledge Influences
Participant Response
One “Understanding what the requirements are and understanding that there are
various agencies and oversight that have to be met in a timely fashion.”
“Well, we have a compliance officer who monitors activities and we also have a
fairly robust credentialing department (that) makes sure that everyone is properly
credentialed in their particular field.”

Two “I don't know that I have a great understanding of how we do it. But as far as I
know, we send an email to our compliance officer with any issues that we have
and then it just snowballs from there.”

Three “The main way we do it is we have an incident, an incident reporting system. So,
the incident reporting system goes to our compliance officer and then it goes up
for review.”

Four “We have a whole set of rules that we follow and review. We have, you know,
outcomes compliance. To me, oftentimes means compliance with the billing sort
of ends of things.”
“So typically we have a compliance committee that meets fairly regularly like
once a month or every couple of months, but you know Covid has kind of made
that much more difficult.”

Five “The big thing (is) policies and procedures … you can have all the policies and
procedures you want, but when you get multiple departments, making multiple
procedures, about the same thing that's where you run into problems with
compliance.”
“There's the overall compliance plan that we all had to sign and read, and it
talks about billing and, you know, maintaining standards and all of those things.”

Six “Okay, yeah. I mean, there's a compliance officer and there's a compliance
training every year and there's mostly policies and procedures, and you know,
there's people that that look over all their different areas.”

Eight “Having processes in place and adhere to them along with policies and
procedures.”
“Currently we have the HIPPA training and policies and procedures written but
not completely approved. We also have a compliance officer and a compliance
team.”

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Results and Findings for Motivation Causes
Several interview questions were asked to assess the motivational influences affecting the
clinical department chairpersons’ ability to implement the healthcare compliance program and
improve the organizations healthcare compliance rate. The results and findings are reported
using the categories of attributions theory and self-efficacy theory and the assumed causes are
included in each category. Table eight shows the motivational influences for this study and their
determination as an asset or need.
Table 8
Motivational Assets or Needs as Determine by the Data
Assumed Motivation Influence

Asset or Need
Attributions Theory

Clinical department chairpersons need to have
attributions theory the most as they are
responsible for educating organizational
employees on healthcare regulatory
compliance issues
Asset - Seven out of seven, or 100%, of the
clinical department chairpersons demonstrate
they meet the motivation influence

Asset - Five out of seven, or 71%, of the
clinical department chairperson demonstrate
they meet the motivation influence

Self-Efficacy

Clinical department chairpersons need to have
the confidence in their job performance to help
achieve the organizational and stakeholder
goals
Asset - Six out of seven, or 86%, of the clinical
department chairperson demonstrate they meet
the motivation influence

Asset - Five out of seven, or 72%, of the
clinical department chairpersons demonstrate
they meet the knowledge influence

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Attributions Theory
Influence 1. The clinical department chairpersons need Attributions Theory.
Interview findings. The first motivational influence included in this study was adaptive
attributions, or attributions theory, as this influence is critical for the clinical department
chairpersons to possess since they are responsible for the education of their employees on
regulatory healthcare issues. According to Rueda (2011), attributions refer to an individual’s
belief in why they succeed or fail at a specific task or activity and just how much control they
contribute towards those results. The literature agrees with the concept that when an individual
views their success or failure as a direct result of the efforts they put forth, the more likely the
individual is to try harder to succeed at completing tasks or activities (Mayer, 2011).
During the interview process the clinical department chairpersons were asked to describe
which qualities should each employee of the organization possess to help achieve compliance
with healthcare regulations and to describe the importance of employee professional
development regarding healthcare compliance issues. Upon analysis of the answers to the
aforementioned questions, the data mostly aligns with the literature showing that seven out of
seven, or 100%, of the clinical department chairpersons were able to provide qualities that each
employee of the organization should possess to help achieve compliance. Also, five out of seven,
or 71%, of the clinical department chairperson could describe the importance of employee
professional development regarding healthcare compliance issues.
Participant three was able to describe the importance of employee professional
development saying, “Yeah, I think professional development goes along with a lot of different
areas and it helps develop understanding of the system as a whole and also helps develop, you
know, leaders and future supervisors.” This clinical department chairperson continued to discuss
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what professional development means for the long-term aspects for both the employee and the
organization in developing future leaders. Furthermore, participant three followed up their
answer with examples of qualities employees should possess to help achieve compliance with
healthcare regulations saying:
It's about learning and growing, and not being perfect. So, we make lots of mistakes. It's
always going to happen every organization makes mistakes. The ones that progress are
the ones that learn from the mistakes. The ones that don't are the ones that hide the
mistakes so employees should be willing to learn and problem solve together, essentially,
and communicate openly in a safe environment.
Here, the clinical department chairperson mentioned two benefits to the organization; the first
was to have employees learn from mistakes that are made and the second was for the
organization to grow from these learning experiences. This participant demonstrated an
understanding of what the employees and the organization need to succeed and not be afraid to
fail and that the organizations that succeed are the same organizations that learn from their
mistakes. This clinical department chairperson agreed with the literature that the more the
employees have control in the outcomes of their successes or failures at tasks the more the
employees will try harder to succeed.
Participant five was also able to describe the importance of employee professional
development regarding healthcare compliance issues saying, “Professional development helps if
they're interested in some of those things and then they want to learn more. Because most places
have some kind of an inspection protocol that happens at some point in their lives.” This clinical
department chairperson was aware that the more the employees learn their respective duties the
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more successful they will be when it comes time for them to demonstrate their skills in an event
such as an inspection.
Also, this clinical department chairperson provided a key quality an employee should
possess to help achieve compliance with healthcare regulations. According to this participant,
“The most important thing is to be honest. For example, you don't provide patient care without
gloves. But, some people are afraid to say something because they don't want to get in trouble.
So, honesty is the best thing.” This participant on the quality of being honest while employees
conduct their duties in the healthcare industry and is able to provide examples of what should not
be done and how other employees may not handle situations in positive ways. This clinical
department chairperson highlighted that if one employee hesitates to be honest that creates a
domino effect among the employees in not doing the right thing, which can negatively affect
overall compliance of the organization. This clinical department chairperson was able to point
out that for employees to be successful at their tasks or activities they need to have control in
affecting those outcomes.
Both participants one and four briefly described the importance of employee professional
development regarding healthcare compliance issues, but did not provide any examples to
articulate their discussions. Participant one says, “Well, I think that continuing education is very
important in helping make the day-to-day routines and functions and maintaining compliance.
We make certain that people are up to date on their requirements for educational requirements.”
Similarly, participant four says, “Over the years we've done sort of trainings on this is what you
need for this billing code. This is what you need for that billing code. It's constantly trying to
update staff on what those rules mean.” Both clinical department chairpersons have an idea of
the importance of professional development, but neither of these participants provided specific
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examples of what employees could learn to help them grow regarding healthcare compliance
issues.
However both of these clinical department chairpersons were able to provide qualities
that employees should possess to help achieve compliance with healthcare regulations.
Participant four says, “A willingness to learn and to willingness to comply with what we, you
know, with the regulations that are put in place.” Although this clinical department chairperson
did not elaborate on the willingness they mention, they did urge learning about regulations that
affect the organization. Also, participant one says, “I think charging people in the department
with areas that they would be responsible for. For example, a dental assistant would be
responsible for sterilization of instruments and treatment areas while another employee can
update the policy and procedure manual.” Here, the clinical department chairperson was thinking
about how to create more responsibility among the employees to help understand the nature of
compliance. By giving more responsibility to each employee, this participant appeared to be
attempting to increase their employees’ ability to be successful at achieving compliance with
healthcare regulations.
When it comes to the clinical department chairpersons providing the qualities employees
should possess to help achieve compliance with healthcare regulations, all seven participants
were able to provide examples of what qualities are needed. For example, participant two says, “I
would say honesty is quite important as is, accountability, and good communication.” Participant
six adds, “The biggest one I think is probably just wanting to do a good job because, I mean,
hopefully rules are there to help make sure everything stays safe and effective.” Finally,
participant eight says, “Continuing education, changes to processes especially those that do not
work, changes to policies and procedures and to abide by these changes.” All of the clinical
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department chairpersons provided rather short answers, but were able to communicate qualities
they felt that employees should possess to help achieve compliance with healthcare regulations.
None of the participants elaborated or provided examples to help illustrate their responses, but
their answers pointed to what the employees need to be successful at their tasks or activities.
Furthermore, both participants two and six were not able to describe the importance of
employee professional development regarding healthcare compliance issues. Participant two
mentioned what is needed from the employees to help spur development saying, “To get a good
understanding of what's expected of them. You know, the one thing that I think is hindering
development is when people don't really know what to expect.” This clinical department
chairperson did not stress any importance of professional development, but rather what is needed
to help the employee think about developing. Also, participant six mentioned that knowing the
rules is important saying, “Yeah, I mean, I think, you know, if you want your employees to
follow the rules then they have to know what they are, and I definitely think that's important.”
This clinical department chairperson suggested understanding rules is important, but fails to
describe the importance of professional development. Both of these clinical department
chairpersons did not provide the importance of employee professional development regarding
healthcare compliance issues or how this deficiency could lead the employees to fail in
completing their tasks or activities successfully.
Document analysis. The Compliance Plan that NTHC uses to help guide the employees
on healthcare compliance as well as the related training documents were used for analysis in this
part of the study. The first motivational influence was the clinical department chairpersons need
attributions theory as it is critical for them to educate their employees on healthcare regulatory
compliance issues.
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The Compliance Plan provides a section dedicated to managers and supervisors that
describe the responsibilities as they relate to healthcare regulatory compliance. NTHC stresses to
their managers and supervisors the importance of compliance for the employees and the
organization in this section. The clinical department chairpersons are technically managers and
supervisors and the organization provides the information that maintaining compliance is a
mandatory part of evaluating the performance of their managers and supervisors (“NTHC
Compliance Plan,” 2017).
There are a total of seven responsibilities that are detailed within the
Managers/Supervisor Responsibilities section of the Compliance Plan. The responsibilities
include completing annual trainings on information systems, ensure all of the employees they
supervise read and sign compliance acknowledgement forms, fulfill discussions with employees
on compliance policies as they relate to the organization, and make sure all employees know that
compliance training is an important part of their employment. The responsibilities continue by
informing the clinical department chairpersons that all employees need to understand that
disciplinary actions will be enforced on any employee who knowingly or unknowingly violate
the compliance requirements. Finally, the responsibilities sections inform the clinical department
chairpersons that they need to pay attention to any and all revisions to the Compliance Plan and
that they need to inform the Compliance Officer of any new employees that have joined the
organization (“NTHC Compliance Plan”, 2017).
In summary, the data from the interview process of this influence shows that while there
are seven out of seven, or 100%, of the clinical department chairpersons who are able to provide
qualities that each employee of the organization should possess to help achieve compliance, there
are five out of seven, or 71%, of the clinical department chairperson that can describe the
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importance of employee professional development regarding healthcare compliance issues. The
literature agrees with the concept of attributions theory in that when an individual sees their
success or failure as a direct result of their efforts, the more likely the individual is to try harder
to succeed at completing tasks or activities (Mayer, 2011). The interview data shows that the
clinical department chairpersons understand this influence and want to educate their employees
on healthcare compliance issues.
The organization’s Compliance Plan provides to the clinical department chairpersons the
responsibilities they are expected to follow to help the organization achieve compliance. There
are specific responsibilities and the document also provides the consequences if these
responsibilities are not met. The organization stresses to the clinical department chairpersons that
compliance is a critical component in their annual evaluations, which provides for the motivation
to educate the employees on the importance of achieving and maintaining healthcare regulatory
compliance.
Self-Efficacy
Influence 1. The clinical department chairpersons need Self-efficacy Theory.
Interview findings. The second motivational influence included in this study and that the
clinical department chairpersons need to achieve the organizational and stakeholder goals is self-
efficacy theory. According to Rueda (2011) self-efficacy is described as the belief that the more
an individual believes in their competence and expectations for positive outcomes, the higher
their motivation will be to complete tasks and activities with more engagement, persistence, and
hard work. Also, Parajes (1996) agrees that self-efficacy is the inner belief an individual
possesses regarding competent capabilities to complete tasks, or perform functions, at a high
desired level. The literature reinforces this concept in that, historically, when AI/AN tribal
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nations take over the delivery of healthcare to their reservation communities the residents of
those communities have witnessed an improvement in health outcomes overall (Walker, 2019).
During the interview process the clinical department chairperson were asked two
questions regarding self-efficacy including: how would a robust healthcare compliance program
support maintaining or increasing compliance on an organization-wide level and what benefits
do you think might be associated with increased compliance rates. The data showed that six out
of seven, or 86%, of the clinical department chairpersons could describe how a robust healthcare
compliance program could support maintaining or increasing compliance rates on an
organization-wide level. The data also revealed that five out of seven, or 72%, of the clinical
department chairpersons could provide what benefits they think might be associated with
increased compliance rates. Both of these positive results align with the literature on self-efficacy
and make this influence an asset in this study.
Participant five provided good examples of both a robust healthcare compliance program
that supports maintaining or increasing compliance rates and the benefits they believed might be
associated with increased compliance rates. According to participant five, “You can have yearly
seminars introducing everybody to everything and have them take a test on key points that are
part of compliance. But, that always doesn't work very well because sometimes in the translation,
things aren't quite the same.” Here, this clinical department chairperson provided suggestions on
how a compliance program can address compliance issues to help all employees learn. For the
organization to offer annual seminars on compliance and have employees test on the compliance
subject matter is a good way to motivate employees to not only be aware of compliance issues,
but to better complete their duties, tasks, and activities successfully. This participant also
suggested that these activities should be handled by a quality department and be taught from a
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top down approach to avoid any miscommunication. These suggestions from the participant
provided examples on how a robust healthcare compliance program would support maintaining
or increasing compliance rates on an organization-wide level.
Furthermore, participant five pointed out that,
If you have a healthcare facility, and they're passing their inspections, and they have
documentation of the things they're doing, and people are buying into doing, you know,
whether it's washing their hands or doing the other things that increases the likelihood
that they're going to be compliant on other types of issues that come up.
Here, the clinical department chairperson spoke to the effects of preparing employees to be more
efficacious in performing their tasks or activities and how this could lead to more compliant
outcomes from all employees. The participant provided a great benefit that they think might be
associated with increased compliance rates, which is increasing the probability of healthcare
employees to be more compliant in completing their tasks, duties, and activities. The higher the
compliance rates of the organization, the more likely the employees will work with the mindset
of being compliant when performing their work duties.
Other good examples about a robust healthcare compliance program and how it would
support maintaining or increasing compliance on an organization wide level came from
participant three. This participant says, “I think a compliance program is the ability to see the
repeated issues and repeated mistakes and so by having that compliance team in place, they can
communicate to the CEO, or administration, what's happening.” Here, this participant was able
to think about the organization’s compliance program and how it can be more effective in
addressing compliance issues on an organization wide scale. More specifically, the compliance
program could provide direct communication to the administration of the organization to help
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alleviate mistakes that might otherwise continue and potentially hurt the organization’s
compliance rate.
Furthermore, participant three provided examples of the benefits they think might be
associated with increased compliance rates saying, “Patient satisfaction and employee
satisfaction in both of those would increase productivity. You're able to build this larger more
complicated program when people understand the compliance issues.” With this response, this
participant mentioned how patient and employee satisfaction can increase productivity as well as
how the work atmosphere can be more enjoyable for the employees, which translates to
improved patient care. This clinical department chairperson gave great examples of benefits they
think might be associated with increased compliance rates as they relate to the self-efficacy that
they need to help achieve the organizational and stakeholder goals of this study.
Participants one, four, six, and eight all provided answers that point to having the right
components for a robust healthcare compliance program and how it would support maintaining
or increasing compliance on an organization wide level. Participant one says, “Having
knowledgeable and experienced compliance officers” is a critical element to include in the robust
healthcare compliance program and participant eight agrees saying, “Having a compliance
officer that is knowledgeable of the continuing changes in healthcare.” Participants four and six
both suggested other positions within the organization that should be a part of the robust
healthcare compliance program saying, “I think it starts with the (compliance) committee in
identifying problems and training of new people who are coming in” and “I think training
supervisors (on) how to coach and manage some of those some things,” respectively. These
responses from the clinical department chairpersons demonstrated they have a common approach
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to self-efficacy to help achieve both the organizational and stakeholder goals of this
improvement study.
When discussing the benefits that could be associated with increased compliance rates,
participants one, four, and six focused on how the organization receives the benefits, overall.
Participant one says, “A high level of comfort with auditing.” Participant four claims, “If you get
your compliance stuff down, you're less likely to have to do work to fix problems, you know, to
go back and spend time and energy trying to do things that you've done.” Finally, participant six
states, “Well, hopefully better patient outcomes.” All three clinical department chairpersons were
looking at the benefits that affect the organization and not just the employees alone. However, by
providing these responses the participants showed that they were thinking of how increased
compliance rates can affect the self-efficacy of the employees of the organization to help achieve
the organization and stakeholder goals of this study.
Overall, the clinical department chairpersons were able describe how a robust healthcare
compliance program could support maintaining or increasing compliance rates on an
organization-wide level.
Document analysis. The Compliance Plan and related training documents that NTHC
uses to inform the employees on healthcare compliance were used for analysis in this part of the
study. The second motivational influence is the clinical department chairpersons need self-
efficacy theory to help achieve the organizational and stakeholder goals of this study.
A section within the Compliance Plan provides disciplinary actions for any employee
who violates the organization’s code of conduct. The first paragraph of this section includes the
language, “Disciplinary actions will be consistently enforced, including discipline of individuals
responsible for the failure to detect an offense” (“NTHC Compliance Plan,” 2017, p.26). Here,
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the document tries to enforce a way of thinking among their employees to be more self-
efficacious. The disciplinary measures described in this section of the document address
violations that an individual both knowingly or unknowingly commits.
The level, or severity, of the violation dictates the degree of the disciplinary action that
applies to the employee who commits the violation, according to the Compliance Plan. Also, the
clinical department chairpersons are made aware of these disciplinary actions and what is
expected of them regarding the misconduct of their employees. The clinical department
chairpersons need to ensure the employees receive compliance training, are encourage to self-
disclose misconduct, and that adherence to the Compliance Plan can be included in their
performance evaluations (“NTHC Compliance Plan,” 2017). These disciplinary actions are
described in an effort to motivate the clinical department chairpersons to motivate their
employees to be more self-efficacious in completing their tasks, activities, and duties.
In summary, the second motivational influence analyzed in this study was that the clinical
department chairpersons need self-efficacy theory to help achieve the organizational and
stakeholder goals. The interview data reveals that 86%, or six out of seven, of the clinical
department chairpersons were able to describe how a robust healthcare compliance program
could support maintaining or increasing compliance rates on an organization-wide level. Also,
five out of seven, or 72%, of the clinical department chairpersons could provide what benefits
they think might be associated with increased compliance rates.
The analysis of the Compliance Plan document from NTHC revealed that the
organization tries to motive the clinical department chairpersons to be more self-efficacious
when it comes to being compliant in completing their tasks, activities, and duties. The document
outlines the disciplinary measures that take affect if any of the employees knowingly or
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unknowingly commit a violation while performing their duties. The clinical department
chairpersons are held to a higher standard in regard to these disciplinary measures as adherence
to compliance is a component of their performance evaluation. This approach appears to be a
tactic from the organization to motivate the clinical department chairpersons to be more aware of
compliance with respect to self-efficacy.
Overall, the positive results from the interview data, combined with the reinforcement of
disciplinary actions against the clinical department chairpersons from the organization’s
Compliance Plan, suggest that this portion of the study aligns with the literature on self-efficacy
theory thereby making this influence an asset within this study. Table nine identifies common
comments from the participants regarding the assumed attributions theory and self-efficacy
motivation influences.

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Table 9
Participants Common Comments Related to the Assumed Attributions Theory and Self-efficacy
Motivation Influences
Participant Response

One “Well, I think that continuing education is very important in helping make the
day-to-day compliance.”

Two “I would say honesty is quite important as is accountability and good
communication.”

Three “Yeah, I think professional development goes along with a lot of different areas
and it helps develop understanding of the system as a whole and also helps
develop leaders and future supervisors.”
“It's about learning and growing, and not being perfect.”
“Patient satisfaction and employee satisfaction in both of those would
increase productivity.”

Four “Over the years we've done sort of trainings on this is what you need for this
billing code and this is what you need for that billing code.”
“A willingness to learn and to willingness to comply with the regulations that are
put in place.”
“Well hopefully better patient outcomes.”

Five “Professional development that helps with if they're interested in some of those
things and then they want to learn more.”
“The most important thing is to be honest. If you have an employee who looks
the other way, when they know that somebody is walking around on and say, for
instance, drawing blood with no gloves on that's a no-no. You don't do direct
patient care handling fluids without gloves. But some people are afraid to say
something because they don't want to get in trouble. And so Honesty is the best
thing.”
“You can have yearly seminars and show and introduce everybody to
everything and have them take a test on key points that are part of compliance.”

Six “I think training supervisors (on) how to coach and manage some of those
some things.”

Eight “Continuing education, changes to processes especially those that do not work,
changes to policies and procedures and to abide by these changes.”

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Results and Findings for Organization Causes
Several interview questions were asked to assess the organizational influences affecting
the clinical department chairpersons’ ability to implement the healthcare compliance program
and improve the organizations healthcare compliance rate. The results and findings are reported
using the categories of cultural models and cultural settings and the assumed causes are included
in each category. Table 10 shows the organizational influences for this study and their
determination as an asset or need.
Table 10
Organizational Assets or Needs as Determine by the Data
Assumed Organization Influence

Asset or Need
Cultural Models

The organization needs a culture of continual
improvement
Need – Two out of seven, or 29%, of the
clinical department chairpersons indicate the
organization could not meet the influence

Need - Seven out of seven, or 100%, clinical
department chairpersons indicate the
organization meets the influence

Cultural Settings

The organization needs regular and periodic
training programs
Need – Seven out of seven, or 100%, of the
clinical department chairpersons indicate the
organization could not meet the influence

Need – Seven out of seven, or 100%, of the
clinical department chairpersons indicate the
organization meets the influence

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Cultural Models
Influence 1. The organization needs a culture of continual improvement.
Interview findings. The first organizational influence in this study focused on cultural
models and, more specifically, that the organization needs a culture of continual improvement.
Rueda (2011) posits that cultural models refer to the common rational representation of how the
world should work and are used to characterize an organization, its business setting, and even
individuals. Also, cultural models themselves are characterized as dynamic traits and are
expressed through cultural practices, such as behaviors or rules, of the organization (Rueda,
2011). The literature advocates that with respect to healthcare compliance issues, as well as
protecting the available resources to the healthcare organization, the leadership of the
organization should take the time to ensure that the organization continues to improve to remain
in compliance with all applicable laws (Shuren, 2001).
The clinical department chairpersons were asked to describe how the organization
provides support to its employees to create an atmosphere of compliance and what would the
organization need to provide to allow for their continued improvement with healthcare
compliance issues. The interview data shows that only two out of seven, or 29%, of the clinical
department chairpersons were able to describe how their organization provides support to its
employees to create an atmosphere of compliance, which does not align with the literature.
However, in contrast, 100%, or seven out of seven clinical department chairpersons were
able to provide what the organization would need to provide to allow for their continued
improvement with healthcare issues, aligning with the literature. This stark difference in the data
reveals that the organization has a gap in their ability to provide the support to create an
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atmosphere of compliance for their employees making this organizational influence a need
within this study.
In regard to the first question to describe how the organization provides the support to
create an atmosphere of compliance, participant two explains, “We have a compliance officer
that's available at one of our sites. Our clinical supervisor tends to really promote people being,
you know, forthcoming and honest on scenarios and not really being scared of repercussions.”
Here, the clinical department chairperson acknowledged the availability of the compliance
officer of the organization and that they can rely on the clinical supervisor to be supportive of
their efforts to remain in or achieve compliance with their job duties. According to this
participant, these types of support factors from the organization can lead to an atmosphere of
compliance.
Participant three provided a similar response regarding the support of the organization
promoting a compliance atmosphere saying, “I think just by dedicating a team and allowing
compliance to pull members for the team from different departments I think that's the main way
they have that support from the administration.” This answer from the clinical department
chairperson revealed that the organization puts forth a good effort in how they support the
employees in creating an atmosphere of compliance. Dedicating a team made up of members
from the various clinical departments of the organization indicated a strong support for
compliance to be an important subject on which the employees should focus. This effort from the
organization was a strong support measure to create an atmosphere of compliance.
Five of the participants did not agree with the previous two clinical department
chairpersons on how the organization provides support to its employees to create an atmosphere
of compliance. For example, participant five talked about how the organization does not take a
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good approach to teaching compliance saying, “They come around and do an inspection and say
you're not doing this, you're not doing that. And that I find detrimental because people do not
respond to critics criticism very well.” Here, the clinical department chairperson discussed the
inability of the organization to provide constructive criticism to help the employees understand
why they need to be better at certain duties to create the atmosphere of compliance the
organization needs.
Participant four discussed current worldwide events that may contribute to the
organization’s ability to create an atmosphere of compliance saying, “Not sure we do a great job
of that particularly right now with Covid going on. I think it's something that we need to pay
more attention to.” This clinical department chairperson refers to the Novel Coronavirus, or
COVID-19, pandemic that has disrupted the operations of so many industries, especially the
healthcare industry, as the driving factor to ignore compliance and focus on safety measures for
patients instead. This participant referenced the current pandemic caused by COVID-19 as an
obstacle for the organization to fully provide support to the employees to create an atmosphere of
compliance. One of the limitations this participant mentioned is the fact that the organization has
moved all communication through email and not many in-person activities have resumed since
the COVID-19 pandemic began, which has limited the employees’ interaction at the
organization. This participant questioned how many employees truly read all of their email
messages. This limitation can be an understandable reason behind the organization’s inability to
create a culture of continual improvement.
Participants one, six, and eight did not provide enough detail or examples of how the
organization provides support to the employees to create an atmosphere of compliance.
Participant one says, “I think maybe that's where I find that a certain level of comfort is knowing
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exactly what my compliance requirements are, understanding the law, understanding our local
policies and procedures.” This response from the clinical department chairperson was rather
short and mentioned only what they think should be the supportive measures from the
organization.
Participant six says, “Well, there's the compliance officer you can ask questions, too, and,
yeah, I think they probably have our policies and procedures posted.” Again, the clinical
department chairperson provided what they think the organization does to provide the support to
create an atmosphere of compliance. The participant could not, however, provide specific
measures the organization takes to help the employees work in a compliant atmosphere.
Lastly, participant eight provided a rather short response saying, “Employee’s feel they
can submit their complaint without being chastised and the complaints are investigated by the
compliance officer.” Here, this clinical department chairperson discussed the procedure of
reporting and how the employees can feel when filing a complaint. They did not, however,
provide any details on how this example could lead the organization to create an atmosphere of
compliance.
When the clinical department chairpersons were asked what the organization would need
to provide to allow for their continued improvement with healthcare compliance issues, seven
out of seven provided a response that suggested that they know what they need from the
organization to address this issue. From the answers collected, there were three common themes
that were discovered in the data. The clinical department chairpersons all agree that the
organization needs to provide clear and approved policies and procedures on healthcare
compliance, time for all employees to learn about healthcare compliance, and adequate staffing
of the organizations compliance program.
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Participant five provides one of the best responses to this question saying, “The most
important thing is time. It takes time to do all of the things that you need to do. That's the thing
that's most important giving people time to do what you ask of them.” Here, Participant five
explained that time and staffing are the more important assets an organization can provide to
help the employees improve on healthcare compliance issues. This clinical department
chairperson suggested that if the organization expects the employees to improve on healthcare
compliance then the organization needs to dedicate the time to educate the employees and the
staff to provide that education.
In a similar response, participant three mentioned that time and adequate resources are
the important components the organization can provide to the employees to help improve on
healthcare compliance issues. Also, this clinical department chairperson mentioned the current
global pandemic caused by COVID-19 as a reason to be even more concerned about improving
on healthcare compliance issues saying, “I think adequate staffing and commitment of resources.
Because when staffing levels fall short, especially during Covid, then that program is one of the
first to just kind of be put on hold and that has consequences long term.” Again, the clinical
department chairperson suggested that this concern regarding possible staffing shortages due to
the COVID-19 pandemic could lead to either the organization reducing its commitment to
improving on healthcare compliance issues or ensuring it has enough staff to address the issue of
maintaining compliance with healthcare regulations.
Lastly, participant eight stressed having strong policies and procedures. Participant eight
says, “Having all policies and procedures to be approved first of all and continuing education on
compliance changes and updates.” Here, the clinical department chairperson suggested that the
organization can provide both approved policies and procedures and continued education on
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compliance issues as a means to promote a culture of continued improvement. According to this
participant, these two commitments from the organization can help the employees improve on
healthcare compliance issues.
Document analysis. The Compliance Plan from NTHC and the related training
documents that are used to inform the employees on healthcare compliance were used for
analysis in this part of the study. The first organizational influence focuses on cultural models
and that the organization needs a culture of continual improvement.
The Compliance Plan has a section that provides procedures for the proper management,
reduction, or elimination of conflicts of interests that could develop among the organizations
employees. The process begins with the identification of a conflict of interest involving an
employee and how the Compliance Officer will notify both the employee and the employee’s
supervisor. The Compliance Officer and the supervisor will work together to determine what
actions are necessary to manage, reduce, or eliminate the conflict of interest. In more serious
matters involving a conflict of interest the Compliance Officer will notify the Compliance
Committee, or higher authority, to determine what level of the conflict and the appropriate
actions to take to resolve the conflict of interest. No matter the outcome of the conflict of interest
the employee will be notified of the conditions and restrictions applied to them to effectively
manage, reduce, or eliminate the conflict (“NTHC Compliance Plan,” 2017).
Based on the procedures detailed in the Compliance Plan, the organization contributes to
the employees continued improvement on healthcare compliance issues. By identifying the
potential conflicts of interests that could exist among the employees, the organization is, in
effect, coaching the employees to be aware of such conflicts and how the conflicts will be
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addressed. This action from the organization allows for the employees to improve on healthcare
compliance issues.
In summary, the interview data from this organizational influence reveals that only two
out of seven, or 29%, of the clinical department chairpersons were able to describe how their
organization provides support to create an atmosphere of compliance. While 100%, or seven out
of seven clinical department chairpersons, were able to describe what the organization would
need to provide to allow for their continued improvement with healthcare compliance issues. The
data shows that the organization has a gap in their ability to create a compliance atmosphere for
the employees despite having 100% of the clinical department chairpersons having the ability to
identify what the organization can provide to the employees to help improve on healthcare
compliance issues. This finding makes the first organizational influence a need within this study.
Analysis of the Compliance Plan of NTHC shows the organization puts forth an effort to
help the employees continuously improve on healthcare compliance issues. The organization
addresses the procedures to properly manage, reduce, or eliminate any conflicts of interests that
may exist among the employees. These procedures apply to all employees and help them
understand their involvement in the organizational compliance efforts. By allowing the
employees to learn what constitutes a conflict of interest and what needs to happen to effectively
address the situation the organization is demonstrating how the employees can improve on
healthcare compliance issues.
Cultural Settings
Influence 1. The organization needs regular and periodic training programs.
Interview findings. Cultural settings were the second organizational influence in this
study and focuses on the organizations need to have regular and periodic training programs.
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Rueda (2011) asserts that cultural settings are the concrete versions of what is commonly
referred to as a social context as they answer who, what, when, where, why, and how of the
practices that make up our daily routines. Additionally, training is typical in teamwork and
process analysis as well as looks at specific content, such as techniques, to build trust among
team members based on the separate skills of each team member (Clark & Estes, 2008). The
literature states that healthcare delivery gaps are often related to a racial divide that exists
between patients and the healthcare professional to where the healthcare professional does not
make an effort to understand the cultural aspects of the patient to provide proper care (Purtzer &
Thomas, 2019).
The clinical department chairpersons were asked to describe an ideal compliance training
program provided by the organization and how would healthcare compliance training benefit
their abilities to maintain or increase the overall compliance rate of the organization. The
interview data shows that seven out of seven, or 100%, of the clinical department chairpersons
could not provide a description of an ideal compliance training program that is provided by the
organization. Conversely, 100%, or seven out of seven clinical department chairpersons could
provide how healthcare compliance training would benefit their abilities to maintain or increase
the overall compliance rate of the organization. The data shows that a need does exist within the
second organizational influence within this study.
Regarding the first question, all seven participants provided similar responses describing
an ideal compliance training program that the organization could provide, not necessarily what
the organization is currently providing. For example, participant three says, “I think the ideal
program is to have the committee and then to assign tasks to the committee members, and then
they can report back to the committee. Basically, have compliance measurements and
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assignments and essentially all it quality improvement.” Here, this clinical department
chairperson discussed a procedure to incorporate more participation from the compliance
committee in a manner that is conducive to strengthening the compliance program. The
discussion suggested that these types of actions from the compliance program are not currently
happening and this participant feels these actions will help the organization overall with
addressing compliance concerns.
Participant five stated that the organization had compliance training in place before the
organization started to grow in size saying, “At one point, before we got so big, we had
compliance meetings where we got to talk to the people who were putting together the
compliance program. We haven't had time to do that in a couple of years.” In this response, this
clinical department chairperson explained that the organization made a previous effort to provide
compliance training that included the employees. However, according to this participant, these
compliance trainings have not taken place for a couple of years. This clinical department
chairperson did not provide any discussion on why these compliance training, or activity,
stopped taking place.
Participant six gave a response that suggests there is a compliance training currently
happening, but talked about ways to improve the current model. Participant six states, “I think
they're fine. I think probably the big thing would be to have it less focus on like the one
mandatory training a year and probably more thoughtful conversation throughout.” Here, this
clinical department chairperson discussed their experience participating in an annual training
concerning healthcare compliance and suggests that this effort was not enough to keep the
employees thinking about compliance over a longer period of time. This participant continued to
offer a solution making the compliance training more engaging and beneficial for the employees
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over the course of the year and not offer a single annual training. The organization offers
compliance training, but it appears this training may not provide substantive material to keep the
employees educated on compliance issues.
Participants one, two, four, and eight all provided answers that suggest the organization
should offer compliance training that benefits the employees in more effective ways. For
example, participant one says, “I think maybe interaction with the presenters. Examples of non-
compliance that are germane to, you know, to our particular situation.” Participant two suggested
more time for comprehension saying, “I would say just one that gives us time to absorb the
information and then maybe re-address later because it seems like often we will go through, you
know, issues quickly and then they go into the background.” This participant suggested having
periodic iteration of the compliance material may help employees improve on maintaining
compliance.
In a suggestion provided by participant four, the compliance training should be provided
by an individual who is proficient in healthcare compliance saying, “Make sure that you have
somebody who's well trained in and well versed in the compliance and in the rules.” Lastly,
participant eight says, “First step during orientation is to take the new employees to all facilities,
plus provide them with a list of individuals they could call for questions related to the various
departments.” This clinical department chairperson discussed the high probability of employees
retaining the training information when it is taught by an individual who is highly proficient in
healthcare compliance. Lastly, participant eight suggested a more hands-on approach saying the
training could allow for the employees to tour the healthcare facility and provide those
employees with resources from each department should they have any compliance concerns with
any of those departments. This clinical department chairperson also suggested this activity be
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focused on individuals who are new hires of the organization and how it would benefit them to
know on whom they can rely when it comes to compliance matters.
When asked how healthcare compliance training would benefit their abilities to maintain
or increase the overall compliance rate of the organization, seven out of seven, or 100%, of the
clinical department chairpersons answered in a way that suggested they are well aware of the
benefits of healthcare compliance training. Participant three provided a response that included
benefits for both the employees and the organization saying, “I think it would help if it was
focused on the site and if it was succinct. I think generic compliance training on a large scale
that's an hour or so long is minimally effective.” Here, this clinical department chairperson
mentioned that the compliance training would be more helpful if the training incorporated a
component that focused on the organization and not solely on universal compliance issues. The
concern of this participant was focused on the effectiveness of the compliance training and how
the benefits of the training could be increased for both the employees and the organization.
Participant eight also spoke to the benefits for the organization by describing an
understanding of what needs the employees have regarding healthcare compliance. According to
participant eight, “The more compliance training given to this organization will provide the tools
necessary to recognize the areas needing improvement. These areas may consist of developing
employee education and training programs.” This clinical department chairperson wanted
compliance training to be the means in which the organization improves its problem areas. This
participant felt that, with the help of compliance training, the organization could improve various
areas of operations to develop compliance comprehension and educate employees on compliance
issues.
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Participant four described how compliance training would benefit their abilities in a
couple of ways saying, “Well, I think in two ways. One, it would help me make sure that I'm in
compliance with my duties. And then as (clinical department chairperson) would help me to
counsel other providers on how they can do the scenes.” Here, the clinical department
chairperson is maintaining compliance in their own roles within the organization. This
participant was looking at both their own benefits as well as how they can use those benefits to
help other employees in the organization. This answer, although short in nature, provided a great
deal of thought from the participant about how compliance training would benefit their abilities
to maintain or increase the overall compliance rate of the organization.
Participants five and six provided answers that focused on the structure and specifics of
compliance training and felt that the training should be taught with this specified focus in mind.
Participant five says, “More structure, I guess, is what I think would help a lot because people
don't, you know, they'll get a deer in the headlight look when you mention compliance.” Also,
participant six states, “More specifics on our biggest payers such as Medicaid, you know,
making sure we know all the Medicaid rules.” Here, these two clinical department chairpersons
were concerned about the structure of the compliance training as well as teaching specific
compliance regulations regarding the organizations largest revenue source, Medicaid. These two
participants suggested that employees will be less confused when the subject of compliance is
discussed with a more defined structure and are provided specific compliance regulations. With
their responses, these clinical department chairpersons discussed how compliance training would
benefit their abilities to maintain or increase the overall compliance rate of the organization.
Participants one and two provided answers that reflected consistency and subjects of
importance regarding compliance training. Participant two says, “If we get do it consistently I
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think that we all have a good idea of what's expected of us. And, if we can follow those
guidelines, hopefully, we'd be a little more efficient in providing healthcare for our patients.”
Participant one adds, “Having staff really understand what compliance is, number one, and what
issues are most important to us in our organization. You know, examples may include cultural
awareness, for example.” With these responses, both clinical department chairpersons were
concerned with the amount of compliance trainings that are given to the employees over time
and what subject material is offered during compliance trainings. Participant two and one
brought to mind the need for more discussion on compliance with both how much employees
receive and what is discussed regarding compliance matters important to the employees. Both
clinical department chairpersons were able to discuss how compliance training would benefit
their abilities to maintain or increase the overall compliance rate of the organization.
Document analysis. NTHC has a Compliance Plan and related training documents that
are available to the employees on healthcare compliance and were included in this analysis
section of this study. The second organizational influence focuses on cultural settings and, more
specifically, that the organization needs a culture of continual improvement.
Within the Compliance Plan, there is a section that is titled, “On-Going Education and
Training” and includes that training and education will provide employees an explanation and
applicability of Federal regulations that apply to healthcare organizations. These regulations are
Federal legislation including the False Claims Act, the Social Security Act, the Federal Anti-
Referral Laws, the Anti-Kickback Laws, and Health Insurance Portability and Accountability
Act (HIPAA) Laws. NTHC requires that the education and training is mandatory and encourages
interactive participation from all employees during the training (“NTHC Compliance Plan,”
2017).
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NTHC employs a Compliance Officer, according to the document, who determines each
employee’s level of instruction required regarding the ethical and legal standards including the
aforementioned Federal regulations as well as organizational standards, such as coding, billing,
and business practices. The document mentions that the each employee is strongly encouraged to
comply with the Compliance Plan and with all laws that apply to the organization to maintain
their employment. Also, the document reminds the clinical department chairpersons that it is
their responsibility to ensure the employees comply with the Compliance Plan. Lastly, the
document requires that all employees sign an acknowledgement statement that they have
received the training on an annual basis (“NTHC Compliance Plan,” 2017).
In summary, regarding this organizational influence, the interview data shows that seven
out of seven, or 100%, of the clinical department chairpersons do not provide a description of an
ideal compliance training program that is provided by the organization. Conversely, seven out of
seven, or 100%, of the clinical department chairpersons could provide how healthcare
compliance training would benefit their abilities to maintain or increase the overall compliance
rate of the organization. A gap does exist from the organization in their ability to provide an ideal
compliance training program for the employees to gain important education and training on
healthcare compliance. The clinical department chairpersons, however, know exactly how
effective compliance training would help them maintain or increase the overall compliance rate
of the organization. This contrast in the data makes this organizational influence a need within
this study.
The Compliance Plan and related training documents provided by NTHC requires
mandatory annual compliance training on healthcare regulations for all employees. The
document states that the organization will ensure the annual compliance training will include
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education on various Federal regulations that are pertinent to healthcare regulations. The
Compliance Plan also mentions that the training will be tailored to each employee based on their
need regarding ethical and legal education on healthcare compliance. Although NTHC has this
section included in the Compliance Plan, the interview data suggests that the organization does
not provide this training as outlined. Table eleven identifies common comments from the
participants regarding the assumed cultural models and cultural settings organization influences.

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Table 11
Participants Common Comments Related to the Assumed Cultural Models and Settings
Organization Influences
Participant Response

One “Having staff really understand what compliance is number one, and what
issues are most important to us in our organization. You know, examples may
include cultural awareness, for example.”

Two “We have a compliance officer that's available at one of our sites. Our clinical
supervisor tends to really promote people being forthcoming and honest on
scenarios and not really being scared of repercussions.”
“If we get do (the training) consistently I think that we all have a good idea of
what's expected of us. And, if we can follow those guidelines, hopefully, we'd be
a little more efficient in providing healthcare for our patients.”

Three “I think adequate staffing and commitment of resources.”
“I think it would help if (the training) was focused on the site and if it was
succinct. I think generic compliance training on a large scale that's an hour or so
long, that I think that's minimally effective.”

Four “Not sure we do a great job of that particularly right now with Covid going on.
I think it's something that we need to pay more attention to.”
“Make sure that you have somebody who's well trained in and well versed in the
compliance and in the rules.”

Five “They come around and do an inspection and say you're not doing this, you're
not doing that. And that I find detrimental because people do not respond to
critics criticism very well.”
“More structure, I guess, is what I think would help a lot because people don't,
you know, they'll get a deer in the headlight look when you mention
compliance.”

Six “There's (the) compliance officer you can ask questions to and I think they
probably have our policies and procedures posted.”
“More specifics on like, Medicaid, you know, making sure we know all the
Medicaid rules.”

Eight “Employee’s feel they can submit their complaint without being chastised and
the complaints are investigated by the compliance officer.”
“Having all policies and procedures to be approved first of all and continuing
education on compliance changes and updates.”
“The more compliance training given to this or any other organization will
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provide the tools necessary to recognize the areas needing improvement. These
areas may consist of developing written standards of conduct, written
policies and procedures and/or changes, developing employee education and
training programs, developing effective ways of communication and
developing corrective action plans for all non-compliant issues within our
organization.”

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CHAPTER FIVE: RECOMMENDATIONS
Introduction and Overview
This chapter discusses the recommendations for the assumed Knowledge, Motivation,
and Organizational (KMO) influences identified in this study. The recommendations are
grounded in a principle from a theory that corresponds to the KMO influence and follows the
findings discussed in Chapter 4. The recommendations will be implemented as a training
program provided to the clinical department chairpersons. This training program is focused on
healthcare regulatory compliance and will provide benefit to the knowledge and motivation of
the clinical department chairpersons. The training program will be evaluated using the
Kirkpatrick and Kirkpatrick (2016) New World Kirkpatrick model and use four levels of
evaluating training programs that include: Level 1 Reaction, Level 2 Learning, Level 3 Behavior,
and Level 4 Results.
Recommendations for Practice to Address KMO Influences
One knowledge influence related to procedural knowledge was validated to be a gap
during the data collection while two knowledge influences were validated to be assets. The data
indicates that the clinical department chairpersons of NTHC demonstrate limited procedural
knowledge to know ethical responsibility to report any compliance issue. In addition, two
organizational influences related to cultural model, the organization needs a culture of continual
improvement, and cultural setting, the organization needs regular and periodic training programs,
were validated to be gaps during the data collection. The data shows that the organization,
NTHC, neither demonstrates the ability to provide the support to create an atmosphere of
compliance nor provides regular and periodic training programs for the employees.

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Knowledge Recommendations
The assumed knowledge influences for NTHC‘s clinical department chairpersons and
their needs are listed in Table 12 based on the data gathered and analyzed through interviews and
document analysis. Clark and Estes (2008) argue that for performance goals of an organization to
be achieved, a gap analysis is necessary to evaluate if employees know how to achieve the
performance goals. Also, Krathwohl (2002) provides a well-articulated summary about goals
stating that for goals to be accomplished, employees should have a complete understanding of
the expectations of duties as discussed with the hierarchy of leadership. To this end, the
prioritization of the list of assumed knowledge influences begins with declarative knowledge
followed by procedural knowledge and concludes with metacognitive knowledge. Table twelve
also presents recommendations of each prioritized knowledge influence that connects to
theoretical principles.
Table 12
Summary of Knowledge Influences and Recommendations
Knowledge Influence
Finding

Principle and
Citation
Context-Specific
Recommendation
Clinical Department
Chairpersons need to
understand the importance
of a compliance program.
(D)
Information
learned
meaningfully and
connected
with prior
knowledge is
stored
more quickly and
remembered
more accurately
because it is
elaborated with
prior learning
(Schraw &
McCrudden,
Provide information,
such as compliance
manuals, and
experiences that help
clinical department
chairpersons make
sense of the material
rather than just focus
on memorization.

Connect learning to
clinical department
chairpersons’
interests to encourage
meaningfulness.
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2006).

How individuals
organize
knowledge
influences how
they
learn and apply
what they know
(Schraw &
McCrudden,
2006).

Clinical Department
Chairpersons need to know
ethical responsibility to
report any compliance
issue. (P)
Continued
practice
promotes
automaticity and
takes less
capacity in
working memory
(Schraw &
McCrudden,
2006).

Modeling to-be-
learned strategies
or
behaviors
improves
learning,
and performance
(Denler, Wolters,
&
Benzon, 2009).

Frequent practice
spread out over
shorter learning
sessions, such as
quarterly trainings, is
more effective for
learning
than one longer
session.

Provide job aids,
such as flowcharts, to
help clinical
department
chairpersons acquire
new behaviors
through
demonstration and
modeling.

Clinical Department
Chairpersons need to know
how work performance
influences overall
compliance of the
organization. (M)
The use of
metacognitive
strategies
facilitates
learning
(Baker, 2006).
Break down complex
tasks and encourage
individuals to think
about content in
strategic
ways.
Note: (D) indicates Declarative, (P) indicates Procedural, and (M) indicates Metacognitive.

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Increase procedural knowledge of clinical department chairpersons’ ethical responsibility to
report any compliance issue.
The results and findings of this study indicate that the clinical department chairpersons of
NTHC demonstrate limited procedural knowledge to know ethical responsibility to report any
compliance issue. The responses from the clinical department chairpersons’ interviews indicate
that the majority do not completely understand the current process available within their
organization in utilizing the services supplied by the organization’s compliance program in
reporting any compliance issue. Recommendations selected from the Information Processing
System Theory and the Social Cognitive Theory is used to help close this procedural knowledge
gap. Schraw and McCrudden (2006) posit that continued practice promotes automaticity and
takes less capacity in working memory, while Denler et al. (2009) argue that modeling to-be-
learned strategies or behaviors improves learning and performance. The recommendations to
address this lack of procedural knowledge are to provide frequent practice spread out over
shorter learning sessions, which is more effective for learning than one longer session, and to
provide job aids, such as a flowchart, to help clinical department chairpersons acquire new
behaviors through demonstration and modeling.
Clark and Estes (2008) suggests that training is how-to knowledge and skills that people
acquire, but need to practice with corrective feedback to help them achieve certain goals at work.
Additionally, Clark and Estes (2008) state that job aids, such as flowcharts, help facilitate
individuals achieving performance goals in a manner that allows them to accomplish those goals
on their own. To help close the gap in procedural knowledge, quarterly training should be
offered to the clinical department chairperson to provide frequent practice spread out over
shorter learning sessions that is more effective for learning than one longer session. Also, the job
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aids, specifically flowcharts, should help the clinical department chairpersons utilize the
reporting procedure established by the organization in reporting the compliance issues.
Organization Recommendations
The assumed organizational influences for NTHC, the clinical department chairpersons,
and their needs are listed in Table thirteen based on the data gathered and analyzed through
interviews and document analysis. Clark and Estes (2008) suggest that organizations that fail at
achieving performance goals can blame the failure on not having adequate processes and
materials even if the employees possess top motivation and exceptional knowledge and skills.
Rueda (2011) concurs that even if an individual understands the what, when, and why factors,
and has the motivation to achieve an organization's goals, there are organizational features that
may impede their performance. These features include the organizational structure, policies and
practices, and how the individuals interact with each other within the organizational setting.
Considering these variables and the factors associated with organizational influences, the
prioritization of the list of assumed organizational influences begins with cultural models
followed by cultural settings. Table thirteen also presents recommendations of each prioritized
knowledge influence that connects to theoretical principles.

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Table 13
Summary of Organization Influences and Recommendations
Organization Influence

Principle and
Citation

Context-
Specific
Recommendati
on
The organization needs a culture
of continual improvement.
(Cultural Models)
Measurement of
learning and
performance are
essential
components of
an effective
accountability
system capable
of
improving
organizational
performance.
(Dowd & Shieh,
2013 and
Golden, 2006)

Utilize
assessments,
such as quizzes
on healthcare
compliance
issues, to drive
instruction and
provide timely,
concrete, goal-
focused
feedback to the
employees of
the organization
to accomplish a
culture of
continual
improvement.

The organization needs regular
and periodic training programs.
(Cultural Settings)
Organizational
effectiveness
increases when
leaders identify,
articulate, focus
the
organization’s
effort on, and
reinforce the
organization’s
vision; they lead
from the why.
(Knowles, 1980).

Establish
concrete goals
aligned with the
mission
and priorities of
the organization
and complete
regular and
periodic
training to
address the why
focus of
leadership.

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Create a culture of continual improvement of the organization.
The results and findings of this study indicate that the healthcare organization, NTHC,
does not promote a culture of continual improvement for their employees even though the
clinical department chairpersons were able to identify what the organization would need to
provide to allow for their continued improvement with healthcare compliance issues. A principle
that is rooted in the accountability of the organization would help close this performance gap.
Measurement of learning and performance are essential components of an effective
accountability system capable of improving organizational performance. To this end, Dowd &
Shieh (2013) and Golden (2006) found that systems of accountability should address how
learning is measured. This principle suggests that clinical department chairpersons would benefit
from employees completing assessments concerning healthcare compliance issues that affect the
organization and comprehensive feedback on their use of those assessments. The two-part
recommendation then is for the organization to provide assessments, such as quizzes on
healthcare compliance issues, to drive instruction and provide timely, concrete, goal-focused
feedback to the employees of the organization to accomplish a culture of continual improvement.
Clark and Estes (2008) state that the culture of an organization should align with all
essential policies, procedures, and communication the organization has established. This
alignment can contribute to goal selection for the organization and the processes and procedures
to accomplish those goals. Rueda (2011) concurs that an organization’s cultural model
contributes to how the organization is structured, which includes the practices, policies, and
values of the organization. Additionally, Dowd and Shieh (2013) and Golden (2006) found that
systems of accountability should address how learning is measured. Therefore, the organization
should provide to the employees of the organization assessments, such as quizzes, to drive
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instruction of healthcare regulatory compliance and provide timely, concrete, and goal-focused
feedback to the employees to achieve a culture of continual improvement.
Create regular and periodic training programs for the organization.
The results and findings of this study indicate that the healthcare organization, NTHC,
does not provide regular and periodic training programs despite the clinical department
chairpersons’ ability to identify how healthcare compliance training would benefit their abilities
to maintain or increase the overall compliance rate of the organization. A principle that focuses
on the leadership of the organization would help close this performance gap. Organizational
effectiveness increases when leaders identify, articulate, focus the organization’s effort on, and
reinforce the organization’s vision; they lead from the why. This principle should focus on the
organization’s vision correlating to the improvements in employees’ learning outcomes. The
recommendation then would be to establish concrete goals aligned with the mission and
priorities of the organization and create regular and periodic training to address the why focus of
the leadership of the organization.
Clark & Estes (2008) state that when organizations institute a change process, training is
typical in teamwork and process analysis as well as looks at specific content, such as techniques,
to build trust among team members based on the separate skills of each team member. Rueda
(2011) suggested that cultural settings are the who, what, when, where, why, and how of the
everyday life routines of the organization and that when any of these factors experience a change
then it can be viewed that the organization’s cultural setting also changes. Waters et al. (2003)
found that focusing the work on the school’s vision was correlated with improvements in student
learning outcomes. Applying this principle to the organization, the focus should be on the
organization’s vision correlating to the improvements in the employees’ learning outcomes.
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Therefore, the organization needs to establish concrete goals aligned with the mission and
priorities of the organization and create regular and periodic training programs to help the
leadership of the organization focus on leading from the why.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The integrated implementation and evaluation plan will use the New World Kirkpatrick
Model. Kirkpatrick and Kirkpatrick (2016) state that there are three key reasons to evaluate
training programs that include program improvement, to capitalize on the transfer of learning to
employee behavior that contributes to organizational results, and to validate the value of training
programs to the organization. The New World Kirkpatrick Model includes four levels of
evaluating training programs: Level 1 Reaction, Level 2 Learning, Level 3 Behavior, and Level 4
Results. According to Kirkpatrick and Kirkpatrick (2016), these four levels of evaluation are
presented in reverse order as this is the order the levels should be considered during the planning
phase of a training program.
Level 4 is defined as “the degree to which targeted outcomes occur as a result of the
training”. Level 3 is “the degree to which participants apply what they learned during training
when they are back on the job.” Level 2 is defined as “the degree to which participants acquire
the intended knowledge, skills, attitude, confidence and commitment based on their participation
in the training.” Level 1 is “the degree to which participants find the training favorable, engaging
and relevant to their jobs” (Kirkpatrick & Kirkpatrick, 2016, p. 10). Utilizing the New World
Kirkpatrick Model as the framework for the implementation and evaluation plan will allow
Native Traditions Health Care (NTHC) to measure the success and quality of the training
programs that they desire, want to deliver, and find valuable.
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Organizational Purpose, Need and Expectations
The mission of NTHC is "to provide primary care, traditional healing, preventative care,
and wellness promotion to all members of the community, as intended by the Creator" (NTHC,
2017, p.1). NTHC provides clinical services in the following areas: dental, medical, optometry,
pharmacy, behavioral health, and public health education. The overall goal of NTHC is to
become a “medical center of excellence that provides high-quality, comprehensive, and
integrated health care and wellness services” (NTHC, 2017, p.1). The organizational
performance goal of NTHC is that, by 2025, NTHC will improve its regulatory compliance rate
by 30%. This goal comes from the mission statement and the overall goal of the organization.
The goal of this research project is to study NTHC's performance related to reducing gaps of
healthcare delivery quality to American Indian reservations and Alaska Native communities.
The identified stakeholder goal is by 2025, clinical department chairpersons of NTHC
will implement the healthcare compliance program with at least a 90% consistency as measured
by regular random evaluations. These regular random evaluations will determine the
stakeholder’s ability to successfully implement the regulatory compliance program. This critical
measurable level of achievement came from the high level of importance of the stakeholders to
accomplish the stakeholder goal. NTHC recognizes that for the organization to become a
healthcare facility of excellence that provides high-quality, comprehensive, and integrated
healthcare to the members of the community, protection of resources available to the
organization is paramount. To this end, the proposed solutions to address the performance gaps
include implementing regular healthcare regulatory compliance training to all employees of the
organization. The desired outcome of the proposed solution is to increase the overall compliance
rate of the organization by 30%.
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Level 4: Results and Leading Indicators
Table fourteen provides the desired outcomes both internal and external, the metric used
to measure the success of the identified outcome, and the method used to collect the data. There
are five desired outcomes that include three external outcomes and two internal outcomes, which
will be the result from the implementation of the healthcare compliance program for all
employees of the organization. The three external outcomes are to increase the number of
assessments for the employees, increase the number of trainings per year for the employees, and
increase the community satisfaction of quality healthcare delivery. The two internal outcomes
are to increase procedural knowledge of clinical department chairpersons’ ethical responsibility
to report any compliance issue and increase confidence to implement the healthcare compliance
program.

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Table 14
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome

Metric(s)

Method(s)

External Outcomes

1. Increased number of
assessments for
employees

Number of quizzes taken in a
year

Semi-annual evaluations of
employees asking how the
assessments affected their
performance

2. Increased number of
trainings per year for
employees

Number of trainings offered on
annual basis

Number of employees trained
in a year

Annual surveys

3. Increased community
satisfaction of quality
healthcare delivery

Percent of positive feedback
from community members

Quarterly check-ins with
random community members
who utilize the healthcare
services of the organization

Internal Outcomes

4. Increased use of correct
procedure to report any
compliance issue

Number of compliance issues
reported

Assessments conducted on
stakeholders to gauge
proficiency

5. Increased confidence to
implement the healthcare
compliance program

90% confidence to implement
compliance program

Quarterly random evaluations to
assess confidence

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Level 3: Behavior
Critical Behaviors
The stakeholders of focus in this study are the clinical department chairpersons of Native
Traditions Health Care. Critical behaviors are described as the various behaviors that individuals
perform on the job that can have a significant impact on the desired targeted outcomes
(Kirkpatrick & Kirkpatrick, 2016). The first critical behavior is the ability of the clinical
department chairpersons to know ethical responsibility to report any compliance issue. Table
fifteen identifies the critical behaviors of the stakeholders, the metric used to measure success,
the method used to collect the data, and the timing for evaluation.
Table 15
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior

Metric(s)

Method(s) Timing

1. Correct use of
the reporting
procedure for
compliance issues

Number of
compliance issues
reported within a year

Demonstration of flow
chart on reporting
compliance issues
(Knowledge assessment
provided by Compliance
Department)

Semi-annual

Required Drivers
Required drivers are developed in the behavior level, or Level 3, of the New World
Kirkpatrick Model as they are a key factor in the results level, or Level 4, and are described as
processes and systems that reinforce, encourage, reward, and monitor (Kirkpatrick &
Kirkpatrick, 2016). The data indicates that the clinical department chairpersons do not possess
the procedural knowledge influence to successfully achieve the stakeholder or organizational
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goals. Additionally, the organization lacks the organizational influences to assist the clinical
department chairpersons in achieving the stakeholder or organizational goals. Table sixteen
identifies the required drivers to support the critical behaviors of the clinical department
chairpersons to achieve the stakeholder outcomes.
Table 16
Required Drivers to Support Critical Behaviors
Method(s)

Timing

Critical Behaviors
Supported
1, 2, 3 Etc.

Reinforcing

Concrete goals aligned with
the mission and priorities of
the organization

Semi-annually 1
Models and feedback to build
self-efficacy and enhance
motivation

Quarterly 1
Provide feedback that stresses
the nature of learning

Semi-annually 1
Encouraging

Provide timely, concrete,
goal-focused feedback to
employees

Quarterly 1
Rewarding

Performance incentive when
learning shows employees
understand how what they do
affects the organizational
compliance rate

Quarterly 1
Public acknowledgement
when new behaviors are
demonstrated and meet a
Semi-annually 1
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certain benchmark

Monitoring

Organization Leadership
discusses use of models to
build self-efficacy and
feedback to enhance
motivation

Quarterly 1
Organization Leadership
checks to gauge goals
maintaining alignment with
organization mission and
priorities

Quarterly 1

Organizational Support
Native Traditions Health Care must provide the clinical department chairpersons with the
necessary resources and support to increase the achievement of both the stakeholder and
organizational goals. First, the organization should utilize assessments, such as quizzes on
healthcare compliance issues, to drive instruction to not only the clinical department
chairpersons, but to all employees. Also, the organization needs to provide timely, concrete,
goal-focused feedback to the employees of the organization with regard to the use of the
assessments to accomplish a culture of continual improvement within the organization. Second,
the organization needs to establish concrete goals aligned with the mission and priorities of the
organization and complete regular and periodic training to address the why focus of the
stakeholders and leadership. Goal setting should be a significant activity of the organization and
combining that with regular and periodic training would greatly assist in accomplishing those
goals. The ability of the organization to provide these supports of the critical behaviors of the
stakeholders is paramount in achieving the stakeholder and organizational goals.
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Level 2: Learning
Learning Goals
Clinical department chairpersons need to possess specific knowledge, skills, and
motivation to support their Level 3 critical behaviors. Upon successful completion of the
recommended solutions, or the successful implementation of healthcare compliance program, the
stakeholders will be able to:
1. Know ethical responsibility to report any compliance issue, (Procedural)
2. Apply the correct procedural process when reporting any compliance issue,
(Procedural)
3. Believe that their effort to educate employees on healthcare compliance issues
will result in a higher compliance rate for the organization, (Attributions)
4. Have the confidence in their job performance to implement the healthcare
compliance program with at least a 90% consistency and increase the
organizational compliance rate by 30%. (Self-efficacy)
Program
The aforementioned learning goals will be beneficial to the knowledge and motivation of
the clinical department chairpersons and will be achieved through training focused on healthcare
regulatory compliance. To enhance and support the knowledge of the clinical department
chairpersons, the organization will provide information, such as compliance manuals, and job
aids, such as flowcharts, as well as explicit instruction and models that explain and demonstrate
effective learning strategies. The training will be completed on a semi-annual basis, will be
conducted with a live in-person session, and will take six hours to complete (one day).
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During the six hour training session, the participants will be supplied with all information
regarding regulatory compliance manuals from federal and third party (insurance) agencies.
These will further support the learning of the stakeholders by providing a visual representation of
all regulations, policies, and laws that affect the operations of the healthcare organization.
Additionally, flow charts will be utilized to illustrate the process in reporting compliance issues
using the proper channels of support. The explicit instruction and models will help the clinical
department chairpersons understand the importance of their job duties and how their routine
activities affect the overall compliance rate of the organization.
Evaluation of the Components of Learning
Clinical department chairpersons need to demonstrate the procedural knowledge of the
ethical responsibility to report any compliance issue and have the confidence in their job
performance to help achieve the organizational and stakeholder goals. Kirkpatrick and
Kirkpatrick (2016) state there are five components to Level 2 Learning: knowledge, skills,
attitude, confidence, and commitment. To this end, Table seventeen lists the evaluation methods,
or activities, and timing for these components of learning.
Table 17
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies)

Timing

Procedural Skills “I can do it right now.”

Demonstrate the ability to recognize a reportable
compliance issue

During the training session
Demonstrate the process of reporting the
compliance issue using the job aides provided

During the training session
Peer feedback on the procedure completed

During the training session
124

Administer a post test on the reporting procedure

At the end of the training session
Attitude “I believe this is worthwhile.”

Observations of the participants by the instructor
demonstrating their effort to recognize the
benefit of what the training is asking them to do
on the job

Throughout the training session
Breakout group discussions on the value the
training is adding to their ability to do their jobs

During the training session
Confidence “I think I can do it on the job.”

Breakout group discussions on practice and peer
feedback

During the training session
Administer posttest on confidence of practice

After the training session
Commitment “I will do it on the job.”

Individual implementation plans During the training session

Breakout group discussions on practice and peer
feedback

During the training session
Administer posttest on commitment to the
practice

After the training session

Level 1: Reaction
Table eighteen identifies the various methods, or tools, used to identify the reactions of
clinical department chairpersons to the training program. Kirkpatrick and Kirkpatrick (2016)
state there are various examples of evaluation methods to incorporate in addition to the formative
methods used, such as surveys. These additional methods include observations by the instructor,
briefly and periodically asking participants how things are going, and utilizing a dedicated
observer of the training session. It is important to evaluate the reaction of the clinical department
125

chairpersons to the training session as it can help in the achievement of the stakeholder and
organizational goals.
Table 18
Components to Measure Reactions to the Program
Method(s) or Tool(s)

Timing

Engagement

Participation in breakout sessions and
activities

During the training session
Completion of the training

After the training session
Instructor observations

After the training session
Training evaluation

One-week after the training session
Post tests

After training session
Relevance

Brief pulse-check with participants using
group discussion

At various intervals of the training session
Training evaluation

One-week after the training session
Customer Satisfaction

One-week after the training session
Training evaluation

One-week after the training session

Evaluation Tools
Immediately Following the Program Implementation
After completing the initial training session, all clinical department chairpersons will be
asked to complete a survey to help determine knowledge acquisition and the effectiveness of
Level 1 and 2. The results of the survey will show how effective the training session was with
126

the participants and the level of engagement the participants had with the training session when
evaluating Level 1 Reaction. As far as evaluating Level 2 Learning, the survey results will show
how effective the training session had on the clinical department chairpersons’ procedural
knowledge and skill, attitude, confidence, and commitment to implementing the healthcare
compliance program and raising the regulatory compliance rate of the organization. Kirkpatrick
and Kirkpatrick (2016) state that although surveys are an effective method to gauge various
learning factors of participants the focus of the survey should be on high priority items such as
overall satisfaction, engagement, relevance of the material taught, and the quality of the training
session. Proposed surveys for this evaluation appears in Appendices A and B.
Delayed for a Period after the Program Implementation
Approximately 90-days after the initial session, a second session will occur that will
focus on the implementation effort of the healthcare compliance program. The second session
will provide the clinical department chairpersons relevant time for peer feedback on the
experiences in implementing the various factions of the healthcare compliance program, defining
policy to assist with the implementation, and the organizational support they need to successfully
implement the program. Additionally, the second session will provide time to evaluate all four
levels of the New World Kirkpatrick Model.
At the end of the second session, a survey will be administered that will measure the
clinical department chairpersons satisfaction and relevance of the training session (Level 1), the
confidence and value of the material they learned in the training session (Level 2), applying what
the clinical department chairpersons learned in the training program to the implementation of the
healthcare compliance program in the healthcare organization (Level 3), and the degree to which
127

their efforts in implementing the healthcare compliance program has in raising the regulatory
compliance rate of the organization (Level 4).
Data Analysis and Reporting
The Level 4 goal of the implementation plan is to provide the clinical department
chairpersons with the knowledge and organizational support to implement the healthcare
compliance program with at least a 90% consistency. The Level 4 goal is measured by semi-
annual assessments and self-disclosure statements on ability and confidence. Each week, the
reviewer will track the number of times the clinical department chairpersons discussed
implementing the compliance program principles and strategies to achieve a 90% consistency.
The data will be communicated to the organization’s leadership team to record progress and offer
suggestions for successful implementation of the healthcare compliance program. Figure two
demonstrates an example of a dashboard that can present the data for leadership and clinical
department chairpersons regarding training. Similar dashboards can be created for Level 1, 2,
and 3 for the leadership team. Figure two provides the sample dashboard to report progress in
achieving the stakeholder goal.

128

Figure 2
Sample dashboard to report progress in achieving the stakeholder goal

Summary
The Kirkpatrick and Kirkpatrick (2016) New World Kirkpatrick Model provides a
comprehensive method to determine the desired results of training, how individuals apply what
they learn, how participative the individuals are in the training to acquire knowledge, skills,
attitude, confidence, and commitment to goals of the training process, and how favorable,
engaging, and relevant the training is to the individuals. These four levels of a training evaluation
model will help the clinical department chairpersons achieve the stakeholder goal of successfully
implementing the heatlhcare compliance program with a 90% consistency. The expectation in
utilizing this framework is to analyze the data to take appropriate action in following the
described recommendations and achieve the stakeholder goal. Ultimately, this framework will
assist in achievement of the organizational goal of increasing the organizational compliance rate
by 30%.
129

Limitations and Delimitations
This study includes various limitations and delimitations, which were either identified at
the beginning of this study or as the study occurred. The research scope of this study focuses on
reducing gaps in healthcare delivery quality on AI reservations and AN communities and utilizes
Clark and Estes’ (2008) knowledge and skills, motivational, and organizational influences gap
analysis framework to address organizational performance and achieve the organizational and
stakeholder goals. Additionally, this study includes an ethnography qualitative design as the
methodological approach and collects data from virtual interviews and documents and artifacts
analysis.
One limitation is the sample size included in this study and the size of the organization
identified as the focus. The organization is rather new having opened in 2016 and is in the
process of growing its services to the reservation communities. As such, only eight clinical
departments were identified as major departments of the overall organization and only those
leaders were identified as the stakeholders of this study. One limitation that exists within this
sample size limitation is that only seven out of the eight stakeholders responded to the interview
requests.
Another limitation is finding the proper documents and artifacts from the organization to
analyze to help substantiate the answers from the clinical department chairpersons in their
interviews. Again, with the organization being a rather new entity the documents may be rather
new and fail to support the answers of the stakeholders or help answer any of the research
questions of this study.
A major limitation is the timing in which this study occurred. The data collection
happened during an international pandemic caused by the Novel Coronavirus, also known as
130

COVID-19 that caused many businesses, including the healthcare industry, to either shutdown
completely or operate in limited ability. The COVID-19 pandemic affected the manner in which
the interviewers conducted the interviews of the stakeholders by moving them to an online forum
called Zoom, which is a virtual video conferencing platform that allows individuals to
communicate through an online method using both video and audio technology. This way of
collecting data made the interview experience less personal for the participants affecting their
comfort level with the interviews and made it difficult for the interviewer to create a safe
environment for the interviewees to provide more truthful answers.
Delimitations for this research study include the boundaries established by the researcher
and the types of questions asked during the interview process. The stakeholders only included
the eight clinical department chairpersons of the organization, but this study could have included
the individuals who hold positions that work closely with regulatory practices of the
organization. Furthermore, the determination of the questions that is appropriate for the
interviews focus on the knowledge and skills, motivation, and organizational influences
concerning healthcare regulatory compliance. The data collected and analyzed, i.e., the
interviews and documents, determines how the clinical department chairpersons interact with
these influences to achieve the organizational and stakeholder goals of this study.
Future Research
This study evaluated seven assumed influences contributing to the organizational goal of,
by 2025, NTHC will improve its regulatory compliance rate by 30%. The stakeholder goal of
this study is that by 2025 the clinical department chairpersons of NTHC will implement the
healthcare compliance program with at least a 90% consistency as measured by regular random
evaluations. Eight clinical department chairpersons were identified to participate in this study as
131

stakeholders of the organization and seven of the eight participants responded to the interviews
and provided answers. The data from the interviews were combined with document analysis to
identify the knowledge, motivation, and organizational influences that affect the organization
and stakeholders in achieving the organizational and stakeholder goals of this study.
Interviews with other members of the organization’s workforce can be included in any
future research to further evaluate the assumed knowledge, motivation, and organizational
influences included in this study. As NTHC continues to grow and expand there is the potential
for new clinical departments to be established. These new department will have new department
chairpersons and they could be included as stakeholders in any future research. Furthermore,
existing departments could expand in services and personnel and any employees from these
expanded departments could potentially be included as stakeholders. Additionally, more medical
providers could be interviewed in any future research to further evaluate the assumed knowledge,
motivation, and organizational influences established in this study.
Additionally, this study did not include interviews with the patients who interact with the
organization in various ways. The perspective provided by these potential stakeholders could
give a new sense of how the assumed knowledge, motivation, and organizational influences
could be evaluated in achieving the organizational and stakeholder goals of this study. Also, this
study was confined to only one of two healthcare organizations that exist on the reservation of
the Indian Tribe of the Northern Rockies. By expanding the scope of this research study to
include the other organization, which is owned and operated by the Indian Health Service, may
add to the understanding of how healthcare regulatory compliance is achieved, maintained, and
increased to protect the resources available to provide healthcare to the reservation communities.

132

Conclusion
The purpose of this research study is to address the problem of reducing the gaps in
healthcare delivery quality on American Indian reservations and Alaska Native (AI/AN)
communities. This study used the Clark and Estes (2008) Gap Analysis framework and evaluates
the clinical department chairpersons’ knowledge, motivational, and organizational influences
through interviews and document analysis. The findings in this study were established through
data collection and analysis from stakeholder interviews and organizational documents. These
findings help provide recommendations that propose to close the knowledge, motivational, and
organizational gaps affecting the stakeholders and organization’s ability in achieving the
organizational and stakeholder goals of this study. The Kirkpatrick and Kirkpatrick (2016) New
World Model is used to identify an implementation and evaluation plan to successfully
incorporate proposed recommendations established in this study.
The key findings from this study include the stakeholders’ possession of the declarative
knowledge influence of understanding the importance of a healthcare compliance program and
the metacognitive knowledge influence of the need to know how work performance influences
overall compliance of the organization. Also, the stakeholders have the motivation influence of
attributions theory in that they understand they are responsible for educating organizational
employees on healthcare regulatory compliance issues. The clinical department chairpersons also
have high self-efficacy as they demonstrate the confidence in their job performance to help
achieve the organizational and stakeholder goals.
The findings include validated gaps of the clinical department chairpersons’ procedural
knowledge of the need to know their ethical responsibility to report any compliance issue and the
two organizational influences to have a culture of continual improvement and regular and
133

periodic training programs. The first finding of this study is that the clinical department
chairpersons do not have the procedural knowledge to know their ethical responsibility to report
any compliance issue. Three of the seven clinical department chairpersons were able to describe
certain steps that exist within the current compliance process available for reporting any
compliance issues within the organization. All seven clinical department chairpersons were not
able to provide a full description of how to report any compliance issue including any steps from
beginning to end within that process. Furthermore, the organization, NTHC, does not promote a
culture of compliance by not establishing a culture of continual improvement. While a couple of
the stakeholders identified components of a functional compliance program, all seven clinical
department chairpersons did not agree that the organization supplied the resources to promote a
culture of continual improvement. Additionally, all seven clinical department chairpersons could
not agree that the organization provides regular and periodic training programs to help them
achieve the organizational and stakeholder goals of this study.
By successfully implementing the recommendations established in this study is a good
start for the organization to achieve the organizational goal of improving the regulatory
compliance rate by 30% by 2025. Successful implementation of the established
recommendations will also lead to the achievement of the stakeholder goal of the clinical
department chairpersons of NTHC implementing the healthcare compliance program with at
least a 90% consistency as measured by regular random evaluations by 2025. Should NTHC fail
to incorporate the established recommendations they risk the failure to close the knowledge and
organizational gaps identified in this study. This failure can hinder the ability of NTHC and the
clinical department chairpersons to achieve identified goals in this study and address the problem
134

of reducing the gaps in healthcare delivery quality on American Indian reservations and Alaska
Native (AI/AN) communities.

135

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Appendix A
Survey Administered Immediately Following Initial Training Session
Level 1 and 2 Assessment
Please place an X in the appropriate box with which you agree:
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
1. The training
session held my
interest

2. The value added
to my job duties
was evident in the
training taught

3. The training
facilitator made the
training
information
interesting for me

141

4. The training
information taught
helps in my ability
to implement the
healthcare
compliance
program

5. I would
recommend this
training session to
other

For questions 6 through 10, please use the following rating scale:
1.
None or very
low level
2.
Low level
3.
Mid-level
4.
High level
5.
Very high level

Please circle the rating you feel you have achieved after completing the initial training session.
Please use the comment boxes to explain your rating.
6. Knowledge of the
importance of a

1

2

3

4

5
142

compliance program
Comments:
7. Knowledge of the
ethical responsibility
of reporting a
compliance issue

1

2

3

4

5
Comments:
8. Knowledge of how
work performance
influences overall
compliance of the
organization

1

2

3

4

5
Comments:
9. Confidence to
implement the
healthcare
compliance program

1

2

3

4

5
143

Comments:
10. Commitment to
implement the
healthcare
compliance program

1

2

3

4

5
Comments:

11. Which part of the training was the most beneficial to you and your job duties?

12. Which part of the training do you feel needs improvement?

13. What material from the training do you feel provides the best information to help you
implement the healthcare compliance program?

14. In 90-days, we will meet again to focus on the implementation efforts that have taken place
since this initial training session. What do you feel are the most important areas to focus on to
successfully implement the compliance program?

15. Please provide any additional comments you may have regarding this training session.

144

Appendix B
Survey Following the Implementation Focus Session
Level 1 through 4 Assessment
Place an X in the appropriate box to indicate the degree to which you agree with each statement.

Strongly
disagree
Disagree Neutral Agree Strongly
Agree
1. The
implementation
focus session
held my interest

2. The
implementation
focus session
was a valuable
activity

3. Clinical
department
chairpersons
understand the
importance of a

145

compliance
program
4. Clinical
department
chairpersons
can explain the
process of
reporting
compliance
issues

5. Clinical
department
chairpersons
can explain how
performance
affects overall
compliance

146

6. Clinical
department
chairpersons
can identify
compliance
issues

7. Clinical
department
chairpersons
can educate
employees on
compliance
issues

8. Clinical
department
chairpersons
can identify
when
performance is
negatively
affecting the
organization's

147

compliance rate
9. I am
confident that
we can
successfully
implement the
healthcare
compliance
program

10. I see the
value in
implementing
the healthcare
compliance rate

148

11. I am
committed to
completing the
implementation
of the
healthcare
compliance
program

Abstract (if available)

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Asset Metadata

Creator Underwood, Carlton (author)

Core Title Reducing gaps in healthcare delivery quality on American Indian reservations and Alaska Native communities: an improvement study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-05

Publication Date 04/26/2022

Defense Date 03/09/2022

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

Tag Alaska Native,American Indian,Compliance,healthcare,OAI-PMH Harvest,quality

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee chair), Andres, Mary (committee member), Ronquillo, John (committee member)

Creator Email ccunderw@usc.edu,underwoodcct@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111117819

Unique identifier UC111117819

Document Type Dissertation

Format application/pdf (imt)

Rights Underwood, Carlton

Type texts

Source 20220427-usctheses-batch-933 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

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

Repository Email cisadmin@lib.usc.edu