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

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The Attrition and Lack of Medical Follow-up of Patients in Research in a Primary Care Setting
A Gap Analysis

by

Elia Salazar

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 2021

Copyright 2021 Elia Salazar

Epigraph
Todo a su tiempo.

iii

Dedication
To my parents, Ramiro and Micaela Salazar. Thank you for instilling in me the importance of an
education, hard work, determination, and resiliency in order to shape the woman I am today. I
wish to also thank my sister, Raiza Salazar. Thank you for keeping it real with me at all times
and for pushing me to keep going. I also dedicate this to my extended Salazar and Sanchez
family - ¡Si se pudo! I love you all.

iv

Acknowledgements
Above all, thanks be to God, as faith was the guiding light throughout this journey.
To my wonderful dissertation committee – Dr. Adibe, Dr. Canny, and Dr. Robles. Thank
you for your time and invaluable guidance and feedback throughout this process. It has been an
honor and pleasure to work and learn from you all.
My sincerest gratitude to my closest friends, Cohort 11 crew, and colleagues (special
shoutout to the LRCC lab at the USC Chan Division) for your continued support. There are not
enough words to describe how much I appreciate you all being there for me, and for the love and
encouragement I have felt since day one.
To my person - my loving, selfless and supportive partner, Cesar Plascencia, thank you
for your patience, kind-heartedness, and care. You literally have been there for me every step of
the way – the good, the bad, to everything in between in this rollercoaster of a ride. And, thank
you to the Plascencia family for constantly reminding me of who I am and everything else I have
yet to accomplish – especially mi suegra, Yolanda
†
(q.e.p.d.).

v

Table of Contents
Epigraph .......................................................................................................................................... ii
Dedication ...................................................................................................................................... iii
Acknowledgements ........................................................................................................................ iv
Introduction to the Problem of Practice .......................................................................................... 1
Organizational Context and Mission .............................................................................................. 2
Importance of Addressing the Problem .......................................................................................... 3
Purpose of the Project and Questions ............................................................................................. 3
Organizational Performance Status ................................................................................................. 4
Organizational Performance Goal ................................................................................................... 5
Stakeholder Group of Focus ........................................................................................................... 6
Table 1 ................................................................................................................................ 7
Review of the Literature ................................................................................................................. 8
Implementation Science ...................................................................................................... 9
Cultural Sensitivity in Primary Care ................................................................................. 10
Primary Care Models and Practices in Research .............................................................. 10
Trends in Research ........................................................................................................................ 11
Assessment of Research Practices ................................................................................................ 12
Challenges in Research Practices ...................................................................................... 12
Barriers in Patient Retention ............................................................................................. 13
Predictors of attrition and loss to follow-up ..................................................................... 14
Patient attrition in randomized control trials .................................................................... 14
Approaches to Patient Retention ................................................................................................... 15
Integrating Retention Strategies in Research Protocols .................................................... 15
Research training methods ................................................................................................ 16
Recruitment methods ........................................................................................................ 17
Knowledge, Motivation and Organizational Influences ............................................................... 18
Table 2 .............................................................................................................................. 19
Knowledge Influences .................................................................................................................. 20
Table 3 .............................................................................................................................. 23

vi

Motivation Influences ................................................................................................................... 24
Table 4 .............................................................................................................................. 27
Organizational Influences ............................................................................................................. 28
Table 5 .......................................................................................................................................... 33
Interactive Conceptual Framework ............................................................................................... 34
Data Collection and Instrumentation ............................................................................................ 36
Interviews ...................................................................................................................................... 36
Interviews Procedures ................................................................................................................... 37
Sampling Strategy and Timeline ................................................................................................... 37
Findings......................................................................................................................................... 38
Participating Stakeholders ............................................................................................................ 38
Knowledge, Motivation, and Organizational Findings ................................................................. 39
Knowledge Findings ..................................................................................................................... 40
Table 6 .............................................................................................................................. 40
Table 7 .............................................................................................................................. 47
Motivation Findings ...................................................................................................................... 48
Table 8 .............................................................................................................................. 49
Table 9 .............................................................................................................................. 50
Organizational Influence Findings ................................................................................................ 52
Table 10 ............................................................................................................................ 53
Table 11 ............................................................................................................................ 54
Table 12 ............................................................................................................................ 58
Solutions and Recommendations .................................................................................................. 61
Knowledge Influences and Recommendations ............................................................................. 61
Table 13 ............................................................................................................................ 62
Motivation Influences and Recommendation ............................................................................... 64
Table 14 ............................................................................................................................ 65
Organizational Influences and Recommendation ......................................................................... 66
Table 15 ............................................................................................................................ 67
Limitations and Delimitations ....................................................................................................... 70

vii

Conclusion .................................................................................................................................... 71
Appendix A: Participating Stakeholders with Sampling Criteria for Interviews ......................... 73
Appendix B: Protocols .................................................................................................................. 76
Appendix C: Credibility and Trustworthiness .............................................................................. 79
Appendix D: Ethics ....................................................................................................................... 80
Appendix E: Implementation and Evaluation Plan ....................................................................... 82
Organizational Purpose, Need and Expectations .............................................................. 82
Level 4: Results and Leading Indicators ...................................................................... 83
Table 16 ............................................................................................................................ 83
Level 3: Behavior .............................................................................................................. 83
Table 17 ............................................................................................................................ 84
Table 18 ............................................................................................................................ 85
Level 2: Learning .............................................................................................................. 86
Table 19 ............................................................................................................................ 88
Level 1: Reaction .............................................................................................................. 88
Table 20 ............................................................................................................................ 89
Evaluation Tools ........................................................................................................................... 89
Data Analysis and Reporting ........................................................................................................ 90
Appendix F: Definitions ............................................................................................................... 91
References ..................................................................................................................................... 92

viii

List of Tables
Table 1: Organizational Mission, Global Goal, and Stakeholder Performance Goals 7
Table 2: Knowledge, Motivation, and Organizational Influences, Types, and Assessments for
Analysis 19
Table 3: Knowledge Influences, Types, and Assessments for Analysis 23
Table 4: Motivation Influences, Types, and Assessments for Analysis 27
Table 5: Knowledge, Motivation, Organization (KMO) Worksheet: Organization 33
Table 6: Summary of Research Team Knowledge Findings 40
Table 7: Knowledge Influences, Interview Results 47
Table 8: Summary of Research Team Motivation Findings 49
Table 9: Motivation Influences, Interview Results 50
Table 10: Summary of Organization Findings 53
Table 11: Organizational Influences, Interview Results 54
Table 12: Identified Influences, Literature Source for Influence, and Finding Synopsis 58
Table 13: Summary of Knowledge Influences and Recommendations 62
Table 14: Summary of Motivation Influences and Recommendations 65
Table 15: Summary of Organization Influences and Recommendations 67
Table 16: Outcomes, Metrics, and Methods for External and Internal Outcomes 83
Table 17: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 84
Table 18: Required Drivers to Support Critical Behaviors 85
Table 19: Evaluation of the Components of Learning for the Program 88
Table 20: Components to Measure Reactions to the Program 89

ix

List of Figures
Figure 1: CGHWC’s Interactive Conceptual Framework 35

x

List of Abbreviations
CGHWC Carter General Hospital and Wellness Center

CLT Cognitive Load Theory

DHS Department of Health Services

EBP Evidence-Based Practices

IOM Institute of Medicine

IS Implementation Science

KMO Knowledge, Motivation, and Organizational

MA Medical Assistant(s)

MD Medical Director(s)

OT Occupational Therapy/Therapist(s)

PCC Patient-Centered Care

PCCM Patient-Centered Care Model

PC-CSHC Patient-Centered, Culturally Sensitive Health Care

PCMH Patient-Centered Medical Home

PCP Primary Care Provider(s)

PI Principal Investigator

RCT Randomized Control Trial

RN Registered Nurse

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Abstract
This study examined the high attrition and lack of medical follow-up of minority patients who
participate in a research study in a primary care setting. Using the Clark and Estes (2008) gap
analysis framework, this study utilized a qualitative approach that included semistructured
interviews in order to identify and analyze the knowledge, motivation, and organizational factors
that influence patient attrition and retention. Findings from this study indicated the need of
addressing research staff’s knowledge and motivational influences pertaining to patient retention.
Furthermore, the organizational factors identified confirmed the need for the alignment of the
organization’s missing with cultural settings and practices. The solutions and recommendations
to address the validated needs are provided along with the implementation and evaluation
framework based on the Kirkpatrick and Kirkpatrick’s (2016) New World Model.

1

Introduction to the Problem of Practice
This section will discuss the high attrition of minority patients in research in a primary
care setting. On the national level, the United States’ (U.S.) population grew by 19.5 million
people from 2010-2019 – specifically a growth rate of 20% for Latino or Hispanics, 29% for
Asian Americans, and 8.5% for Black populations (Frey, 2020). Ethnic and racial minorities are
defined as American Indians and Alaska natives, Black or African Americans, Hispanic or
Latino, Asian Americans, Native Hawaiians, and other Pacific Islanders (Chow, Foster,
Gonzalez, & McIver, 2012). Patient attrition among minority patients proves to be a challenge
among healthcare research (Flores et al., 2017; Sangi-Haghpeykar et al., 2009; Siddiqi et al.,
2008). A systematic review of randomized control trials (RCTs) in top medical journals showed
a dropout rate of 20% or higher for minorities in clinical trials (Bell, Kenward, Fairclough, &
Horton, 2013). Furthermore, more than 10% of responses, in a national survey of RCTs related
to primary care outcomes, were missing for various reasons such as withdrawal from the study or
lost to follow-up (Hewitt et al., 2010). In conjunction, missed appointments in primary care
clinics not only interfere with providing appropriate care for chronic health conditions, but also
cause a major burden on healthcare systems’ costs and the effectiveness of the delivery of
healthcare services (Perron et al., 2010). Moreover, patient attrition among clinical and
community-based research studies related to a chronic health condition, such as diabetes, poses a
serious threat to the management of health behaviors, and the quality of life of minority patients
(Gucciardi, 2008).

2

Organizational Context and Mission
The Carter General Hospital and Wellness Center (CGHWC) (pseudonym) is housed
within one of the largest public health systems on the West Coast. It is one of the major training
centers in the U.S. with over 900 medical residents training in various specialties each year
(CGHWC website). Within the Los Angeles area, the CGHWC is a hub and training center for
over 1,000 attending physicians, interns, and residents from the local medical school. Various
specialty units operate within the CGHWC facility treat patients who require medical, surgical,
and mental health services. Within its respective county, the CGHWC provides both outpatient
and inpatient services; the inpatient tower accommodates about 600 private patient rooms. The
CGHWC also houses several centers for patient well-being and behavioral support. The
CGHWC integrates services in-house, but also alongside community-based partnerships and
events.
The demographic composition data for this metropolitan Los Angeles region is: 55%
Latino, about 17% are White (non-Latino), about 7% are African American, about 19% are
Asian, less than 1% are Native Hawaiian/Pacific Islander, and 2% are two or more races (CHIS,
2016; OMB, 2018). Additionally, about 12% of this minority population are uninsured while the
rest are insured through Medicare and Medicaid (5.6%), employee-based (33.4%), or privately-
purchased insurance (4.2%) (CHIS, 2016). These demographics highlight the gap in care and
representation in research, and the need for providing sensitive health care services to minority
patients. Additionally, the rates for missed appointments tend to be higher in clinics within
underserved populations and for patients insured under Medicaid than with any other type of
insurance (DuMontier et al., 2013; Kaplan-Lewis & Percac-Lima, 2013).

3

Importance of Addressing the Problem
This dissertation addresses the need to increase patient retention among research
participants in a primary care clinic setting. The problem of high patient attrition among minority
patients is important to address because of the underrepresentation of this group in research and
the research literature. Racial and/or ethnic minorities comprise less than a fourth of research
participants in health-related research (Khubchandani et al., 2016; Bonevski et al., 2014). Data is
not reflective of the larger U.S. population fundamentally limiting how interventions are created
for specific minority groups’ needs (Bonevski et al., 2014). Moreover, long recruitment periods
can further demotivate other study participants to continue their participation and lead to
increasing direct costs increasing (Gul & Ali, 2009). The inability to recruit and retain patients,
or participants, in a study can affect the internal and external validity of the study (Gul & Ali,
2009). The low representation of minority patients in recruitment numbers, and the sample size,
also carries negative implications to the statistical power of a study and increases in direct costs.
Furthermore, the reduction of statistical power can also introduce potential bias (Siddiqi et al.,
2008). Thus, it is critical to have a representative sample of minority patients in research studies
in order to be able to generalize the studies’ findings and to ensure sufficient statistical power for
the study.
Purpose of the Project and Questions
The purpose of this project is to conduct a gap analysis to examine the knowledge,
motivation and organizational influences that interfere with CGHWC’s mission to provide
culturally sensitive care services and achieve the performance goal. This study explores the
knowledge and motivation of the research team in reducing participant attrition via an
implementation science research study within a primary care clinic. The analysis began by

4

generating a list of possible or assumed interfering influences that were examined methodically
to focus on actual or validated interfering influences. While a complete gap analysis would focus
on all stakeholders, for practical purposes the stakeholders that were focused on in this analysis
were the clinical staff and research staff contractors at the CGHWC
As such, the questions that guided this study were the following:
1. What is the research team’s knowledge and motivation related to CGWHC’s goal of 20%
retention of minority research study patients?
2. What is the interaction between organizational culture and context and research team’s
knowledge and motivation?
3. What are the recommended knowledge and skills, motivation, and organizational
solutions to achieve 20% patient retention?
Organizational Performance Status
The organizational problem of focus for the CGHWC was the high attrition of minority
patients, among those who participated in an implementation study for diabetes management, in
their primary care clinic. According to a data analysis by a national healthcare insurance
organization, those patients in a primary care setting who never no-showed to their appointments
had an attrition rate of about less than 19%, while about 32% of patients who had one or more
no-shows did not return within 18 months (Hayhurts, 2019). As the current tracking system
stands, the CGHWC already has certain parameters and measures by which patients are being
held accountable for their attendance (e.g. cancellations, no-shows, and loss-to-follow-up rates).
According to the medical directors (MDs), the current overall attrition, or dropout, rate within
the primary care clinic is 20%. As such, the organizational goal is to remain at 10% attrition or
lower benchmarked against the Standards of Care recommendation for Patient Centered Medical

5

Home (PCMH) models. PCMH has become the evolving delivery healthcare model that aims to
provide quality healthcare services to improve patient outcomes around chronic disease
management and reduce healthcare costs (Williams, Jackson, & Powers, 2012). The rates for
missed appointments tend to be higher in clinics in underserved populations and for patients who
are covered under Medicaid than with any other type of insurance and showed high prevalence
of comorbidities (DuMontier et al., 2013; Kaplan-Lewis & Percac-Lima, 2013).
Missed appointments, or no-shows, in primary care clinics are one of the main causes of
inefficient healthcare systems that lead to poorer health outcomes for patients, are attributed to
wasteful healthcare dollars, and inefficient use of healthcare providers’ time (Kaplan-Lewis &
Percac-Lima, 2013; Perron et al., 2013). In order to show improved health outcomes for all its
patients that is in alignment with their mission, it is important for the CGHWC to follow a
protocol for patient retention. Inadequate retention of minority patients can lead to gaps in
patient care, the costs of healthcare, and in the quality of delivery of care (Kheirkhah et al. ,
2015; Federman et al., 2001). Accountability is an essential component to the involvement of
patients as truly being the center of care and delivery of services (Miller et al., 2018). Thus,
should the organization’s goal not be achieved, it could pose liability and affect securing future
funding. Most importantly, not having these services in place can negatively affect patients’
access to care and the (self-) management of their chronic health conditions as it disrupts
provider’s efforts to provide continuous care (Kaplan-Lewis & Percac-Lima, 2013; Nuti et al.,
2012).
Organizational Performance Goal
The organizational performance goal for the CGHWC is by June 30, 2021, the CGHWC
will implement the use of a patient-centered research protocol to retain 20% of minority patients

6

recruited for a study in their primary care clinic. This goal was outlined after previous
discussions with some of CGHWC Medical Directors (MDs) and the Principal Investigator (PI)
at the partnering university. The CGHWC’s mission places an emphasis on providing "culturally
sensitive care" in addition to "affordable and accessible care" for its patients (CGHWC website,
2020). Accordingly, the CGHWC will institutionalize a patient-centered research protocol in
their primary care clinics with a specific focus on the management of chronic health conditions
such as diabetes. In addition, within the last 48 months, the medical leadership team has been
advocating for a move towards an integrated Patient Centered Medical Home Model (PCMH) to
address the high patient attrition and no-show rates at the clinic level. To note, a patient’s
appointment is a “no-show” when the patient does not show up for their scheduled appointment
(Kheirkhah, Feng, Travis, Tavakoli-Tabasi, & Sharafkhaneh, 2016). Additionally, the
Department of Health Services (DHS) strategic plan focuses on streamlining a mechanism
related to a patient’s care and treatment plan by forging partnerships across various agencies
(DHS, 2018).
Stakeholder Group of Focus
The stakeholder group of focus for the organization was the research team, which
included faculty, students (masters-level research assistants and doctoral residents), occupational
therapist (OTs) clinicians from the partnering university who are contractors for the CGHWC,
and medical staff (medical directors (MDs), medical assistants (MAs), front office clerks,
registered nurses (RN), and clinical pharmacists) employed at the CGHWC. The PI designed and
oversaw the implementation science study in collaboration with the OT clinicians and MDs;
student RAs from the partnering university were heavily involved in the recruitment and
consenting portions of the research process; and the OT clinicians along with the doctoral

7

residents provided the lifestyle management services in the study during the implementation
phase. The medical staff within the clinics are the gatekeepers of direct patient access (Solimeo
et al., 2017). Medical staff, such as the front office clerks, check in the patients for their
appointments, inform the patients’ providers of registration status, verify insurance information,
and guide patients to the appropriate clinic area. There are also the MAs who take the patients’
vitals, schedule (or reschedule) future appointments, and refer patients to any additional ancillary
services such as the laboratory or pharmacy; RNs can further refer patients to other services such
as the wellness center. This stakeholder group is important in order to help achieve the
organizational performance goal due to their continual point of contact with patients and
potential study participants. The research staff also play a pivotal role in the recruitment and
retention of patients (Nierse et al., 2011). These stakeholders contribute to the achievement of
the organization’s performance goal via direct engagement and interaction with one another on
various levels of the PCMH model and with what is outlined in research grant proposals.
Table 1
Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
“To provide fully integrated, accessible, affordable and culturally sensitive care one person at a
time.”
Organizational Performance Goal
By June 30, 2021, the CGHWC will retain 20% of minority patients recruited for clinical research
studies in their Adult Outpatient Clinic.
Stakeholder 1 Goal Stakeholder 2 Goal Stakeholder 3 Goal
By February 2020, the
CGHWC will conduct a needs
assessment in the Adult West
Outpatient clinic.
By March 2020, leadership
will create a plan of action for
the research team to implement
the protocol at their respective
clinics.
By May 2020, the research
team at the Adult West Clinics
will be provided with and will
pilot test the research protocol.

8

Review of the Literature
The literature review examined the high attrition and lack of medical follow up of
minority patients in a primary care clinic. In order to help inform the problem of practice, this
section reviews the general research on the importance of patient engagement, recruitment, and
retention in healthcare research. The literature review also provides an overview of patient
recruitment and retention in community-based research along with recommended practices.
Then, the literature review provides an explanation of the Clark and Estes (2008) gap analysis
that will focus on knowledge, motivation, and organizational influences in this study. This
section defines the types of knowledge, motivation, and organizational influences examined and
the assumed research team knowledge, motivation, and organizational influences on
performance. Lastly, the literature review section will end with a presentation of the conceptual
framework guiding this study.
There are aspects of theoretical frameworks in research that are applicable within a
primary care setting (Valentijn et al., 2013). In particular, the conceptual framework around a
user-centered design is an innovative approach in health care (Witteman et al., 2015). A user-
centered design is an established method used to optimize the user experience and the
effectiveness of a system or service. Healthcare systems are working on ways to support research
in healthcare to develop interventions that are more effective. Research in healthcare targets
frameworks and models for assessment of impact, methodological approaches for evaluation,
and the reliability and validity of measures and metrics (Banzi et al., 2011; Biering et al., 2015).
Investment in healthcare research models can improve cost effectiveness and return on
investment in these settings (McCullough, 2018). Specifically, research within a primary care
setting highlights new developments in the last decade that include training, scope of care, care

9

teams, treatment, and payment models (Holtrop et al., 2018). Some of these recent new
developments include ongoing development related on patient-centered care focus,
implementation of a patient-centered medical home, and use of standards as well as other
practice transformative strategies to implement an incentive payment system. For this particular
implementation science study carried out in the primary care clinic in the CGHWC, it evaluated
emergent care trends in healthcare delivery, which included:
(1) The integration of nontraditional providers into the primary care PCMH model to
deliver high quality and comprehensive primary care and (2) the value of utilizing nontraditional
providers to address chronic health conditions management in a primary care setting.
Implementation Science
The growing field of Implementation Science (IS) seeks to inform how evidence-based
interventions have the capacity to be adopted, implemented, and maintained in healthcare
settings successfully (Holtrop et al., 2018). The field of IS helps facilitate evidence-based
practices (EBPs) that include medical interventions for health concerns (Bauer et al., 2015).
Implementation science shares similar characteristics with quality improvement and
dissemination methods. Implementation research pays attention to the external validity of
research studies compared to the internal validity of clinical trials. Furthermore, implementation
studies either asses or measure change with response to planned interventions by deploying
mixed-methods designs and identifying factors such as the patient, provider, clinic, organization
as well as the community and political contexts, on the broader spectrum, that impact perception
on across multiple layers. In addition, IS theory grounds itself on and requires the involvement of
interdisciplinary research teams. Implementation science research aims to improve the adoption,

10

adaptation, delivery and sustainability of effective interventions used by providers, clinics,
organizations, communities, and other systems of care (Brown et al., 2017).
Cultural Sensitivity in Primary Care
It is evident across the literature that there has been increasing calls on the national level
for a patient-centered, culturally sensitive health care (PC-CSHC) system (Tucker et al., 2015).
This is heavily because healthcare providers have to provide healthcare services to a more
culturally diverse patient population. Furthermore, there is growing evidence that lack of
culturally sensitive healthcare contributes to the costly health disparities seen in our nation, and
ethnic minorities are more likely to experience dissatisfaction with the health care system
compared to their non-Hispanic white counterparts. Consequently, these unsatisfactory
experiences with the healthcare system is linked to poorer healthcare outcomes among minority,
low-income, and underserved populations. Data from a national PC-CSHC project among 67
healthcare sites found that the more patients were satisfied with the culturally sensitive
healthcare treatment and services they received, the more they were willing to adhere to their
treatment regimens (Tucker et al., 2011).
Primary Care Models and Practices in Research
For research studies that predominantly enroll minority patients, there are recommended
components of healthcare practices for clinics housed within a primary care model (Dy et al.,
2015). The four pillars of primary care practice include: first-contact care; the continuity of care
over the course of time; the concern for the entire patient as comprehensive; and the coordination
of other parts of the healthcare system (Bodenheimer & Pham, 2010). Patient care in a primary
care setting must start with an understanding of strengths and areas for improvement for the
organization and its healthcare providers, along with the needs of the population being serviced

11

(Paez et al., 2008). This approach permits providers to develop attitudes and behaviors that are
culturally competent and implement in their respective clinics. Thus, a common practice in
primary care is the transition to and implementation of a patient-centered care model (PCCM).
The Institute of Medicine (IOM) defines patient-centered care (PCC) as, “respecting and
responding to patients’ wants, needs, and preferences, so that they can make choices in their care
that best fit their individual circumstances” (IOM, 2001, p.48-50). Furthermore, Newell and
Jordan (2015) state quality care in healthcare is defined as, “care that is safe, effective, timely,
efficient, equitable, and patient-centered” (IOM, 2001, p.4; Newell et al., 2015).
Trends in Research
Given the demographic shifts and transformations in healthcare, the disparities within
distinct populations become more and more evident particularly among minority groups. Even
though minorities constitute about a third of the U.S. population, they comprise only 10% of
clinical trials (Sangi-Haghpeykar et al., 2009). As such, there is a proposal for a PCCM approach
to address factors such as communication barriers between patient-provider relationships and
other institutional prejudices (Renzaho et al., 2012). A PCC model also proves to be beneficial to
patient satisfaction, adherence to treatment recommendations, and the self-management of the
patients’ chronic health conditions (Levinson, Lesser, & Epstein, 2010). A PCC approach takes
into consideration patients’ unique backgrounds and circumstances and recognizes that there is
no “one-size-fits-all” approach (Sidani, 2008).
Office visits within a primary care setting account for 25% of the U.S. expenditures in
health, and as such, it is needed to account for these missed visits (Michael et al., 2013). Due to
changes in clinical care systems, there has been a recent push for primary care to shift to a
patient-centered medical home (PCMH) model. PCMH is a mechanism for the organization of

12

the delivery of various healthcare services across a range of patient needs (Jackson et al., 2013).
This PCMH model calls for continual quality improvement of interventions and tailoring existing
interventions accordingly based on theoretical frameworks (Sidani, 2008). A collaborative
approach between PIs and medical healthcare providers would be needed in the development and
execution of clinic-based research that is inclusive of patients’ care needs (Banzi et al., 2011).
Additionally, the creation of collaborative and multidisciplinary teams are necessary during the
development of research studies. As such, the allocation of space and time is critical for
members of the primary care and research teams to develop strategies for the intervention.
Currently, research conducted in primary care settings that are also transitioning to the PCMH
model experience a series of challenges (Landon et al., 2010).
A patient-centered (PC) model within primary care focuses on provider and staff
behaviors and their attitudes along with implementing policies and creating an environment that
enables patients to feel comfortable and respected (Tucker et al., 2011). PC models center on the
patient-provider relationship and strive to empower patients (Renzaho et al., 2012; Tucker et al.,
2007). Having a diverse staff and research team can raise awareness of cultural issues and
establish standards for effectively interacting with minority patients (Paez et al., 2008). The use
of a patient-centered culturally sensitive health care (PC-CSHC) model can lead to improved
health outcomes and an increase in patient adherence (Tucker et al., 2007).
Assessment of Research Practices
Challenges in Research Practices
A major challenge in research is the difficulty in retaining minority patients in research
studies. Minority patients who are potential candidates for studies are less likely than Whites to
be approached and enrolled to participate in a study or clinical trial (Flores et al., 2017).

13

Furthermore, retention rates are lower for minority patients who speak another language other
than English. Flores et al. (2017) also mention that participants who miss baseline assessment
appointments tend to reflect higher attrition in completing future assessments. The under-
representation of minority patients in research studies has negative implications for research
studies (Humphreys et al., 2013).
According to Baxter et al. (2012), a representative study cohort is needed to reduce
selection bias risk and to maintain the representative nature of the sample for generalizable
findings. The low representation of minority patients in studies can threaten the understanding of
disease incidence for various chronic health conditions. Similarly, Biering et al. (2015) report
potential bias in studies that contain repetitive measures often reported by patients. In
longitudinal and cohort studies, attrition can be attributed to patients moving or relocating,
becoming too ill, or finding participating too time consuming. Alongside the challenges within
research practices, it is also important to keep in mind the array of barriers related to patient
attrition and retention.
Barriers in Patient Retention
There are several barriers associated with the lack of minority patient participation in
research studies. Low participation and high attrition of minority participants is often attributed
to lack of knowledge of the research process, communication and language barriers, and distrust
of treatment in research (Baxter et al., 2012). Patients also identified cost as the most common
barrier to accessing and engaging in healthcare services (Raja et al., 2015). Some additional
potential barriers for low participation include transportation, time, communication, and other
cultural barriers such as mistrust in both the medical and research communities (Sangi-
Haghpeykar et al., 2009). Minority patients were more likely to be withdrawn from the principal

14

investigator due to noncompliance, while whites withdrew consent. Therefore, PIs and
researchers need to examine and address barriers to participation that are associated with
socioeconomic status and education (Resnik, 2009). To address recruitment challenges, study
protocols should be not only culturally competent, but more so patient-centered and utilize
approaches that help build on relationships with participants along with trust of research team. In
conjunction with these barriers tied to patient retention, other predictors of patient attrition need
to be identified and addressed.
Predictors of attrition and loss to follow-up
There is often a mutual assessment of factors associated with participant attrition and loss
to follow-up in clinic settings and research studies (Gucciardi, 2008). Attrition occurs at any time
point after the participant consented to participation (Siddiqi et al., 2008). Retention is most
important given that high rates of attrition can affect statistical power and threaten internal
validity. Gill et al. (2012) also define attrition as the loss to follow-up due to poor compliance,
the inability to commit, lack of interest, or discharge. Moreover, there tends to be recruitment
restrictions in research by means of inclusion and exclusion criteria (Jiandani et al., 2016). In
other words, some studies may require patients to attend a certain number of sessions and tend to
be excluded if they are unable to meet such criteria. Therefore, it is important to adapt and cater
research recruitment and retention strategies to special populations (Horowitz et al., 2009; Rivera
et al., 2017).
Patient attrition in randomized control trials
Within the context of the CGHWC, the high attrition of minority patients poses to be a
problem particularly for the randomized control trials (RCTs) that take place in the clinics. The
early identification of potential reasons for this high attrition can target and reduce patient

15

attrition early on (Siddiq et al., 2008). Early predictors of attrition tend to appear during the early
stages of the research study such as the consenting and screening process. This is due to delayed
contact time between consent and next contact, or in the later stages, low education during the
screening phase.
Attrition is defined as any point after consent when a participant is lost to follow up
(Siddiqi et al., 2009). Gill et al., (2012) further define attrition as the loss to follow-up following
self-discharge, lack of interest, unable to commit to a certain amount of time, or discharging due
to poor compliance. Patient satisfaction - and even dissatisfaction - with primary care models
contributes to the high attrition and no-show rates documented in these clinics. Based on a
patient satisfaction survey, Michael et al. (2013) reported areas for improvement in wait times
included improving phone call response times plus the availability of other referral services.
These influences in research study logistics uncover one layer of patient attrition, yet further
assessment of other factors will reveal additional gaps in patient retention. Based on these
definitions and criteria of attrition, this study will examine various approaches and strategies to
target retention.
Approaches to Patient Retention
Integrating Retention Strategies in Research Protocols
Missed appointments pose a problem in primary care outpatient clinics as they exhaust
administrative and medical resources (Perron et al., 2013). A systematic review suggests
utilizing text-message reminders in clinical trials prove to be the most effective in reducing the
rate of missed appointments. While postal reminders are effective as well, they prove to be costly
and are less utilized in comparison to text-message reminders. Research assistants would be the

16

ones who would be making the reminder phone calls first during a set time of day and then
sending out a follow-up text-message reminder to the patients.
While infrastructure supports with delivery of services for PCC, PCC must include a
continuous relationship with the patients’ primary care provider(s) (PCP), empathetic and
emotional understanding to support care, along with trust, and patient activation and enablement
to make their own informed choices (Levinson et al., 2010). The implementation of patient
retention strategies to reduce attrition and loss to follow-up start at the clinic level with a
patient’s medical visit. If there is a long delay in scheduling a next appointment, a patient is more
likely to cancel or simply not show up to that appointment (Liu et al., 2010). However, if a
patient is provided with the option to attend the day of their request, they are more likely to
attend and be seen by their healthcare provider(s). Along with strategies for retention in primary
care clinics, there could also be the incorporation of a synergistic tactic within research teams in
this primary care setting (Peikes, et al., 2014). This could mean incorporating a team-based
approach in which staff will work closely with patients and their caregivers in the coordination
of quality healthcare services.
Research training methods
Many patients have expressed in semistructured, qualitative interviews a desire for their
healthcare providers to provide step-by-step explanations of any procedures or services, focus on
body language among the clinic, and time management (Raj et al., 2010). There are specific
recommendations for research recruitment methods and procedures to address patient retention.
In order to transform the current system, PC communication training for health practitioners is
often recommended as a training practice (Miller et al., 2018). Furthermore, improved
communication also leads to improved clinical outcomes for chronic health conditions such as

17

diabetes (Levinson et al., 2010). Communication is multi-dimensional in a PCMH model and
comes in the form of dialogue with and actively including and consultation patients in the
research process (Levinson et al., 2010; Nierse et al., 2011). Other provider behaviors that have a
positive impact on patient satisfaction and treatment adherence include courtesy, friendliness,
encouragement, reassurance and positive reinforcement.
Recruitment methods
Research in a primary care setting requires a multi-layer technique that includes
practitioners and providers who are the gatekeepers of patient services and treatment. Within a
primary care setting, recruiting for research studies can begin with involving providers in all
phases starting from providing context to the patients, inviting patients to participate, and
obtaining patients’ over the course of the study. Bower et al. (2014) propose three focus areas
regarding recruitment - innovative methodology, infrastructure, and expanding on patient
engagement. One recommendation is to start with identifying any organizational and
professional barriers in addition to any barriers the patients may encounter (Ngune et al., 2012).
Therefore, an effective recruitment method is having the active participation from providers in a
primary care setting. In this systematic review of the literature, direct and indirect strategies
engage patients and participants as well as clinicians and other healthcare providers.
The Clark and Estes (2008) Gap Analytic Conceptual Framework
The various components of the Clark and Estes (2008) gap analytic conceptual
framework are discussed as they pertain to research team knowledge, motivation, and
organizational factors related to the performance goal of retaining 20% of minority patients
participating in a research study. According to Clark and Estes (2008), it is necessary to develop
knowledge for performance if stakeholders are unclear on how to accomplish their performance

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goals, and to detect when additional education could be needed. The four knowledge types for
evaluation will be factual, conceptual, procedural, and metacognitive knowledge (Anderson &
Krathwohl, 2001; Rueda, 2011). Assessment of motivational indices are needed to achieve
performance and stakeholder goals. Motivation, at its core, is the internal metacognitive process
that influences how learners begin goal-orientated behaviors and how they maintain them
(Mayer, 2011). According to Schunk et al. (2009) and Clark and Estes (2008) motivational
indices include active choice, persistence, and effort. In addition, organizational influences
within an organization play a role in recognizing performance shortfalls.
Knowledge, Motivation and Organizational Influences
This review of scholarly literature focuses on the knowledge, motivation, and
organizational influences the CGHWC requires to achieve their organizational performance
goals. The organizational goal is by June 2021, the CGHWC will retain 20% of minority patients
recruited for a study in their Adult Outpatient clinic. The stakeholder group of focus will be the
research team, which consists of clinic staff at these CGHWC clinics and research team from the
partnering university. The performance goal of this stakeholder group is by June 201, the
research team at the CGH2C will utilize X research protocol (a patient-centered protocol) in 90%
or greater of research studies.
Table 2 shows the different knowledge, motivation, and organizational (KMO) influences
for evaluation in this model along with KMO assessment methods.

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Table 2
Knowledge, Motivation, and Organizational Influences, Types, and Assessments for Analysis

Organizational Mission

“To provide fully integrated, accessible, affordable and culturally sensitive care one person
at a time.”

Organizational Global Goal
By June 30, 2021, the CGHWC will retain 20% of minority patients recruited for a research
study in their Adult Outpatient clinic.

Stakeholder Goal
By December 2020, the research team will utilize X protocol (a patient-centered protocol) in
90% or greater of research studies.

Knowledge Influences 1. Research team need to know which
parts of patient enrollment are
difficult to conduct. (Factual)
2. Research team will need to know
how to incorporate strategies for
enrollment and retention.
(Conceptual)
3. Research team must know proper
procedure and follow protocol for
patient screening and enrollment.
(Procedural)
4. Research team need to know how to
reflect on their effectiveness out in
the clinics. (Metacognitive)
Motivation Influences 1. Utility Value – Research team need
to see the value in appropriately
carrying out research protocol in
clinics.
2. Self-Efficacy - Research team believe
they can effectively carry out
research protocol processes.
Organizational Influences 1. Cultural Model Influence 1:
The willingness to adjust and modify
current research processes and
implement a protocol.
2. Cultural Model Influence 2:
Creating a sense of trust among
research team (academic vs. clinical)
and research participants.

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3. Cultural Setting Influence 1:
Supervisors (such as the medical
directors and principal investigators
along with the managers) must
allocate time designated for training
and hands-on practice of skills and
modules.
4. Cultural Setting Influence 2:
Research team must have effective
role models within their respective
research teams and on-site clinics as
they develop and implement the
research protocol.

Knowledge Influences
There are knowledge-related influences pertinent to the achievement of the organizational
and performance goals for the CGHWC. As such, the application of knowledge-related
influences for developing skills are needed for research team to reach their performance goal.
According to Clark and Estes (2008), it is needed to increase knowledge for performance, as
individuals are unclear on how to accomplish their performance goals and to further identify
when additional education is needed. Therefore, the four knowledge types for assessment will be
factual, conceptual, procedural, and metacognitive knowledge (Krathwohl, 2002; Rueda, 2011).
Factual knowledge will focus on the various contextual domains and terminology about
research protocols. Conceptual knowledge will capture all of the categories, principles, theories,
models, and structures in the research protocol (Krathwohl, 2002; Rueda, 2011). Following these
authors’ guidelines, the third type of knowledge - procedural knowledge - will allow examination
of the procedure and methodology on how to properly recruit and consent. Lastly, Krathwohl
(2002) and Rueda (2011) describe metacognitive knowledge as the awareness to an individual’s
cognition as well as how an individual solves problems. The following sections will discuss the

21

four knowledge types and knowledge influences that play a role for the CGHWC research team
to realize their performance goal.
Research team need to know which parts of patient enrollment are difficult to conduct.
As a starting point for declarative, or factual, knowledge influences, is the understanding of the
fundamental regulations and mechanisms within research. In order to achieve the performance
and stakeholder goals described, the organization should assess baseline knowledge of research
team. The cognitive load theory (CLT) will provide the basis for studying different material
types and how these will assist the learners – research team – in gaining new knowledge and
skills (Van Gerven et al., 2002). The research team will be able to practice different portions of
the protocol as they recruit and consent patients from various health centers into a research study
(Deans for Impact, 2015; Van Gerven et al., 2002).
Research team need to know how to incorporate strategies for enrollment and
retention. In order to achieve their performance goal, the knowledge influence the research team
need is to fully understand the detailed steps with regards to research procedures. This
conceptual knowledge type will provide the basis for assessing research team knowledge and for
the creation of strategies to train staff adequately to accomplish their performance goal
(Krathwohl, 2002; Rueda, 2011). The research team will become informed of at least three
different research enrollment steps. Moreover, learning happens in combination with new ideas
based on prior ideas already known and via hands-on worked examples (Deans for Impact,
2015). This prior knowledge will enable the learners, in this case the research team, to gain new
knowledge utilizing curricula, or in this instance, a research protocol (Deans for Impact, 2015).
Therefore, the use of modeling working examples will aid in the mastery of new knowledge and
so that learning takes place. Rodger et al. (2008) propose partnerships along with a set of

22

guidelines and frameworks for student placements that will facilitate learning experiences of not
only students but will also provide educational support for clinical staff. This ties to the
recommendation by Hidi and Renninger (2006) to engage students along with the medical staff
in “real-life” activities to encourage cooperation among the larger group of learners via mutual
problem-solving activities (Schraw & Lehman, 2006).
Research team must know proper procedure and follow protocol for patient screening
and enrollment. The third knowledge type – procedural – will be addressed through practicing,
as it is key when learning new information (Mayer, 2011). Additionally, Deans for Impact
(2015) highlight the importance of combining learning with practicing different types of
problems. In relation to the performance and stakeholder goals, this is important given the
complexity of research in health centers. Harris et al. (2010) discusses the importance of
designing student placements in community-based organizations that build on organizational
capacity that enhances student learning through various partnership activities. Thus, research
team will be tasked with practicing recruitment, screening, and enrollment procedures.
Research team need to know how to reflect on their effectiveness when in service in
clinic. Lastly, as it pertains to metacognitive knowledge, as research team become integrated into
their respective clinical settings, their reflections on their own individual abilities will also help
with achieving the performance goal. To better understand and carry out knowledge tactics, the
holistic research team must recognize their own knowledge as learners (Baker, 2006). According
to Baker (2006), the utilization of assessments and reflections impacts cognitive processes and
how knowledge and information are effectively stimulated.
Table 3 shows the different knowledge types to be evaluated in this model along with
knowledge-influence assessment methods.

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Table 3
Knowledge Influences, Types, and Assessments for Analysis

Organizational Mission

“To provide fully integrated, accessible, affordable and culturally sensitive care one person at a
time.”

Organizational Global Goal

By June 30, 2021, the CGHWC will retain 20% of minority patients recruited for a research
study in their Adult Outpatient clinic.

Stakeholder Goal

By February 2020, the research team will utilize X protocol (a patient-centered protocol) in 90%
or greater of research studies.

Assumed Knowledge
Influences
Knowledge Type (i.e.,
declarative (factual or
conceptual),
procedural, or
metacognitive)
Knowledge Influence Assessment
Research team need to
know which parts of patient
enrollment are difficult to
conduct.
Factual

Quiz/test will be administered to
assess baseline knowledge.
Research team need to
know how to incorporate
strategies for enrollment
and retention.
Conceptual Interviews: Research team will be
asked to paraphrase at least three
steps of enrollment.
Research team need to
know proper procedure.
Procedural

Observation: Medical staff will be
asked to practice going through
screening and enrollment procedures.
Research team need to
know how to reflect on their
effectiveness out in the
clinics.
Metacognitive

Survey/document analysis: Research
team will be asked to assess their
own effectiveness using patient
satisfaction questionnaires.

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Motivation Influences
Motivational influences are needed to achieve the CGHWC’s performance and
stakeholder goals. While the aforementioned knowledge sections focused on learning from
experiences (Mayer, 2011; Rueda, 2011), this section will focus on factors that influence how
goals are initiated and maintained (Clark & Estes, 2008; Grossman & Salas, 2011; Rueda, 2011;
Schunk et al., 2009). Motivation, at its core, is the internal metacognitive process that influences
how learners begin goal-orientated behaviors and how they maintain them (Mayer, 2011).
According to Schunk et al. (2009) and Clark and Estes (2008) motivational influences include
active choice, persistence, and effort. Addressing motivational limitations within an organization
will support with any performance deficiencies and will result in positive outcomes. Thus, the
two theories, or constructs, for discussion in the following sections include the expectancy value
theory and self-efficacy theory.
Expectancy Value Theory. Expectancy Value Theory proposes that motivation for
choices is through the expectation of successfully completing a task and value of the task around
certain domains (Eccles, 2006). Assessments under Expectancy Value Theory include interviews
with particular focus on the value of a task along with observations focused around active choice
and persistence. Research team will need to identify the value of implementing the patient-
centered care protocol and believe they can attain the performance goal of 20% patient retention.
Research team need to see the value in appropriately carrying out research protocol in
clinics. The first motivational influence associated with the CGHWC performance goal is the
expectancy value theory with particular focus on attainment and utility value. Expectancy value
theory examines the following central questions, “Can I do the Task?” and “Do I want to do the
task?” (Eccles, 2006). Rueda (2011) describes attainment value as the significance an individual

25

ties to completing a task well. Utility value encompasses how valuable that individual sees a
certain activity or task to accomplish their upcoming goals (Rueda, 2011). Additionally,
expectancy value motivational theory assesses achievement-related activities in relation to
factors such as beliefs, experiences, and aptitudes along with various cultural norms, social roles
(Eccles, 2006). Furthermore, to target both attainment value and utility value, Eccles (2006) and
team encourage incorporating tasks or situations that focus on competence and autonomy. And
so, in order to tackle this motivational influence, it would behoove the research team to address
the benefits of the outlined research protocol tasks along with any risks associated with not
completing them accordingly (Mayer, 2011; Rueda, 2011).
Self-Efficacy Theory. Self-efficacy theory places focus on the expectancies for success
(Bandura, 1982). Self-efficacy beliefs are fundamentally the self-perceptions one has about their
capabilities (Pajares, 2006). Individuals create their own self-efficacy beliefs through the
interpretation of information that comes from mastery, experience, social persuasions, and
physiological reactions. Such self-efficacy beliefs are the groundwork for motivation, well-
being, and personal accomplishment among individuals and nurture the expected outcomes. The
research team needs to feel confident in their abilities, or believe in their abilities, to complete
the task – implementing a patient-centered care protocol - for the performance goal of 20%
patient retention.
Research team believe they can effectively carry out research protocol processes. The
second motivational influence related to the research team performance goal is the self-efficacy
theory. Under this theory, self-efficacy beliefs consist of judgements that one holds about how
their capabilities influences their learning or how they perform (Bandura, 1982; Grossman &
Salas, 2011; Pajares, 2006). In relation to the social cognitive theory, these self-efficacy beliefs

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inform the motivation around performance goals and the actions around it (Bandura, 2005;
Bandura, 2000). Self-efficacy literature suggests that as individuals feel confident about their
abilities to learn, they are more likely to become motivated to transfer training into their
respective sites (Grossman & Salas, 2011).
Along with the use of worked examples, given that most of the research team will have
limited experience with research protocols, pairing them with a peer model or models will be
greatly beneficial (Denler et al., 2006; Pajares, 2006). Moreover, Pajares (2006) emphasizes
considering that self-efficacy beliefs are both personal and social constructs, verbal messages
and other social cues received influence these self-efficacy beliefs. As such, the research team
will complete surveys to evaluate their beliefs on how to effectively implement research protocol
processes (Mayer, 2011; Rueda, 2011). Concerning the implementation of the patient-centered
research protocol, managers must make it clear how the educational training sessions will prove
useful to patients in these studies (Aguinis & Kraiger, 2009).
Table 4 contains the assumed motivational influences discussed in the section above along with
the assessment methods.

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Table 4
Motivation Influences, Types, and Assessments for Analysis

In summary, the knowledge and motivation gap analysis for the CGHWC organization
and performance goals will provide the framework for the research team to engage in tasks that
will lead to patient retention. Goal orientation allows us to assess and observe how and why
research team participate in specific research protocol activities (Yough & Anderman, 2006).
Within this organization, research team will be asked to indicate goals that will lead to patient
retention. Yough and Anderman (2006) further emphasize that an individual’s unique
characteristics and their context influence the types of goals set in their learning environments.
Organizational Mission

“To provide fully integrated, accessible, affordable and culturally sensitive care one person at a
time.”

Organizational Global Goal

By June 30, 2021, the CGHWC will retain 20% of minority patients recruited for a research
study in their Adult Outpatient clinic.

Stakeholder Goal

By June 30, 2021, the research team will utilize X protocol (a patient-centered protocol) in 90%
or greater of research studies.

Assumed Motivation Influences Motivational Influence Assessment
Utility Value – Research team need to see the
value in appropriately carrying out research
protocol in clinics.
Written survey item
“It is important for me to understand the
consent process for our research participants.”
(not important at all – very important)
Self-Efficacy – Research team need to believe
they can effectively carry out research protocol
processes.
Written survey item
“I feel confident about my ability to recruit and
consent patients.” (strongly disagree- strongly
agree)
Interview item:
“How do you feel about your ability to recruit
and consent patients?”

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As such, the formation of a strong organizational culture is needed in order to achieve the
organizational and performance goals effectively (Schein, 2004).
In keeping these knowledge types and motivation influences in mind towards the creation
of a new research protocol for the research team, Auiginis and Kraiger’s (2009) description of
training encompasses both learning and development aspects that a team should use to progress
organizational effectiveness. Grossman and Salas (2011) further emphasize that training should
also incorporate the “what” with cognitive processes - such as the information that staff need to
know to carry out their tasks, the exact steps to carry out those tasks, and how they can feel like
they are performing successfully. Hence, research team must be thoroughly trained and certified
on the research terminology, recruitment, and consenting processes. This will be accomplished
via the implementation of a patient-centered research protocol in order to achieve their
performance goal.
Organizational Influences
Along with knowledge and motivation influences, organizational influences are also
important to address for the achievement of the CGHWC’s performance and stakeholder goals
related to minority patient retention. Features of organizational culture that need to be taken into
consideration for the gap analysis include cultural models and cultural settings, in addition to
policies and practices. Culture is the collection of learned values, goals, beliefs, emotions, as
well as the processes that were developed over time in various environments of interaction
(Clark & Estes, 2008). Schein (2017) also describes culture as the tangible and visible levels –
artifacts, beliefs and values, and assumptions - to an individual. Mainly, the assumed cultural
models and cultural settings within the CGHWC will be discussed.

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Cultural models are those invisible factors within a society that develop from a collective
transmission of information, shared experiences and interactions, and collective schema
(Gallimore & Goldenberg, 2001). Cultural settings are also described as individuals coming
together to achieve something throughout time. For this reason, change within organizations is
fundamentally part of the overall development of both individuals and organizations (Kezar,
2001). Therefore, organizational barriers need to be assessed and addressed in order to achieve
the outlined stakeholder and organizational goals.
In a primary care healthcare institution, the culture is characterized as transitioning over
to a patient-centered medical home (PCMH) care model. The push for this recent trend, or
change, is due to changes in the clinical care systems and healthcare systems are working on
ways to support research in healthcare that develops more effective interventions (Banzi et al.,
2011; Crabtree et al., 2011). Crabtree et al. (2011) promote PCMH models as they call for
continual quality improvement of health research interventions along with the tailoring of
interventions based on theoretical frameworks. Furthermore, the PCMH model calls for the
cross-collaboration of multidisciplinary teams during the development of research studies. Thus,
an understanding of an organization’s culture is needed to move the organization to meet their
performance goal. Using the Clark and Estes’ (2008) gap analytic framework, the CGHWC’s
organizational culture will be examined.
Cultural Models. Cultural models are the shared schemas and understandings of how the
world functions or expectations of how it should (Gallimore & Goldenberg, 2001; Rueda, 2011).
These are present within a specific community that share similar ways of thinking and
responding to various challenges and conditions. Rueda (2011) highlights that cultural models
play a role in how organizations provide structure and inform those structures along with polices,

30

practices, and values. This section will discuss the cultural models that affect the CGHWC to
achieve their research team goal of implementing a culturally sensitive research protocol to
retain 20% minority patients in research studies.
Willingness to adjust and modify current research processes and implement a patient-
centered care model. Paez, Allen, Carson, and Cooper (2008) highlight that the patient-centered
care model in a primary care setting must start with an understanding of strengths and areas for
improvement for the organization and its healthcare providers, along with the needs of the
patients being served. This PCC model approach permits providers to develop attitudes and
behaviors that are culturally competent and to be implemented in clinics. Similarly, Clark and
Estes (2008) highlight that those core beliefs embedded within an organization’s culture, can
provide the guidance for goal-making decisions and those processes to achieve organizational
goals. Moreover, the diverse clinic staff and research team in the organization can advise
healthcare providers in the improvement of the delivery of services for minority patients.
A cultural model of trust among research team (academic vs. clinical) and research
participants. There are various barriers associated with low minority patient participation in
clinical research studies, which one being a culture of trust among research teams and patients.
In particular, Baxter et al. (2012) encourage researchers to examine and address the barriers to
participation that are associated with socioeconomic status and education. These two points are
important to keep in mind when addressing recruitment challenges. As such, study protocols
should be culturally competent – or sensitive – and utilize approaches that build on the
relationships with participants and with trust of research team (Baxter et al., 2012). Thus, it is
important to adapt and cater research recruitment and retention strategies to special populations
who participate in clinical research studies (Jiandani et al., 2016). As such, offering a PCCM

31

among CGHWC patients will help the organization achieve their performance goal of patient
retention.
Cultural Settings. While cultural models are dynamic expressions of practices within
organizational cultures (Rueda, 2011), cultural settings are those instances when groups of
individuals collectively execute an activity or action that corresponds to a particular value – or in
other words, those visible aspects of organizational culture (Gallimore & Goldenberg, 2001;
Rueda, 2011). In addition, cultural settings are those social contexts in which practices, policies,
and procedures are executed within organizational culture (Rueda, 2011). This next section will
discuss the cultural settings that have an impact on the CGHWC in implementing a culturally-
sensitive research protocol for 20% minority patient retention.
Research team need to be provided time for training and hands-on practice of research
protocol. The literature showed that patient-centered care training for health practitioners is a
recommended training practice due to the growing need to reduce health disparities and improve
patient health outcomes. In alignment with Schein (2017), organizations need to provide an
element of shared learning in their culture (Edmondson, 2012). Through the continuous
development of reproducible techniques in healthcare competencies, access is advancing in the
field. Cultural competency curricula has shown improved health outcomes regarding patient
adherence (Lie et al., 2011). Furthermore, the use of rigorous training materials across health
professions leads to resource management and the delivery of validated techniques that can be
incorporated (Banzi et al., 2011). The literature further emphasizes the importance of increasing
patient retention of minority patients particularly since high rates of attrition can negatively
impact statistical power of research studies and threaten internal validity (Siddiqi, Sikorskii,
Given, & Given, 2008). Crabtree et al. (2011) encourage researchers to allocate the space and

32

time for members of primary care teams to develop strategies for the intervention. This will
permit the CGHWC and research team to achieve their performance goals of retaining minority
patients.
Research team need to be provided with role models within on-site clinics as they
develop and implement the research protocol. By identifying the organizational and
professional barriers encountered by the institution along with barriers for the patients, the
literature recommends providing active participation from providers in trainings in a primary
care setting (Ngune et al., 2012). Given the multidimensional nature of research studies in
primary care clinic settings, a multi-layered technique for practitioners and providers of patient
services and treatment would provide guidance towards the achievement of the organizational
goal of patient retention. Accordingly, fostering a collaborative approach between the principal
investigators (PIs) and the medical healthcare providers would be needed in the development and
execution of clinic-based research that is inclusive of patients’ care needs (Greene et al., 2012).
Therefore, the CGHWC will incorporate this approach among research team for the retention of
minority patients in research studies.
In summary, research in healthcare targets distinct frameworks and models for
assessment of impact, methodological approaches for evaluation, and the reliability and validity
of measures and metrics (Banzi et al., 2011). Investing in healthcare research models alongside
the PCMH model in primary care, can improve cost effectiveness and return on investment.
These influences associated with research study logistics only uncover a minor layer of patient
attrition, so further assessment of other factors will reveal additional gaps in patient retention in
this setting.

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Table 5 contains the assumed organizational influences discussed in the section above along with
the assessment methods.
Table 5
Knowledge, Motivation, and Organization (KMO) Worksheet: Organization

Organizational Mission
“To provide fully integrated, accessible, affordable and culturally sensitive care one person
at a time.”

Organizational Global Goal
By June 30, 2021, the CGHWC will retain 20% of minority patients recruited for a research
study in their Adult Outpatient clinic.

Stakeholder Goal
By June 30, 2021, the research team will utilize X protocol (a patient-centered protocol) in
90% or greater of research studies.

Assumed Organizational Influences

Organization Influence Assessment
Cultural Model Influence 1:
The organization needs a patient-centered
care model.
Survey questions: “I feel the patient-centered
research protocol improves patient retention
and care; I feel the implementation of the
protocol improved patient outcomes.”
Cultural Model Influence 2:
The organization needs a culture of trust
among research team and research
participants.
Survey questions: “Collaboration among the
research team increased with the
implementation of the research protocol.”
Cultural Setting Influence 1:
The organization needs to provide research
team time for training and hands-on practice
of research protocol.
Survey questions: “I feel I received the
necessary training to carry out the guidelines
in the research protocol.”
Cultural Setting Influence 2:
The organization needs to provide research
team with role models within on-site clinics
as they develop and implement the research
protocol.

Survey questions: “I received the support I
needed from the management team
throughout the implementation of the
protocol”; “My medical director and/or PI
provided all the resources and tools needed
to carry out the protocol effectively.”

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Interactive Conceptual Framework
The conceptual framework depicts the interaction between research team and the
outpatient primary care clinic within the CGHWC. Literature suggests that within primary care
institutions there has been a growth in the transition to a PCMH care model (Crabtree et al.,
2011). The PCMH model calls for the continuous quality improvement process of healthcare
research interventions via cross-collaboration of multidisciplinary research teams (Crabtree et al.,
2011). In order to get an understanding of the CGHWC’s organizational culture as well as the
knowledge and motivational influences, the CGHWC’s conceptual framework was developed.
Based on the conceptual models and theories found in the literature in addition to experiential
knowledge, the conceptual model figure is below.

35

Figure 1
CGHWC’s Conceptual Framework

Carter General Hospital and Wellness Center (CGHWC) (pseudonym)
Cultural Settings and Cultural Models
Culture Model: Willingness to adjust and modify current processes and implement a patient-
centered research protocol;
Cultural Model: The CGHWC needs a culture of trust among research team and research
participants;
Cultural Setting: The CGHWC needs to provide the research team time for training and hands-
on practice of the patient-centered research protocol;
Cultural Setting: The CGHWC needs to provide research team with role models within on-site
clinics as they develop and implement the patient-centered research protocol.

Organization Goal: By June 30, 2021, the Carter General Hospital and
Wellness Center (CGHWC) will retain 20% of minority patients
recruited for clinical research studies in their Adult Outpatient Clinics.
Research team
Knowledge (Factual): Research team needs to know which
parts of patient enrollment are difficult to conduct;
Knowledge (Conceptual): Research team will need to know
how to incorporate strategies for enrollment and retention;
Motivation (Utility Value): Research team needs to see the
value in appropriately carrying out research protocol in
clinics;
Motivation (Self-efficacy): Research team needs to believe
they can effectively carry out research protocol processes.

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Data Collection and Instrumentation
In this section, I discuss interviews as the primary method of data collection and the
process of interviewing. This data collection method was selected due to the small stakeholder
group sample size (n=5) and the homogeneity of the research team who can share their insight
regarding patient attrition and retention (Merriam & Tisdell, 2016). Moreover, the use of
interviews was necessary in this study considering observations were no longer feasible due to
the novel COVID-19 pandemic. The research team was comprised of principal investigators
(PIs), student research assistants (RAs), Occupational Therapy (OT) clinicians, and clinic staff
includes front office clerks, medical assistants, primary care providers (PCPs), and medical
directors (MDs). However, for this study, three members of the research team and two members
of the clinical staff were interviewed. The interviews helped address the knowledge, motivation,
and organizational influences related to the research questions regarding retention of minority
patients.
Interviews
The interviews followed a semistructured interview format. The data collected was
constructed through the interaction from the group’s discussion on their shared knowledge and
views on a specific topic (Merriam & Tisdell, 2016). According to Merriam and Tisdell (2016),
the suggested targeted number of interview participants is between six to ten participants. The
questions aligned with the knowledge and motivation of the research team and the organizational
influences related to patient attrition and retention. The interviews provided me with any other
information that may have been missed during the observations and to confirm the accuracy of
those observations (Maxwell, 2013).

37

Interviews Procedures
Interviews were conducted by two OCL research assistants during times in which
administrative and clinical staff were available (e.g. during the lunch hour gap or after their
regular workday shifts). As the PI of this study, I was unable to conduct the interviews myself
due to the supervisory nature of my role within the organization and the stakeholder group of
focus. The individual interviews conducted took about an hour each to conduct and were held via
Zoom. Data was captured via Zoom’s audio recording option or Otter.ai along with any typed
and/or handwritten notes. These audio transcripts were sent via Otter.ai to the researcher along
with any additional notes. The interview questions were asked in English.
Sampling Strategy and Timeline
Sampling
Strategy
Number in
Stakeholder
population
Number of
Proposed
participants
from
stakeholder
population
Start and End
Date for Data
Collection
Interviews: Nonprobability,
purposeful
There are 40
clinical staff
employees
and 15
research team
employees.
Out of the 55
combined
staff, two
members of
the clinical
staff were
interviewed
and three
members of
the partnering
university
research staff
were
interviewed
team for a
total of 5.
August 2020-
October 2020

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Findings
This section presents the findings of this study through an analysis of the knowledge,
motivation, and organizational influences for the CGHWC as informed by the Clark and Estes’
(2008) gap analysis framework. The focus of this study was to explore the connections between
implementing a patient-centered research protocol via an implementation science study and
increasing patient retention in a primary care outpatient clinic. An in-depth analysis of each
assumed influence will be provided and whether a gap was identified for each assumed
influence. Data was gathered in the form of semistructured interviews to validate the assumed
influences and explore any additional factors needed to achieve the performance goal. The
following section reviews the participating stakeholders and findings in relation to the following
research questions:
1. What is the research team’s knowledge and motivation related to CGWHC’s goal
of 20% retention of research study patients?
2. What is the interaction between the CGHWC organizational culture and context
and research team knowledge and motivation?
3. What are the recommended knowledge and skills, motivation, and organizational
solutions for the CGHWC to achieve 20% patient retention in its primary care
clinic?
Participating Stakeholders
Three of the 15 research staff employed at the partnering university, and who are
contractors at the CGHWC, met the selection criteria and participated in this study’s interviews.
Additionally, two of the CGHWC clinical staff who met the selection criteria were able to
participate in the interviews as well. These two distinct groups (research staff and clinical staff,

39

who collectively are known as the research team for purposes of this study) were interviewed due
to the synergistic nature of the implementation science study in order to implement the patient-
centered research protocol in the primary care clinic. To protect the identity of the individuals
participating in the interviews, no demographic or other identifying information is provided. Each
participant was issued a number between 1 through 5 and identified as Participant 1-5 for the
purpose of this study.
Knowledge, Motivation, and Organizational Findings
A qualitative approached was used to address the research questions. The medical director and
nurse managers at the CGHWC distributed an email to their respective clinic staff informing them
of the study. The research staff contractors from the partnering university were also included in
that email. A total of five interviews were completed by three members of the research staff from
the partnering university and two from the clinical staff at the CGHWC, collectively known as the
research team. These semistructured interviews were conducted following the evaluation phase of
the ongoing implementation science research study in the adult outpatient clinic, and the transition
period during the COVID-19 pandemic to telehealth appointments, or “phone visits”.
These interviews were completed over an eight-week period and each interview took about an hour
via Zoom. Each participant was provided with an information sheet about the study prior to the
interview and each participant gave permission to be interviewed as well as have the interviews be
recorded and transcribed. The PI only received deidentified transcripts via Otter.ai from the two
research assistants. The responses to the interview questions (Appendix B) were saved in a secure
drive and have not been shared with anyone outside of the study. The responses were then analyzed
for the qualitative findings of this study. Findings are organized by the knowledge, motivation,
and organizational influences in relation to the organizational performance goal.

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Knowledge Findings
This study’s knowledge research question is: What is the research team’s knowledge
related to the CGHWC’s goal of 20% retention of research study patients? The assumed
knowledge influences that were evaluated in this study included factual, conceptual, procedural,
and metacognitive knowledge (Table 5). Factual knowledge pertains to the research team knowing
which parts of patient enrollment are difficult to conduct. Conceptual knowledge was the research
team knowing how to incorporate strategies for enrollment and retention. Procedural knowledge
relates to research team knowing the proper procedure and how to follow the protocol for patient
recruitment and enrollment. Metacognitive knowledge identifies the need for research team to
know how to reflect on their effectiveness out in the clinic. Through semistructured interviews,
this study was able to determine if the assumed knowledge needs were validated, as shown in table
6.
Table 6
Summary of Research Team Knowledge Findings
Assumed Knowledge Need Sub-category Validated Not Validated
1. Research team needs
to know which parts
of patient enrollment
are difficult to
conduct.
Factual X
2. Research team will
need to know how to
incorporate strategies
for enrollment and
retention.
Conceptual X
3. Research team must
know proper
procedure and follow
protocol for patient
screening and
enrollment.
Procedural X

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4. Research team need to
know how to reflect
on their effectiveness
out in the clinic.
Metacognitive X

The interview questions were structured so that the participants’ responses would uncover the
knowledge influences that impacted the research team’s ability in implementing a patient-centered
research protocol in a primary care clinic. The questions that were consistent with the conceptual
framework and knowledge influences were the following:
1. Why do you believe patients do not return?
a. What could you be doing differently?
b. What resources or trainings would help do this better?
2. What do you perceive to be challenges in patient retention?
3. What is your experience with implementing a research protocol that is patient-centered?
a. How was that experience for you?
b. What type of support, if any, do you receive from leadership?
All of the five study participants (P1-P5) were asked the same questions outlined above.
However, not all of the five participants were able to respond to the questions related to their
procedural knowledge in such a manner that would indicate a basic or general understanding of
procedures related to patient enrollment and retention. Embedded in the participants’ responses
were their reflections related to their metacognitive knowledge on their ability to comprehend the
importance of a patient-centered research protocol and how their actions impact patient retention.
There was a perceived procedural knowledge gap as the participants struggled to identify and
describe certain aspects of the research protocol as they related to patient enrollment. A sample of
the knowledge influences from the interviews are presented in Table 7.

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As presented in Table 6, the interviews included questions related to the influences that
could be considered factual, procedural, conceptual, and metacognitive. While the research team’s
factual, conceptual, and metacognitive knowledge influences did not appear to reveal any gaps,
the research team did appear to need improvement in procedural knowledge. This was evident by
the inconsistencies and disconnect in articulating their experiences in carrying out concrete
processes and procedures for how to follow the research protocol for patient screening and
enrollment that lead to patient retention. Considering the CGHWC has a high rate of patients who
are lost to follow up and miss their appointments, it is critical the significant amount of employee
knowledge of patient retention and attrition is robust at the time.
Knowledge Finding 1: Research team understands challenges that impact patient retention.
To assess factual knowledge, the research team was asked about the reasons why patients
do not return to their follow-up appointments. By analyzing the interviews, the participants
understood the reasons and circumstances as to why patients do not return to their follow-up
appointments. The qualitative data showed that the research team was able to communicate the
challenges related to patient retention and factors for missed follow-up appointments within the
outpatient clinic. When posed with questions related to perceived challenges with patient retention,
Participant 1 stated:
Aside from contextual barriers (e.g. financial, family), feeling like their needs are not met
or aren’t listened to, and if they feel the provider doesn’t care about them
When posed with the same question, Participant 2 stated:
Not really knowing how to navigate the healthcare system
Across all of the five interview transcripts, the participants stated long wait times in the
clinic, minimal availability of appointments, and unpredictable patient schedules as the main

43

causes as to why patients struggle to return to their medical appointments for follow up. This
validates the participants’ factual knowledge related to the reasons why patients do not return to
the clinic for their follow-up appointments.
Overall, 100% of the participants were clear on the importance of acknowledging these
challenges that impact patient retention in the clinic. Knowledge of the importance of the
organizational goal provides the foundation for developing further training and for modifying
processes to increase patient retention. Participants 3, 4, and 5 all stated availability of
appointments and accessibility of the clinic as major challenges for patient retention. The data
makes it clear the participants had a strong background in factual knowledge of the problem of
practice. However, there is evidence of a need among the research staff and clinic staff being able
to seamlessly integrate the research protocol in the clinic workflow as well as a need for improved
communication.
Knowledge Finding 2: Research team will need to know how to incorporate strategies for
enrollment and retention.
To assess conceptual knowledge, the research team was asked what they perceive to be
challenges related to patient retention in the clinic. By analyzing the interview transcripts, the
participants were able to articulate various obstacles they’ve encountered within the outpatient
clinic. The qualitative data showed research team were well-versed on how to incorporate
strategies for patient retention for follow-up appointments. When posed with questions related to
perceived challenges with patient retention, Participant 1 stated:
Disconnect within health systems and everything is compartmentalized.
Moreover, Participant 3 stated:

44

Very limited in the amount of time you can take off that you will prioritize going to see
your physician who can
All five (100%) of the participants were proficient to the reasons why patients do not return
to the clinic for their follow-up appointments. In all, the participants were clear on the importance
of acknowledging these challenges that impact patient retention in the clinic, thus validating their
conceptual knowledge. The data makes it clear the participants had a strong background in
conceptual knowledge of the problem of practice.
Knowledge Finding 3: Research team needs to know how to implement a patient-centered
protocol in the clinic that will assist with patient retention.
Although the participants understand the importance of barriers and challenges related to
patient retention and are reflective on their roles and experiences to achieve the organizational
goal, it appeared that the participants lacked proficiency in the formal processes to implement a
patient-centered protocol. When asked, about their experience implementing a patient-centered
research protocol,
Participant 1 responded:
Direct experience has been with the intervention end and am able to inform early stages,
what types of measures will be utilized.
When posed with the same question, Participant 3 responded:
And that’s been great because you know as someone with a similar background as the
populations, we’re working with here for example at the primary care clinic that I do feel
there’s a sense of trying to have an understanding of tailoring the intervention and not
assuming anything about the population

45

Based on the qualitative data, the need is there for procedures related to patient screening
and enrollment that will aid with patient retention. Two of the five the participants were not able
to appropriately to respond to this question. The data makes it clear that the participants did not
have a strong procedural knowledge of the problem of practice presented in this study. Since there
is not an institutionalized research protocol in place at the CGHWC, there is a 100% need in
procedural knowledge especially due to the collaboration between two external groups.
Knowledge Finding 4: Research team is reflective on their ability and effectiveness to implement
a patient-centered research protocol in the clinic.
The data reveals that the participants reflected on their ability to implement a patient-
centered research protocol in the clinic. Each of the five participants provided thoughtful and well-
informed reflections about their experiences to implement a culturally-sensitive, patient-centered
research protocol that improved patient retention. When asked to describe and reflect on what they
could do differently with respect to patients returning to their follow-up appointments, Participant
1 responded:
Ask the client what they look to achieve from the appointment; I give my patients
homework – so they can make progress on whatever is being worked on and ask if they
need any additional support
When posed with the same question, participant 2 responded:
Especially now that everyone knows appointments are stalling, they really have been
pushing to have reminder calls
Additionally, Participants 3, 4, and 5 provided similar responses that indicate thoughtful
and insightful responses related to their metacognitive knowledge influence on the problem of
practice for this study. The most common theme amongst the participants was consistently

46

following up with patients regarding their next appointment(s) via reminder calls and text
messages, of mailing information to their homes. Through the interviews, it was clear the research
team understood strategies for increasing patient retention.

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Table 7
Knowledge Influences, Interview Results
Knowledge Influences

Interview Questions Knowledge Type Responses

Why do you believe patients
do not return?
Factual “Aside from contextual
barriers (financial, family),
feeling their needs aren’t met
or aren’t listened to and if
they feel the provider doesn’t
care about them”

“our wait times are pretty
lengthy [to] just be able to get
a provider”
What do you perceive
challenges to be in patient
retention?
Conceptual “Not all clinics or medical
establishments see it
necessary in facilitating
patient experience”

“them trying to get answers
and they get frustrated with
perhaps not really
understanding how the
process works”
What is your experience with
implementing a research
protocol that is patient-
centered?

Procedural “collect information
numerically but also
understand the lived
experience”

“I feel like it’s 100% patient
centered...it’s like a big
cornerstone of our program”
What could you be doing
differently?
Metacognitive “something efficient building
rapport...ask the client what
they look to achieve from the
appointment”

“I think that one of things that
could help is if we had
something like an after-hour
clinic or possibly spruce up

48

our telehealth like our
telemedicine [visits]”

Based on the qualitative data analysis, there was a clear gap between the research staff’s
and clinic staff’s abilities to carry out a patient-centered research protocol in the clinic. The data
from the study shows the CGHWC’s research team lacks procedural knowledge on how to
implement a patient-centered research protocol in the clinic. This knowledge need is due to the
lack of an institutionalized patient-centered research protocol across the primary care clinics. The
participants also appeared reflective on their abilities and experiences to integrate a patient-
centered research protocol as part of a collaborative research team. Given their reflections on their
abilities and experiences in implementing a patient-centered research protocol, the participants did
not appear to show a gap in metacognitive knowledge. Thus, it would be appropriate for the
research protocol and introductory sessions to focus on evidence-based knowledge translation
strategies such as educational materials, outreach, audit and feedback (Stevens et al., 2014).
Motivation Findings
This study’s motivation research question is: What is the research team’s motivation
related to the CGHWC’s goal of 20% retention of patients in a research study? The data gathered
from the interviews suggest that the research team is motivated to engage in tasks centered on a
patient-centered research protocol towards patient retention, but has a motivation gap in the area
of self-efficacy. The interview questions were divided into two motivational theories: utility value
and self-efficacy. The motivation-related interview questions asked about the research team’s role,
their influence related to patient retention, and how they support patient retention. The relevant
interview questions are described in Table 9 along with the narrative of the findings.

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Table 8
Summary of Research Team Motivation Findings
Assumed Motivation Need Sub-category Validated Not Validated
1. Research team needs
to see the value in
appropriately carrying
out research protocol
in the clinic.
Utility Value X
2. Research team needs
to believe they can
effectively carry out
research protocol
processes.
Self-Efficacy X

The interview questions were structured so that the participants’ responses would uncover
the motivational influences that impacted the research team’s ability in implementing a patient-
centered research protocol in a primary care clinic. The questions that were consistent with the
conceptual framework and motivation influence were the following:
1. In what ways does your role influence the retention of patients in the clinic?
a. What are your reasons for helping increase patient retention?
b. What are the benefits of increasing patient retention?
c. How confident do you feel you will be able to do it?
d. Do you believe it’s a good idea? Why or why not?
2. How does the research team support patient retention?
a. What are some of the challenges associated with retention?
b. Which strategies, in your opinion, has been the most effective?
c. What, if anything, do you think is lacking?

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Table 9
Motivation Influences, Interview Results
Motivation Influences, Interview Findings

Interview Questions Motivational Theory Responses

In what ways does your role
influence the retention of
patients in the clinic?
Utility value “Learning about intricacies of
patient...figure out how to
adapt and meet patient needs”

“someone like me who you
know comes from a similar
background can communicate
with them”

“relationship building is the
most successful part of
research and patient
retention”
What are the benefits of
increasing patient retention?
Utility Value “On a clinical level – improve
health outcomes; research
level – better decision
making; individual level –
would help keep patients
coming back”

“I think just being able to
follow them. You know
consistently”

“see some impact and
improved clinical outcomes”
How confident do you feel
you will be able to do it?
Self-Efficacy “I feel pretty like confident”

“I mean I feel like I’m
confident that we can
improve it”
How does the research team
support patient retention?
Self-Efficacy “Acknowledgement of
participant as a person or
individual”

“if we try to develop a good
relationship and people kind
of feel more connected”

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Motivation Finding 1: Research team needs to see the value in appropriately carrying out the
protocol in the clinic.
All of the five participants value implementing a research protocol that focuses on
building relationships with patients that will help improve not only lifestyle management, but
also patient retention. Specifically, Participant 2 acknowledged supporting the team by
collaborating with other providers in the clinic to help address the patient’s needs towards
chronic disease self-management. This same sentiment was shared by Participant 3 who
expressed enthusiasm in the importance of providing quality healthcare for their patients and
building relationships with participants to help them feel listened and empowered to make
changes. Mutually, Participant 1 along with Participant 4 and Participant 5, also shared this same
sentiment of relationship building to promote continuity of care as well as learning about the
intricacies of patients to help their work and the team to figure out how to adapt and meet the
patients’ needs.
Motivation Finding 2: Research team needs to believe they can effectively carry out protocol
processes in the clinic.
Not all of the five participants were able to express confidence in their ability to
implement a patient-centered research protocol in the clinic. Thus, there is 100% need in self-
efficacy among the research team. This is in contract to them seeing value in improving patient
retention. This issue related to self-efficacy indicates the research team do not believe they can
be successful at something they have not implement before. Without an institutionalized patient-
centered research protocol across the primary care clinics, it is evident the participants were not
all able to express confidence about their abilities. While Participant 1, Participant 2, and
Participant 3 were able to acknowledge confidence in the patient-centered protocol, Participants

52

4 and 5 were not able to provide a response. There is a need for cohesion between both clinical
staff and research staff at the CGHWC to implement this protocol as participants shared the same
sentiment as they generally struggle with the concept of implementing a new protocol in the
clinic.
Organizational Influence Findings
The research question that explored the organizational-related influences that impact the
organizational performance goal is: What is the interaction between organizational culture and
context and research team’s knowledge and motivation to achieve 20% patient retention? This
multifaceted question required the exploration of the cultural settings and cultural models of the
CGHWC and how the participants’ knowledge and motivation interacted with the organization’s
cultural settings and cultural models. Even though the organization has a clear mechanism and
platforms to communicate its mission, the CGHWC does not have clear mandates to enforce a
patient-centered research protocol in all its clinics. For this organizational section, the guiding
questions in the interviews were related to the CGHWC’s needs for training and resources
associated to the implementation of a patient-centered research protocol in the primary care clinic.
The relevant questions and corresponding responses are displayed in Table11.

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Table 10
Summary of Organization Findings
Assumed Organization Need Sub-category Validated Not Validated
The willingness to adjust and
modify current research
processes and implement a
protocol.
Cultural Model X
Creating a sense of trust
among the research team and
research participants.
Cultural Model X
Supervisors must allocate
time designated for training
and hands-on practice of
skills and modules.
Cultural Setting X
Research staff must have
effective role models within
their respective units and on-
site as they develop and
implement the research
protocol.
Cultural Setting X

The interview questions were structured so that the participants’ responses would
uncover the organizational influences that impacted the research team’s ability in implementing a
patient-centered research protocol in a primary care clinic. The questions that were consistent
with the conceptual framework and organizational influence were the following:
1. How does your organization attract minority patient participation?
2. What about the organization?
a. How does the organization promote the retention of patients?
b. Can you give an example of the organization not doing anything to
that extent?

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3. If there are research training opportunities within your unit, how would you
describe the types of trainings offered?
a. How beneficial are these trainings?
b. How do you feel they could be improved?
4. Based on personal experience, within your unit, how efficient are research
training programs?
5. What is trust within the organization context for you?
6. What has your personal experience been in collaborating with the research team
in the CGHWC?
Table 11
Organizational Influences, Interview Results
Organizational Influences, Interview Findings

Interview Question Cultural Model or Setting Responses

How does your organization
attract minority patient
participation?
Cultural Model “providing education based
on the demographic being
targeted”

“I think having that staff and
providers that kind of look
like them…can you know are
able to communicate with the
in their language”
How does the organization
promote the retention of
patients?
Cultural Model “biggest thing is ongoing
communication and one on
one providing the help or
assistance the client needs”

“showing the value of OT in
a primary care setting”

“…they started to dedicate
more resources from their

55

clinic to support us in their
facility”
What is trust within the
organization context for you?
Cultural Model “communication and
collaboration are like two big
components of culture”

“there’s an enthusiasm like
let’s try something
new…they definitely
welcomed us into their clinic
team”
If there are research training
opportunities within your
unit, how would you describe
the types of trainings offered?
Cultural Setting “trainings we are put
through…covered in OT
schooling…trained very
different than nurses”

“There are some trainings
that are mandatory and some
of these we have to do to be
in compliance”
What has your personal
experience been in
collaborating with the
research team in the
CGHWC?
Cultural Setting “bridge between researchers
and how reality responds with
participants”

“being able to give my input
about what I’m seeing at
clinic and how it can inform
the study”

Qualitative analysis via interviews was the approach for this study. Research question
two directed the approach for this section. This section of the research developed assumed
influences regarding the organizational influences in supporting patient retention. There are three
themes or findings for this section addressing both cultural models and cultural settings. The
organizational models appear to shed more insight about the KMO factors that affect the
organization than the cultural settings.

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Organizational Finding 1: The CGHWC leadership creates a sense of trust among the
research team and patients, but can improve upon the collaborative nature between the
research contractors and clinical staff.
According to the interview transcripts, the organization can clearly communicate its goals
to the research team (both contractors and clinical staff), but the participants generally noted that
there is a disconnect with organizational processes explicitly with bridging the gap between the
CGHWC and the partnering university. Participant 2 stated that the problem with the County
system is the layers and layers for administration and for it to trickle up. However, this finding
indicated that the CGHWC research team felt that the CGHWC leadership is supportive of
fostering a culture of trust towards patient retention, but the clinical staff felt there could be
improvement upon communication between clinical staff and research contractors. Of the five
participants interviewed, three of them specifically were able to express their experiences with
regards to the collaborative nature of the research team. Throughout the research, the overall
belief of the participants was that there is support from the organization and leadership to offer
resources towards patient retention.
Participant 1 stated leadership is open-minded, trustworthy, and eager to try. In an
interview with Participant 3, they expressed a similar statement as they stated the leadership
within the clinic has been very open and supportive. The participants were enthusiastic about
incorporating strategies and had innovative ideas on how to increase patient retention especially
during the COVID-19 pandemic; they have reached out to patients to inform that they are open
and share with them the availability of limited services. Their overarching goal was to make an
impact on the feasibility of patients returning to their follow-up appointments. The participants
expressed that while they are aware of barriers related to patients missing their appointments,

57

they also believe leadership at their respective organizations want to provide them with the
necessary resources to achieve the performance goal. The CGHWC can foster a culture of trust
by providing the research team holistically with resources and training as well as being
transparent in their communication so that they can incorporate strategies for patient retention.
Organization Finding 2: Lack of accountability for training
There is an organizational need mostly within the clinical staff directly working in the
CGHWC adult outpatient clinic to be better trained with respect to a patient-centered research
protocol. It appears the organization does not have well-defined mandates established to ensure
its clinical staff appropriately partake in research procedures and processes towards patient
retention in the study. Participant 3 recognized that there weren’t any research-specific trainings
offered in the primary care clinic and offered the suggestion to set time for these trainings.
Participant 4 and Participant 5 agreed in unison and acknowledged the clinic only offered
trainings for compliance purposes such as those related to health insurance. Since not all five of
the participants were aware or knew of any research-specific trainings within the primary care
clinic, there is a clear need, and gap between research and clinical trainings, to ensure these
trainings are developed and offered to further the organizational goal of increasing patient
retention.
Organization Finding 3: Patient-centeredness and representation
According to the interviews, the organization is able to carry out its mission of providing
patient-centered care services. All five of the participants agreed that the organization’s efforts
towards a PCMH model that lead towards patient retention are well-communicated by the
leadership to the team through daily briefs and monthly team meetings. The participants’
responses were also consistent with regards to the representation of staff of color in the clinic,

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which also plays a pivotal role in patient-centeredness and patient retention. Through the
collaboration with OT at the partnering university, the CGHWC is working towards the
development of a protocol that is sustainable across its primary care clinics that will provide
support with addressing gaps in patient care.
Most treatment of chronic health conditions, such as diabetes, are provided in a
healthcare provider’s office, which can be proven to be costly and time consuming and offer
little to no self-management education during those visits (Carter, Nunlee-Bland, & Callender,
2011). Based on the findings of this research study, and as supported by the literature, offering a
patient self-management telehealth intervention would permit access to monitoring the patients’
health that can lead to improved health outcomes. The CGHWC clinic has already started a shift
towards that direction, especially during the COVID-19 pandemic.
Table 12
Identified Influences, Literature Source for Influence, and Finding Synopsis
Influence Type Influence Literature Finding Synopsis
Assets
Knowledge
Research team needs to know
which parts of patient enrollment
are difficult to conduct.
In order to
tailor
interventions
to be
culturally
appropriate, it
is important
to take into
consideration
the array of
contextual
factors at play
in primary
care research
(Carroll et al.,
2011).
5 of 5 participants
understand barriers
that impact patient
retention.

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Knowledge
Research staff will need to know
how to incorporate strategies for
patient retention.
By improving
the patient
care
experience, it
will improve
the overall
quality of
care a patient
receives
(Luxford et
al., 2011).

5 of 5 participants
were able to
articulate various
strategies for patient
retention.
Knowledge
Research staff need to know how
reflect on their effectiveness out in
the clinics.
One solution
commonly
offered by
patients and
healthcare
staff is to
provide more
personalized
attention in
patient care
(Brown et al.,
2015).
5 of 5 participants
were able to share
reflections related to
their roles and
patient retention.
Motivation
Research staff need to see the
value in appropriately carrying out
the research protocol in the clinic.

5 of 5 participants
see the value of
implementing the
research protocol
procedures.
Motivation
Research staff need to believe they
can effectively carry out research
protocol processes and procedures
in the clinic.
In order to
help with the
volume of
performance
measures, it
is
recommended
to divide and
delegate tasks
among the
team.
5 of 5 participants
were confident in
their ability
implement the
research protocol.
Organization
Creating a sense of trust among the
research team and research
participants.

Fostering
open and
inclusive
dialogue
between
patients and
5 of 5 participants
stated there is a sense
of trust among the
team and
participants.

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researchers
will help the
research team
learn from
patients’
experiences
ad
perspectives
(Nierse et al.,
2011).
Organization
The willingness to adjust and
modify current research processes
and implement a protocol.
Offering and
maintaining
checks into
current
system such
as team
huddles is
common
strategy in
this setting
(O’Malley et
al., 2014).
5 of 5 participants
were able to
articulate how the
organization is
working towards
patient retention.
Needs
Knowledge
Research staff must know proper
procedure and follow protocol for
patient screening and enrollment.

2 of 5 participants
were restricted in
their ability to
discuss their
experiences with the
research protocol.
Organization
Supervisors must allocate time
designated for training and hands-
on practice of skills and modules.
One practice
to address
this challenge
in primary
care is the use
of team
training and
practice
coaches
(O’Malley et
al., 2014).
3 of 5 participants
were able to discuss
trainings related to
research and indicate
training was lacking
in the clinic.
Organization
Research staff must have effective
role models within their respective
units and on-site as they develop
and implement the research
protocol.

3 of 5 participants
indicated the
research team was
collaborative, but
was lacking in the
clinic.

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Solutions and Recommendations
The findings of this study that were discussed in the previous section presented an
overview of the assumed stakeholder’s and organizational influences in accordance with the
Clark and Estes’ (2008) KMO framework. In this section, the researcher will offer
recommendations to tie the gaps in the knowledge, motivation, and organizational influences.
Based on the KMO findings, this section seeks to answer the third research question guiding this
study: What are the recommended knowledge and skills, motivation, and organizational
solutions for the CGHWC to reach its goal of 20% patient retention? This section will provide
recommendations and solutions for each supported influence based on data and literature.
Furthermore, the researcher will offer measures for accountability and behaviors that will help
achieve the organizational goal.
Knowledge Influences and Recommendations
The knowledge gap that influences the stakeholders’ ability to meet the organizational
goal is procedural. While the participants exhibited factual and conceptual knowledge of the
importance of the challenges that afflict patient retention, and were reflective about their abilities
to carry out the patient-centered protocol, the participants did not display procedural knowledge
related to the necessary procedures of the research protocol. Table 12 provides a summary of the
gap in knowledge influences and the recommendations.

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Table 13
Summary of Knowledge Influences and Recommendations
Assumed Knowledge Influence

Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Research team need to know
which parts of patient enrollment
are difficult to conduct. (F)
N Y 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, 2006)

Supervisors need to
provide research team
with meaningful and
factual information (via a
research protocol) that
will help and support
research team with the
patient enrollment
process and help connect
the research team’s prior
knowledge and skills
with new and relevant
practices.
Research team will need to know
how to incorporate strategies for
enrollment and retention. (C)

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

Effective
observational
learning is achieved
by first organizing
and rehearsing
modeled behaviors,
then enacting them
overtly (Mayer,
2011).
Provide research team
with training to acquire
new behaviors through
demonstration and
modeling.

Research team must know proper
procedure and follow protocol
for patient screening and
enrollment. (P)
V

Y Targeting training
and instruction
between the
individual’s
independent
performance level
and their level of
assisted performance
promotes optimal
learning (Scott &
Palincsar, 2006).

Provide training for
research team that
includes guidance,
modeling, coaching,
practice, feedback, and
other scaffolding during
performance.

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Providing
scaffolding and
assisted performance
in a person’s ZPD
promotes
developmentally
appropriate
instruction (Scott &
Palincsar, 2006).
Research team need to know how
to reflect on their effectiveness
out in the clinic. (M)
N Y The use of
metacognitive
strategies facilitates
learning (Baker,
2006).
Provide research team
with training that
includes an emphasis on
engaging in self-
reflection and self-
assessment; provide
opportunities to debrief
on the process upon
completion of a learning
task.

There are knowledge-related influences that pertain to the achievement of the
organizational and performance goals for the CGHWC. Based on the qualitative data analysis for
this study, the data showed there is a need in procedural knowledge among the research team
related to patient-centered protocol for patient retention. This procedural knowledge gap will be
addressed through recommendations that are grounded in the sociocultural theory. Scott and
Paliscar (2006) recommend targeting training and instruction between the individual's
performance level and the level their performance is assisted in order to achieve optimal
learning. Moreover, providing scaffolding and assisted performance in a person’s ZPD promotes
developmentally appropriate instruction (Scott & Palincsar, 2006). Thus, the research team needs
to be provided with guidance that includes modeling, coaching, practice, feedback, and other
scaffolding during their performance in the clinic.
Tharp and Gallimore (1989) postulate that through modeling - such as observing others -
a person can learn how different components of complex behaviors can come together and
visualize how they are assembled and sequenced in different settings. Moreover, having peer

64

models prove to be effective resources for assisted performance. In team-based healthcare, like
primary care in the CGHWC, feedback consists of measuring and assessing a person’s
performance, comparing it to standards and/or targets (in this case, PCMH standards), and
delivering results. Lastly, regarding practice for knowledge and learning, practice-based learning
in healthcare work settings consists of focusing on situations that lead to personal experiences,
taking these experiences and how they lead to different trajectories, and the comprehension that
arises from recurrent activities (Teunissen, 2015). Thus, research team need to be provided with
training that includes guidance, modeling, coaching, practice, feedback, and other scaffolding
during performance. As such, the application of knowledge-related influences for developing
skills are needed for research team to reach their performance goal.
Motivation Influences and Recommendation
The motivation influences outline in Table 13 provide a comprehensive list of the
assumed motivation influence that was validated in this study’s data collection and analysis.
While the assumed motivation influence of (utility) value was not validated as a motivation gap,
self-efficacy was identified as the motivational gap for the research team. While the stakeholders
value their roles and their abilities to implement the patient-centered protocol to reach their
patient retention goal, they did not display the confidence to apply the new knowledge to the
performance goal.

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Table 14
Summary of Motivation Influences and Recommendations
Assumed Motivation Influence*

Validated
as a Gap
Yes, High
Probability
, No
(V, HP, N)
Priorit
y
Yes,
No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Research team need to see the value in
appropriately carrying out research
protocol in clinics. (Utility Value)
N Y Learning and
motivation are
enhanced if the
learner values the
task (Eccles, 2006).

Rationales that
include a discussion
of the importance
and utility value of
the work or learning
can help learners
develop positive
values (Eccles, 2006;
Pintrich, 2003).
Discussions need to
be held with
research team that
highlight the
importance of the
work and processes
in the clinics in
order to help foster
positive values.

Research team believe they can
effectively carry out research protocol
processes. (Self-efficacy)
V Y Feedback and
modeling increases
self-efficacy
(Pajares, 2006).

Learning and
motivation are
enhanced when
learners have
positive expectancies
for success (Pajares,
2006).
Supervisors need to
provide research
team with
instructional
support
(scaffolding) early
on and feedback,
build in multiple
opportunities for
practice and
gradually remove
support.

Research team need
to be provided with
learning
opportunities to
observe a credible,
similar model
engaging in
behavior that has
functional value.

Less than half of the research team participants did not express confidence, or did not
find it applicable to their roles, to meet carry out the patient-centered research protocol in order
to increase patient retention. In order to help address this motivation influence gap, the research

66

team will need to feel competent and confident enough to implement the procedures and
strategies in the patient-centered protocol to meet the performance goal. Pajares (2006) claims
learning and motivation are enhanced when learners have positive expectancies for success.
A recommendation rooted in self-efficacy theory is to create opportunities for the
research team to implement new initiatives that are complemented by mentoring, support,
scaffolding, and feedback. The creation of a working model of best practices based on prior
experiences and successes from the research team, will provide the clinical staff at the CGHWC
with a model of examples they can apply to their own capabilities. Thus, feedback and modeling
can help increase self-efficacy of the research team. In addition, supervisors need to provide
research team with instructional support early on and build in multiple opportunities for practice
and gradually remove that support. Research team need to be provided with learning
opportunities to observe a credible, similar model engaging in behavior that has functional value.
Organizational Influences and Recommendation
Along with knowledge and motivation influences, organizational influences are also
important to address for the achievement of the CGHWC’s performance goal related to patient
retention. The previous section revealed the gaps in the organization’s ability to support the
stakeholders towards the organizational performance goal. Features of organizational culture that
need to be taken into consideration for the gap analysis include cultural models and cultural
settings, in addition to policies and practices. While the organizational models provide adequate
accountability for the stakeholders, the stakeholders expressed they are not provided with
adequate trainings to accomplish the organizational goal. Table 14 identifies the assumed
cultural models and cultural settings within the CGHWC and the recommendations from the
researcher.

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Table 15
Summary of Organization Influences and Recommendations
Assumed Organization Influence*

Validated
as a Gap
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation

Context-Specific
Recommendation
The organization needs a cultural
model of trust among research team
and research participants. (CM)

N Y Organizational
effectiveness
increases when
leaders are
trustworthy and, in
turn, trust their team
(Rath & Conchie,
2009).

Organizational
performance
increases when
individuals
communicate
constantly and
candidly to others
about plans and
processes (Clark &
Estes, 2008)

The organization
needs to foster
trust and
willingness to
change through
guidance from the
organizational
mission and
implementing
procedures and
norms that lead to
patient retention
via a patient-
centered and
culturally sensitive
research protocol.

Medical directors
will need to foster
an environment of
candid
conversation
which includes
sending out a
statement to staff
in the clinic to
outline the process
and allow space
during huddles and
monthly meetings
for review and
discussion.
Supervisors must allocate time
designated for training and hands-on
practice of skills and modules. (CS)
V Y Effective change
efforts ensure that
everyone has the
resources
(equipment,
personnel, time, etc.)
needed to do their
job, and that if there
are resource
shortages, then
The organization
needs to provide
necessary
resources and
should implement
the following steps
to monitor and
ensure that
adequate resources
are provided:

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resources are aligned
with organizational
priorities (Clark and
Estes, 2008).
1. Establish a
routine
communication
process between
supervisors and
staff.

2. Regularly
monitor the use of
resources to
ensure the
organization is
fiscally
responsible.

3. Align the
allocation of
resources with the
goals and priorities
of the
organization.

CM: Cultural Model
CS: Cultural Setting
The organization and leadership need a cultural model of trust among the research
team. Data analysis from this study found that while there is not a gap in trust among research
team and research participants, there could be improvements in the overall collaborative nature
of the research team as a collective. A recommendation rooted in cultural model theory will help
address this need. Clark and Estes (2008) suggest organizational effectiveness increases when
individuals communicate constantly and candidly to others about plans and processes. As such,
medical directors will need to send out a statement to staff in the clinic to outline the process and
allow space during daily briefs and monthly meetings for review and discussion of incorporating
a patient-centered research protocol into the workflow.
Organizational effectiveness also increases when leaders are trustworthy and, in turn,
trust their team (Rath & Conchie, 2009). The organization needs to foster trust and willingness to
change through guidance from the organizational mission and implementing procedures and

69

norms that lead to patient retention via a patient-centered and culturally sensitive research
protocol. Rueda (2011) highlights that cultural models play a role in how organizations provide
structure and inform those structures along with policies, practices, and values. Leadership will
need to foster an environment of candid conversation, which includes sending out a statement to
staff in the clinic to outline the process and allow space during huddles and monthly meetings for
review and discussion. Additionally, research study protocols need to be culturally sensitive and
utilize approaches that build on the relationships with participants and with trust of research staff
(Tucker, Marsiske, Rice, Jones, & Herman, 2011). Crabtree et al. (2011) promote PCMH models
as they call for continual quality improvement of health research interventions along with the
tailoring of interventions based on theoretical frameworks.
Leadership must allocate time designated for training and hands-on practice of skills
and modules related to the research protocol.
Data analysis found that research team need resources and training related to
implementing a patient-centered research protocol. A recommendation grounded in cultural
settings theory will help address this gap. Cultural settings are those instances when groups of
individuals collectively execute an activity or action that corresponds to a particular value – or in
other words, those visible aspects of organizational culture (Gallimore & Goldenberg, 2001). In
addition, cultural settings are those social contexts in which practices, policies, and procedures
are executed within organizational culture (Rueda, 2011). Effective change efforts ensure that
everyone has the resources (equipment, personnel, time, etc.) needed to do their job, and that if
there are resource shortages, and then resources are aligned with organizational priorities (Clark
and Estes, 2008).

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In alignment with Schein (2017), organizations need to provide an element of shared
learning in their culture (Edmondson, 2012). Crabtree et al. (2011) encourage researchers to
allocate the space and time for members of primary care teams to develop strategies for the
intervention. Therefore, the CGHWC needs to provide necessary resources and should
implement the following steps to monitor and ensure that adequate resources are provided. Such
as establishing a routine communication, process between supervisors and staff that solicits
needs and establishes priorities. Along with regularly monitoring the use of resources to ensure
the organization is fiscally responsible and aligning the allocation of resources with the goals and
priorities of the organization.
Limitations and Delimitations
As a practitioner in the field of public health research, I am cognizant that the stakeholder
group of interest can bound this research study. I attempted to understand the patients’
experiences participating in a research study in a primary care adult outpatient clinic through the
lens of administrative and clinical research team. I acknowledge that by focusing on this
population, I might not have been able to capture the rich narratives from patients directly that
contribute to the literature. In addition, due to data collection stemming from my place of
employment, interview participants might not have been as forthcoming to participate in the
study, thus, affecting the sample size. My study led to a smaller sample size than anticipated
(five participants). Therefore, is not representative of all patient experiences in research in a
primary care setting. Moreover, since I was blinded to who participated and only received de-
identified transcripts from the research assistants, I was unable to reach back out to the
participants for additional clarification. Furthermore, IRB review and approval as well as the
recruitment for this study were significantly limited by the COVID-19 pandemic along with the

71

flu season that conflicted with the clinic staff’s schedules (specifically the nurses and nurse
manager).
Conclusion
The purpose of this study was to understand the knowledge, motivation, and
organizational influences that affect the CGHWC in implementing a patient-centered research
protocol in the primary care clinic. The research team members who were interviewed in this
study recognized the need to institutionalize this type of protocol as an essential component of
the primary care clinic’s stability. Nonetheless, the findings also presented additional insight as
to why the clinic experiences a high rate of patient attrition. Communication of the protocol and
providing clear justification behind additional research-related trainings was one of the themes
identified in this study as a suggestion for leadership. The participants interviewed also noted
that there is representation across the research team that helps promote continuity of care for
patients, but could do a better job in bridging providers from the organization and the partnering
university. This dissertation addressed the need to implement a patient-centered research
protocol in the primary care clinic and the challenge of institutionalizing these processes when
the organization must find ways to communicate shared goals with the partnering university.
This study sought to examine the shared values that the CGHWC primary care clinic
might share with the partnering university and how they could work together to accomplish the
performance goal. Using the Clark and Estes’ (2008) KMO framework, the researcher identified
and evaluated the knowledge, motivation, and organizational gaps that are identified as hurdles
to the implementation of the protocol to achieve the organizational performance goal. The
literature review highlighted the importance of a PCMH model and patient-centered care. While
the concept of an institutionalized patient-centered research protocol in the primary care clinic

72

would help create an opportunity for the clinic to increase patient retention, the findings showed
that additional communication and trainings would also be necessary towards effective
healthcare services and patient satisfaction (Newell & Jordan, 2015). Finally, an implementation
plan was proposed using the Four Levels of the Kirkpatrick and Kirkpatrick (2016) World Model
to offer possible solutions for the CGHWC to create meaningful impact in the area of patient
retention.

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Appendix A: Participating Stakeholders with Sampling Criteria for Interviews
Participating Stakeholders
The stakeholder population of focus was the clinical and research team within the
CGHWC, which is comprised of the clinic’s front office clerks, medical assistants, healthcare
providers, and medical directors in addition to the occupational therapy clinicians and student
research assistants from the partnering university. The stakeholder inclusion criteria are that they
have to be employed or contracted through the County’s system and cleared to interact with
patients. Furthermore, the criteria for County onboarding is completing a background check and
health clearance through the County system, along with Collaborative Institutional Training
Initiative (CITI) Human Subjects Research, Good Clinical Practice (GCP), and Health Insurance
Portability and Accountability Act (HIPAA) certifications. Research team – particularly those
placed directly in the adult outpatient clinics – play a pivotal role in the recruitment and retention
of patients due to their initial and final points of contact with patients. This stakeholder group is
in constant interaction with not only one another, but are on the front-line with regards to direct
patient services thus have an impact on the patient retention performance goal. The next section
will discuss the research methodology as it relates to the knowledge, motivational, and
organizational influences.
Interview Sampling Criteria and Rationale
Criterion 1. Research team employed and/or contracted through the County system and
have access to patient records information are eligible to participate in the focus group. Only
certified and cleared staff that come in direct contact with patients are considered eligible
participants. The research questions ask knowledge and motivation of research team at the
CGHWC. This first criterion for research team will ensure that only those staff who have come

74

in contact with study participants in this specific setting will be captured in order to help address
the K and M aspects in the research questions.
Criterion 2. To be eligible for the interviews, clinic staff and research team must have
participated in at least a prior or current study within the CGHWC County system, specifically
within the adult outpatient clinics. Research team will be the key participants for this study due
the insight their knowledge and motivation influences will provide in relation to the research
questions on minority patient retention.
Interview Sampling (Recruitment) Strategy and Rationale
A nonrandom, or nonprobability, purposeful sampling strategy will be used to select the
participants as it is a qualitative study (Maxwell, 2013; Merriam & Tisdell, 2016). Purposeful
sampling enables the researcher to gain the most insight from a sample that will be information-
rich for learning purposes (Merriam & Tisdell, 2016). Participants were recruited via a
comprehensive email list with up-to-date contact information from the medical director and were
encouraged to participate thought their direct supervisors through reminders during “morning
huddles”. Purposeful sampling will assist with achieving a sample that is representative of the
individuals in a particular setting and will also enable the research to establish productive
relationships with the selected participants (Maxwell, 2013). Using a purposeful sampling
approach, I recruited up to five participants to take part of the interviews (Johnson &
Christensen, 2015). Based on Creswell and Creswell’s (2018) recommendation, this would be
the ideal number of participants before reaching a point of saturation in which data gathering
would stop as it will no longer provide new insight. Given that these clinics within the CGHWC
have ongoing and overlapping research studies with the partnering university, individual,

75

semistructured interviews would provide helpful information when it comes to organizational
influences related to minority patient attrition and retention.
Explanation for Choices
Semistructured interviews were the main methods of data collection for this study, which
included more open-ended questions that permit flexibility when collecting specifi data, or
respsonses, from the participants (Merriam & Tisdell, 2016). This method was selected due to
the small sample size within a qualitative study; this homogenous group of participants –
research team - shared knowledge on specific topics or issues related to patient attrition and
retention (Johnson & Christensen, 2015; Merriam & Tisdell, 2016). Had this study been a
quantitative study with a larger sample size, a probability approach would have been used to
reduce sampling error and have more representative sample (Fink, 2013). In that scenario,
surveys would have been the main form of data collection using a stratified random sampling
strategy to get an equal representation of various demographics and groups (Fink, 2013; Johnson
& Christensen, 2015).

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Appendix B: Protocols
Interview Protocol
Thank you for participating in this focus group. I am a doctoral student at the USC
Rossier School of Education, in the Organizational Change and Leadership program. I am
conducting this research and will need your signed consent prior to participating in the focus
group. I would like to take some time to ask the following questions about your experience in
working with patients and research in your particular clinic. Before we begin, I will provide you
all with the consent form and give you time to read and ask questions. With your consent, I will
record our conversation. I will ask each of you the same question.
First, to get us started, how are you doing (during this time)? Any good things that have
happened? How are you feeling?
I would like to understand a little bit more about perceived reasons as to why patients
may not be returning to their follow-up appointments.
4. Why do you believe patients do not return?
a. What could you be doing differently?
b. What resources or trainings would help do this better?
5. What do you perceive to be challenges in patient retention?
6. How does your organization attract minority patient participation?
These next set of questions are regarding your role and your team’s with patients.
7. In what ways does your role influence the retention of patients in the clinic?
a. What are your reasons for helping increase patient retention?
b. What are the benefits of increasing patient retention?
c. How confident do you feel that will be able to do it?

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d. Do you believe it’s a good idea? Why or why not?
8. How does the research team support patient retention?
a. What are some of the challenges associated with retention?
b. Which strategies, in your opinion, has been the most effective?
c. What, if anything, do you think is lacking?
9. What about the organization?
a. How does the organization promote the retention of patients?
b. Can you give me an example of the organization not doing anything to
that extent?
These next questions ask about any relevant trainings, if any, offered by the organization
that are related to your role.
10. If there are research training opportunities available within your unit, how would you
describe the types of trainings offered?
a. How beneficial are these trainings?
b. How do you feel they could be improved?
11. Based on personal experience, within your unit, how efficient are research training
programs?
a. Tell me more about that.
b. How do you receive the training programs?
c. What is your perception of your training programs?
d. What additional resources do you need or want?
Thank you for sharing with me. Now, I would like to learn more about the organizational
culture at the CGHWC.

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12. What is trust within the organization context for you?
a. What does trust look like in an organization for you?
b. What is your experience with trust in this organization?
13. How would you characterize the support of leadership?
Lastly, could you tell me:
14. What has your personal experience been in collaborating with the research team in the
CGHWC?
a. Tell me about the nature of collaboration.
b. What has your team’s experience been?
15. What is your experience to implementing a research protocol that is patient-centered?
a. How was that experience for you?
b. What type of support, if any, do you receive from leadership?
These are all the questions I have for now. I would like to thank you for your time in
answering these questions and providing valuable insight into your role and the organization. We
hope this will help with next steps in addressing any challenges.

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Appendix C: Credibility and Trustworthiness
I ensured credibility and trustworthiness of the study by conducting ethical research.
Strategies used when analyzing the data included collecting rich descriptions and reflexivity
(Merriam & Tisdell, 2016). The use of member-checking is often used as a strategy to improve
credibility. However, for this study, it was not feasible. Member-checking for this study would
have required me to provide those participants that were interviewed with a copy of the transcript
from those interviews for feedback and to ensure what was captured is true. Through member
checks, the researcher can rule out possible misinterpreting the meaning of what participants said
during the interview and can serve to identify researcher bias (Merriam & Tisdell, 2016).
Due to the novel COVID-19, we were only able to interview 5 members of the research
team. While I did not conduct the interviews myself, I was still able to use reflexivity as the
researcher as I coded the deidentified transcripts I received. Through the use of reflexivity, I was
able to reflect on and capture my biases, dispositions, and assumptions regarding the research
that was conducted (Merriam & Tisdell, 2016). By being transparent and aware of my biases and
assumptions can allow the reader to better understand how I may have arrived at interpretation of
the data (Merriam & Tisdell, 2016). This is what I was able to accomplish considering the
special circumstances in the medical field and within one of the largest public medical centers in
the country.

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Appendix D: Ethics
My current role as a research administrator permits me access to certain spaces and
conversations centered on patient care within a healthcare center and academia. As researcher,
some of the most salient responsibilities are to demonstrate respect for others, maximize benefits
while minimizing risks, and avoid taking advantage of vulnerable populations (Glesne, 2011;
Merriam & Tisdell, 2016). From the early phases of the research study up until its conclusion, I
must follow all ethical guidelines set forth by the Institutional Review Board (IRB). IRB
guidelines would safeguard that, as the researcher, I am able to conduct ethical research given
appropriate training (Merriam & Tisdell, 2016).
Throughout the informed consent process, the research assistants informed the
participants that their participation is voluntary, informed them of any potential risks, and
assured them that they may choose not to participate at any time (Glesne, 2011). Participants
were also provided with a copy of the consent form. It is important to note, that while the study
is within a healthcare setting, there will not be additional collection of protected health
information (PHI) particularly that of patients who interact with research team as part of their
regular healthcare visits and appointments. Furthermore, Rubin and Rubin (2012) remind
researchers to protect and respect participants and guarantee no harm by either coercing,
pressuring or deceiving them. Research assistants informed the participants of their rights via the
consenting process. Permission was also obtained from the participants of the recordings and
were informed if there will be sharing or publishing of such recordings.
The study took place remotely via Zoom between the CGHWC and the affiliated
university campus. In the context of this study, I am an external collaborator and contractor
within the CGHWC and as such, I must remain aware of my professional relationship with the

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stakeholder group – the research team, who are university students and CGHWC clinic staff. In
alignment with Glesne’s (2011) discussion on advocates serving as interveners through their
research, I would further add that I carry on the role of an advocate in relation to healthcare
system and research by promoting change for minority patient care. I will have to remind
research team of my embedded role as researcher along with research administrator and of any
potential ramifications related to their roles and activities.
While I am not a direct supervisor nor explicitly in management - within the scope of
these organizations - I still oversee student research placements to an extent. As such,
acknowledging this at the forefront would help assure students that the study will not jeopardize
their roles and not coerced to participate in the study and have the option to opt out from
participating at any time, and continue with their roles. Concerning the CGHWC staff, they will
also be informed of my role, but assured that it will not negatively affect their workload nor will
there be reprimands should they choose to not participate or opt out.
Given my past experiences in healthcare research settings and coming from an
underserved, minority population, it would be imperative to take into consideration my own
personal biases when it comes to data collection and data analyses so that own personal beliefs
and opinions do not interject or interfere with participants’ responses (Rubin & Rubin , 2012).
Moreover, considering the sensitive nature of working within a healthcare setting, providing
extra protection for at-risk populations is critical. For these reasons, the IRB reviewed the study
including the types of questions for the focus group interviews. I ensured that the interview
questions are not too insensitive or probing in an effort to avoid any additional risks (Krueger &
Casey, 2009; Rubin & Rubin, 2012).

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Appendix E: Implementation and Evaluation Plan
The New World Kirkpatrick Model will be used in the implementation and evaluation
plan for this study particularly Level 4: results and Level 3: behavior. There are four distinct
levels that characterize the New World Kirkpatrick Model: Level 1: Reaction, Level 2: Learning,
Level 3: Behavior, and Level 4: Results, which are implemented in reverse order for planning of
training programs. Level 4 targets the outcomes that are a result of training as well as support
(Kirkpatrick & Kirkpatrick, 2016). Level 3 is the extent to which individuals apply what they
have learned from training in their work setting. The CGHWC will utilize the New World
Kirkpatrick Model in their framework for implementation and evaluation to assess and measure
the implementation for a patient-centered care plan.
Organizational Purpose, Need and Expectations
The CGHWC’s mission is, “to provide fully integrated, accessible, affordable and
culturally sensitive care on person at a time.” The organizational problem of focus for the
GHWC will be the high attrition of minority patients in their adult outpatient clinic. The
organizational goal is to remain at 10% attrition or lower benchmarked against the Standards of
Care recommendation for Patient Centered Medical Home (PCMH) models. Thus, by June 2021,
the CGHWC will retain 20% of minority patients recruited for a research study in their adult
outpatient clinic. Accordingly, the CGHWC will develop and integrate a patient-centered
research protocol in their adult outpatient clinics with a particular focus on the retention of
minority research participants. The stakeholder goal is by June 2021, the research team will
implement a patient-centered and culturally sensitive patient treatment plan in 90% of research
studies in the adult outpatient clinic. In order to show improved health outcomes for all its

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patients that are in alignment with their mission, it is important for the CGHWC to follow a
protocol for patient retention and adherence.
Level 4: Results and Leading Indicators
Table 16
Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
Reduce number of no-shows Number of missed and kept
appointments in EMR schedule
Tracking in Electronic Medical Record
(EMR)
Improved medication
adherence
Number of kept follow-up
appointments in EMR and visits
with clinical pharmacist
Check number of prescription refills
remaining in EMR record

Internal Outcomes
Reduce the time it takes for
scheduling/rescheduling
follow-up appointments
Number of appointments scheduled
and attempted tries (reminder calls)
EMR system logs
Increase retention rate of 20%
for minority patients
Number of visit types Monthly reports generated by medical
directors
Increase availability of
appointments or flexibility or
drop-in
Number of available time slots in the
EMR booking system
EMR log
Increase patient satisfaction Number of complaints and/or praises
from patients
Surveys
Increase confidence or trust Ambulatory Safety and Quality (ASQ)
score
ASQ surveys
Increase medication/treatment
adherence
Days patients report of missed doses Monthly reports
Decrease patient dissatisfaction
with scheduling
Number of complaints from patients CGHWC records

Level 3: Behavior
Critical Behaviors
The behavior level in the New Kirkpatrick World Model is an important system for
monitoring and improving performance (Kirkpatrick & Kirkpatrick, 2016). The key behaviors
that the stakeholder group of focus will demonstrate to achieve the outcomes include dialogue
and interactions with patients and other members of the team, how patients are screened and

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enrolled into a study, scheduling or rescheduling appointments for patient follow-up, and how
patients are discharged after their appointments and/or referred to other services. Research
team’s behaviors will help depict their knowledge of patient intake for the recruitment and
consenting phases of the research study.
Table 17
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Ability of
research team
to know which
parts of
patient
screening and
enrollment are
difficult to
conduct.
Number of trainings
offered during the fiscal
year
Quizzes provided by intranet
system
Quarterly (every three
months)
2. Ability of
research team
create a plan
for contacting
patients and
scheduling for
follow-up
appointments
Number of attempted calls
and voicemails from call
log reports in EMR
Assigning tasks in EMR for
patient follow up
Every week
3. Ability of
research team
to discharge
and refer
patients
following
their
appointment.
Number of appointments
scheduled
Trainings during meetings Quarterly

Required Drivers
Research team need to be provided with appropriate models in the clinics to help foster
positive values. Supervisors need to provide research team with instructional support
(scaffolding) early on and feedback, build in multiple opportunities for practice and gradually

85

remove support. Also, research team need to be provided with learning opportunities to observe
a credible, similar model engaging in behavior that has functional value.
Table 18
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Job aids (or visual aids) for
research team that covers
different techniques for
patient screening and
enrollment
Ongoing 1, 2, 3
Reminders & refreshers by
research coordinator for
research team on how to
conduct screening and
enrollment with potential
research participants
Team morning huddles and
monthly meetings
1, 2, 3
Encouraging
Newsletters
highlights/shoutouts by
medical directors that
showcase research team
accomplishments and patient
retention goals and met
metrics
Monthly 1, 2, 3
Medical directors meet with
executive leadership to
discuss milestones met and
how continuing support can
be provided
Quarterly 2, 3
Rewarding
Medical directors
acknowledge staff anytime
they observe exemplary
behaviors in the clinic floor
Monthly 1, 2, 3
Monitoring
On the floor observation by
medical directors and research
coordinator
Daily 1, 2, 3
CGHWC conduct reviews of
the research team’s progress
Monthly 1, 2, 3

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in implementing the research
protocol
Medical directors and
executive leadership assess
and provide feedback to
research team and discuss
how to continue developing
and improving the research
protocol
Upon completion of
milestones
1, 2, 3

Organizational Support
The organization will help support the stakeholders’ critical behaviors in several ways.
Supervisors need to provide research team with meaningful and factual information (via a
research protocol) that will help and support research team with the patient enrollment process
and help connect the research team’s prior knowledge with new and relevant practices.
Additionally, supervisors will need to provide training for research team that includes guidance,
modeling, coaching, practice, feedback and other scaffolding during performance. Furthermore,
the organization needs to implement a culturally sensitive and patient-centered research protocol
in the clinic. Medical directors will need to send out a statement to staff in the clinic to outline
the process and allow space during huddles and monthly meetings for review and discussion.
The organization needs to provide necessary resources and should implement the following steps
to monitor and ensure that adequate resources are provided:
1. Establish a routine communication process between supervisors and staff that solicits
needs and establishes priorities for budgeting purposes.
2. Regularly monitor the use of resources to ensure the organization is fiscally
responsible.
3. Align the allocation of resources with the goals and priorities of the organization.
Level 2: Learning

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Learning Goals
The following list consists of the learning goals that are essential for clinic and research
team to achieve the critical behaviors outlined in Table 17.
1. Distinguish which parts of patient screening and enrollment are difficult to
conduct (D).
2. Apply the proper steps and procedures for patient screening and enrollment. (P)
3. The CGHWC will implement a culturally sensitive and patient-centered research
protocol in their adult outpatient clinic. (P)
4. Value in appropriately carrying out the research protocol in the clinic. (Utility
Value)
5. Believe they can effectively carry out the research protocol processes. (Self-
Efficacy)
6. Engage in tasks that will lead to the organizational goal of patient retention. (Goal
Orientation)
Program
In order to close the gap in declarative knowledge in this study, a patient-centered and
culturally sensitive research protocol for CGHWC clinic and research team is recommended.
Additionally, in order to close the gap in procedural knowledge, training for clinic and research
team in the CGHWC adult outpatient clinic is also recommended. The CGHWC will develop
and integrate a patient-centered research protocol in their adult outpatient clinics with a
particular focus on the retention of minority research participants. In addition, within the last 48
months, the medical leadership team is advocating for a move towards an integrated Patient
Centered Medical Home Model (PCMH) to address the high patient attrition and no-show rates

88

at the clinic level. Additionally, the Department of Health Services (DHS) strategic plan focuses
on streamlining a mechanism related to a patient’s care and treatment plan by forging
partnerships across various agencies (DHS, 2018).
Evaluation of the Components of Learning

Table 19
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Review of research protocol steps Monthly team meetings
Knowledge checks during training At the end of each section and prior to
commencing next section
Pair share-outs During team meetings
Procedural Skills “I can do it right now.”
Demonstration of ability to screen and enroll
patients
Throughout the training process and
follow-up observations
Demonstration of ability to follow protocol in
clinic setting
Throughout the training process and
follow-up observations
Attitude “I believe this is worthwhile.”
Survey questions At the end of training sessions
Observations On the floor follow-up
Confidence “I think I can do it on the job.”
Survey questions At the end of training sessions
Pre and post assessment At the end of training sessions
Small group or pair discussions During monthly meeting
Commitment “I will do it on the job.”
Discussion Post-training sessions
Observations On the floor follow-up

Level 1: Reaction
According to the Kirkpatrick New World Model, Level 1: Reaction is, “the degree to
which participants find the training favorable, engaging, and relevant to their jobs (Kirkpatrick &
Kirkpatrick, 2019, p. 39). Within Level 1, it is critical to obtain information in order to best

89

utilize resources for a training program. Table 19 lists the methods and/or tools that will be used
for the Level 1 evaluation of the research protocol and training program at the CGHWC.
Table 20
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Facilitator observations During sessions and follow-up in clinic
Program evaluation At the end of the training program
Participants ask questions Throughout training
Relevance
Discussions During sessions and follow-up in clinic
Program evaluation At the end of the training program
Customer Satisfaction
Program evaluations At the end of the training program
Survey At the end of training sessions

Evaluation Tools
Immediately Following the Program Implementation
To assess knowledge, staff will be asked to paraphrase at least three different steps of
patient screening and enrollment. Additionally, at the conclusion of a training program, an
anonymous survey will be sent out to staff for evaluation. This survey will assess if and how the
training applies to and influences staff and if it is emulated by staff during the clinical setting.
Staff will be asked to assess their own effectiveness using patient satisfaction questionnaires.
Appendix B contains the proposed instrument for this evaluation.
Delayed for a Period After the Program Implementation
In order to solicit feedback from the training, an anonymous survey will be disseminated
among the research team. There will be scaled survey items that will assess the degree to which
staff feel it is important to understand research processes. In addition, staff will be asked to

90

answer their scale of confidence in their ability to screen and enroll patients. Appendix C
contains the instrument for this evaluation.
Data Analysis and Reporting
The CGHWC leadership and leadership from the partnering university will receive clear
and significant data with the clinic and research team’s progress and support from focus groups
anecdotal data. Consistent with Kirkpatrick and Kirkpatrick’s (2016) direction on data analysis,
leaders and executives will be informed whether the CGHWC is meeting metric expectations, or
if they are not, and the reasons behind it. Additionally, to support the insights on satisfaction and
progress, CGHWC leadership will also receive reports and analysis of the anonymous surveys
that will be administered at the completion of the training program(s). Figure 1 provides an
example of the type of reporting that will be generated upcoming completion of training sessions
using fictitious data.

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Appendix F: Definitions
Patient-centered medical home (PCMH): approach to provide comprehensive care to
patients (children, youth, and adults); healthcare setting that promotes partnerships between
patients and their providers and the patients’ family (AAFP, 2007).
Patient-centered care (PCC): standard for high-quality care (Bertakis & Azari, 2011);
“providing care that is respectful and responsive to individual patient preferences, needs, and
values, and ensuring that patient values guide all clinical decisions,” (Bloom, 2002; IOM, 2001)

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Asset Metadata

Creator Salazar, Elia (author)

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

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 02/26/2021

Defense Date 12/15/2020

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

Tag clinical research,cultural sensitivity,OAI-PMH Harvest,patient attrition,patient retention,patient-centered care,primary care

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee member), Canny, Eric (committee member), Robles, Darline (committee member)

Creator Email elia.salazar3@gmail.com,eliasala@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-424100

Unique identifier UC11668650

Identifier etd-SalazarEli-9291.pdf (filename),usctheses-c89-424100 (legacy record id)

Legacy Identifier etd-SalazarEli-9291.pdf

Dmrecord 424100

Document Type Dissertation

Rights Salazar, Elia

Type texts

Source 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 a...

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