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Employee engagement and leadership collaboration: a gap analysis of performance improvement teams in healthcare

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Employee engagement and leadership collaboration: a gap analysis of performance improvement teams in healthcare

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EMPLOYEE ENGAGEMENT AND LEADERSHIP COLLABORATION:
A GAP ANALYSIS OF PERFORMANCE IMPROVEMENT TEAMS IN HEALTHCARE
by
Ashley R. Kelly

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

August 2020

Copyright 2020 Ashley R. Kelly

ii
Dedication
I dedicate this dissertation to my late mother and to all of those who have lost their lives
due to medical errors. My mother’s life ended abruptly at the age of 51. There were a number of
factors that lead to her fate but the most prevalent in my mind were the multiple medical
mistakes that occurred during her course of care. If any one of them could have been reversed,
perhaps she would still be here today. I lost her at the beginning of my doctoral program. Though
those were some of the darkest days of my life, I did not waiver in my goal to complete this
program knowing how proud my mother would have been to see me finish.
I considered writing my dissertation on the specific medical errors that lead up to her
death, but chose not to, as I was advised that it may be too emotional of a subject. I decided
instead to write my dissertation on a performance improvement program that I had oversight for
in my place of employment. It wasn’t until my dissertation proposal defense that I realized, I
inadvertently selected a topic that had the potential to prevent the very medical errors that
contributed to my mother’s death.
My mother inspired me to be a better woman, though most of the time, not in the most
conventional ways but nothing in my life has really been conventional. The truth still remains, I
would not be the woman, wife, mother, nor leader I am today without the love and influence of
my mother. It is my hope that this study will spark a fire of change in the healthcare industry
leveraging research-based performance improvement methodology to eliminate medical errors.
No one should lose their life by the very hands of those dedicated to saving and preserving
human life.

iii
Acknowledgements
Thank you to my husband, without whom, none of this would have been possible.
Raising three children, working full time, and juggling the normal challenges of life were enough
to keep us insanely busy on their own. Yet, you did not hesitate for even a second the day I told
you about my desire to pursue this degree. You not only supported me in this journey, you
adopted my dream as your own. You are, and forever will be, my partner in life and very best
friend.
Thank you to my three beautiful children. I have often struggled knowing how much time
we lost these last few years so that I could pursue this goal. Yet you have never once made me
feel guilty. Your understanding and support empowered me to press in during times that I wanted
to give up. As a middle-school drop-out, runaway teen, who started motherhood as a teenager,
my hope is that you will look at my life and see that your past does not define you. You have the
power to be who you want to be. When life gets difficult, you fight on!
Thank you to my dad. You have been a rock for me throughout my entire life. Whenever
life feels upside down, you have been the one I turn to for advice, and you always find a way to
ground me in truth. A few nights in particular come to mind, somewhere in the midnight to
3:00am hour. I bet you never thought you’d still be losing sleep over your daughter this late in
life! Thank you to Christine for never being angry with me for those late night calls to my dad.
Thank you to my Bumpy. We have shared the grief of loss in a few different ways. You
loved my mother so fiercely, and for that I will forever be grateful. Your love for my children
brings joy to my heart every day. You have been an encouragement for me not only in the
pursuit of my dreams, but in life. I feel so incredibly blessed to have you in our lives.
Thank you to my fellow Cohort IX members. This has been a journey we will not soon

iv
forget! I am going to miss watching you talk without realizing you are on mute and receiving the
private messages you would send bringing levity to the course content as we were in our virtual
classes. Although we were robbed of our plans for commencement, and our Disney celebration, I
am looking forward to long-lasting friendships and future networking with each of you.
Thank you to my dissertation committee for your feedback and support. Your words of
encouragement shattered the threatening “Imposter Syndrome” I often struggled with. Lastly,
thank you to Dr. Yates, the best chair in all of USC. Your availability, scaffolding, and relentless
support carried me to the finish line of this program.

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Table of Contents
Dedication…………………………………………………………………………….………….. ii
Acknowledgements………………………………………………………………………………iii
List of Tables……………………………………………………………………………………. ix
List of Figures…………………………………………………………………………………… xi
Abstract…………………………………………………………………………………………. xii
CHAPTER ONE: OVERVIEW OF THE STUDY……………………………………..……….. 1
Introduction of the Problem of Practice…………………………………………...……... 1
Organizational Context and Mission……………………………………………..……… 2
Organizational Performance Status………………...…………………………………….. 3
Related Literature…………………………………...……………………………………. 4
Importance of Addressing the Problem………………..………………………………… 5
Organizational Performance Goal……………………………...………………………… 6
Description of Stakeholder Groups………………………………………………………. 6
Stakeholders Performance Goals………………………………...………………………. 7
Stakeholder Group of Focus……………………………………..………………………. 8
Purpose of the Project and Questions…………………………….……………………… 9
Methodological Framework……………………………………….…………………….. 9
Definitions………………………………………………………………………………. 10
Organization of the Study………………………………………………………………. 11
CHAPTER TWO: REVIEW OF THE LITERATURE………………………………………… 12
Measuring Performance………………………………………………………………… 13
Role of Stakeholder Group of Focus…………………………………………………… 14

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The Clark and Estes Gap Analysis Conceptual Framework…………………………… 14
Stakeholder Knowledge, Motivation and Organizational Influences…………………. 15
Knowledge and Skills…………………………………………………………. 15
Motivation……………………………………….…………………………….. 18
Organization…………………………………………………………………… 22
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation
and the Organizational Context………………………………..……………….. 25
Conclusion…………………………………………………………..………………….. 28
CHAPTER THREE: METHODS……………………………………….…..………………….. 29
Participating Stakeholders………………………………………...……………………. 29
Survey Sampling Criteria and Rationale……………………..………………… 30
Survey Sampling (Recruitment) Strategy and Rationale……………………….. 30
Data Collection and Instrumentation…………………………………………………… 31
Surveys………………………………………………………….………………. 31
Documents and Artifacts……………………………………….……………….. 31
Data Analysis…………………………………………………………………………… 33
Validity and Reliability…………………………………………….…………………… 34
Ethics……………………………………………………………….…………………… 34
CHAPTER FOUR: RESULTS AND FINDINGS………………………….…………………... 36
Participating Stakeholders……………………………………………………………… 36
Determination of Assets and Needs…………………………………………………….. 37
Results and Findings for Knowledge Causes………………...…………………………. 40
Factual Knowledge…………………………………...………………………… 40

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Conceptual Knowledge…………………………………………….…………… 44
Procedural Knowledge…………………………………………….……………. 46
Metacognitive Knowledge………………………………………..…………….. 49
Results and Findings for Motivational Causes………………………….……………… 50
Value……………………………………………………….…………………… 50
Attribution………………………………………………….…………………… 52
Goal Orientation………………………………………………………………… 53
Results and Findings for Organizational Causes……………………………………….. 55
Cultural Models………………………………………………………………… 55
Cultural Setting……………………………………...………………………….. 58
Summary of Validated Influences…………………………...…………………………. 61
Knowledge……………………………………………………………………… 62
Motivation………………………………………………………………………. 63
Organization…………………………………...………………………………... 63
CHAPTER FIVE: RECOMMENDATIONS, IMPLEMENTATION, AND EVALUATION… 65
Organizational Context and Mission…………………………………………………… 65
Organizational Performance Goal…………………………………………….………… 66
Description of Stakeholder Groups………………………………….……….…………. 66
The Goal of the Stakeholder Group for the Study………………….……….………….. 67
Purpose of the Project and Questions……………………………………..……………. 68
Introduction and Overview……………………………………………………..………. 69
Recommendations for Practice to Address KMO Influences…………………..………. 69
Knowledge Recommendations………………………………………….……… 70

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Motivation Recommendations………………………………………………….. 77
Organization Recommendations……………………………………….……….. 81
Integrated Implementation and Evaluation Plan…………………………….………….. 87
Implementation and Evaluation Framework………………………………….… 87
Organizational Purpose, Need, and Expectations………………………….…… 87
Level 4: Results and Leading Indicators…………………..……………. 88
Level 3: Behavior……………………………………………..………… 89
Level 2: Learning…………………………………………………..…… 92
Level 1: Reaction…………………………………………………..…… 94
Evaluation Tools……………………………………………………………..…. 95
Data Analysis and Reporting………………………………………………….... 97
Summary…………………………………………………………………..……. 97
Strengths and Weaknesses of the Approach………………………………………….… 97
Limitations and Delimitations……………………………………………………..……. 97
Future Research………………………………………………………………………… 98
Conclusion……………………………………………………………………………… 99
References……………………………………………………………………………...……… 100
Appendix A: Survey Items…………………………………………………………………….. 107
Appendix B: Document Analysis………………………………………………...…………… 115

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List of Tables
Table 1: Organizational Mission, Global Goal, and Stakeholder Performance Goals…………... 8
Table 2: Knowledge Influence, Knowledge Type, and Knowledge Influence Assessment…..... 17
Table 3: Assumed Motivational Influence and Motivation Influence Assessment…………..… 21
Table 4: Assumed Organizational Influence and Organizational Influence Assessment…..…... 24
Table 5: Survey Results for Role Demographics of Stakeholders………………………...……. 36
Table 6: Participating PITs and Corresponding Performance…………………………..……… 38
Table 7: Survey Results for Factual Knowledge of the Organization’s Goals…………...…….. 41
Table 8: Survey Results for Factual Knowledge of the Definition of a Gap Analysis…...…….. 43
Table 9: Survey Results for Conceptual Knowledge Related to the Relationship Between PIT
Goals and the Organization’s Goals……………………………………………………………. 45
Table 10: Survey Results for Procedural Knowledge Related to the Process for Identifying
Department Performance……………………………………………………………………….. 47
Table 11: Department Analysis for Procedural Knowledge Related to the Process for Identifying
Department Performance………………………………………………………………..……… 48
Table 12: Survey Results for Metacognitive Knowledge Related to PIT Member’s Self-
Reflection of Their Effort Invested to Improve Their Department’s Performance………..…… 49
Table 13: Survey Results for Value Motivation Related to PIT Training……………………… 51
Table 14: Survey Results for Attribution of Success or Failure Within a PIT………….……… 53
Table 15: Survey results for goal orientation of members within a PIT………………...……… 54
Table 16: Survey Results for a Cultural Model of Continuous Improvement Within a PIT….... 56
Table 17: Survey Results for Cultural Model of Partnership Within a PIT…………………….. 57
Table 18: Survey Results for Cultural Setting of Time Resources Within a PIT…………...….. 59

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Table 19: Survey Results for Cultural Setting of Available Tools……………………….…….. 60
Table 20: Knowledge Assets or Needs as Determined by the Data……………………………. 62
Table 21: Motivation Assets or Needs as Determined by the Data…………………….………. 63
Table 22: Organization Assets or Needs as Determined by the Data…………………..………. 63
Table 23: Organizational Mission, Global Goal, and Stakeholder Performance Goals……...… 68
Table 24: Summary of Knowledge Influences and Recommendations………………………… 70
Table 25: Summary of Motivation Influences and Recommendations………………………… 78
Table 26: Summary of Organization Influences and Recommendations……………….……… 81
Table 27: Outcomes, Metrics, and Methods for External and Internal Outcomes……...……… 89
Table 28: Critical Behaviors, Metrics, Methods, and Timing for Evaluation…………..……… 89
Table 29: Required Drivers to Support Critical Behaviors…………………………...………… 91
Table 30: Evaluation of the Components of Learning for the Program……………...………… 94
Table 31: Components to Measure Reactions to the Program……………………….………… 95

xi
List of Figures
Figure 1: PIT Member Conceptual Framework…………………………………...……………. 26

xii
Abstract
The American Healthcare industry has been deploying performance improvement methodology
to enhance patient outcomes for years. However, healthcare costs and deaths caused by medical
errors continue to rise (Makary & Daniel, 2016).. This study evaluated the performance
improvement program of a prominent organization within the healthcare industry. The program
leverages multi-disciplinary front line staff to address performance issues within their
department. These groups are known as “Performance Improvement Teams” (PITs). The study
employed survey and document analysis for approximately 2500 employees within the program.
Using the Clark and Estes (2008) gap analysis framework, knowledge, motivation, and
organizational influences were identified as gaps to the program. Recommendations were
presented for each influence and an implementation plan was offered using the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016 ) to evaluate reactions, learning, behavior
and results.
Keywords: healthcare, performance improvement, employee engagement

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CHAPTER ONE: OVERVIEW OF THE STUDY
Introduction of the Problem of Practice
This study addresses the problem of inconsistent performance improvement measures
resulting from the work of Performance Improvement Teams (PITs) within a prominent
healthcare organization. This healthcare organization, located in the Western United States,
developed a performance-improvement program operated in partnership through labor and
management comprised of multi-disciplinary staff across each medical service area. This
performance improvement model defined these working groups as “Performance Improvement
Teams” (PITs). Members in these PITs are represented by the varying disciplines within the unit.
For example, a Receptionist, a Medical Assistant, and a Manager could make up a representative
group for a Family Medicine department. Some teams have found great success as resulted in
their employee satisfaction surveys, workplace safety metrics, attendance rates, patient
satisfaction surveys, and many other performance metrics. However, some teams have not found
the same level of success, despite receiving the same level of training and access to resources.
The continued success of the PIT model is heavily weighted on the performance
indicators, the perception of the employees, and the engagement of leadership. The variance in
teams reaching success creates a strain on the continued progress of this model, resulting in
decreased participation and engagement. With an ever-evolving health care industry, maintaining
ongoing performance initiatives is key to ensure quality patient care to the community (Jha,
Perlin, et al, 2003). This decline in employee engagement and decreased achievement of
performance measures demonstrate the problem of inequitable team performance. Evidence
highlights employee engagement and autonomy in defining performance measures and goals
lead to higher performance results (Alsted-Søndergaard, Burcharth, et al, 2017; Anand, G.,

2
Chhajed, et al, 2012; Barden, 2004; Peccei & Rosenthal, 2001).
Performance Improvement Teams currently have no process in place to ensure they have
properly identified the source of their problem. The Plan Do Study Act (PDSA) process, which
the teams currently utilize, implements rapid fire tests of change without understanding whether
they are targeting the actual problem or not. Implementing a proven framework such as Clark
and Estes (2008) Knowledge, Motivation and Organization (KMO) gap analysis will help PITs
ensure they are targeting the appropriate sources of the problem.
The current assessment practice for the evaluation of PITs lacks specificity. Each level
for advancement builds on the previous level requirement. However, the indicators are vague and
leave the PIT completely free to develop their own performance metrics. This practice has
resulted in process-heavy assessments. Teams are able to create goals and achieve them without
any actual impact on their department’s performance. Autonomy in goal creation is proven to be
an effective practice (Alsted-Søndergaard, Burcharth, et al, 2017; Anand, G., Chhajed, et al,
2012; Barden, 2004; Peccei & Rosenthal, 2001). However, there must be some scaffolding in
place to direct PITs on appropriate performance measures.
Organizational Context and Mission
The medical centers in this study are made up of three separate entities: a not-for-profit
branch (in-patient services), a health insurance branch (also not-for-profit), and a for-profit
branch (outpatient services). The organization is managed into eight different regions across the
United States with 39 hospitals and 680 medical offices. The regions include Northern
California, Southern California, Colorado, Georgia, Hawaii, Mid-Atlantic States, Northwest, and
Washington.

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This organization prides itself on being one of the most culturally sensitive companies to
work for in the United States with hundreds of awards including ranking in DiversityInc’s Top
50 companies for Diversity 10 years in a row. They offer several business resource groups
providing a culture of inclusion for a variety of groups including race, religion, gender identity,
and more (Organization’s Website, 2018).
The organization’s mission is to provide affordable health care services and to improve
the health of patients and the surrounding communities. The organization maintains a patient-
centered focus where they move beyond treating illness to prevention and wellness
(Organization’s Website, 20017).
Organizational Performance Status
The organization has developed a routine process for goal planning. At a corporate level,
Senior Executives strategize regional initiatives for a three-year plan based on current trends in
the industry, patient feedback, employee satisfaction surveys, and past organizational
performance indicators. The regional initiatives are pushed down to the Area Leaders who meet
with their Department Directors to develop specific, measurable, attainable, relevant and time-
bound (SMART) goals. Once the goals are drafted, they are sent back to corporate for approval.
Once approved, the goals are finalized and pushed out to the entire organization.
These Organizational goals are rolled up and reviewed with labor leaders to develop
employee incentives across the region known as the “Performance Sharing Plan” (PSP). The
PITs are asked to create several short-term goals to meet these PSP incentives. The PITs are
assessed to levels one through five based on specified criteria outlined in a document agreed to
by the union and management leaders known as the “Performance Assessment Tool” (PAT). The
Organization’s goal is to have 85% of the PITs functioning at levels four or five. At the

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beginning of this study, 83% of the PITs were performing at levels four and five (Organization’s
Internal Information, 2019). However, there is a great deal of scrutiny made by both
management and labor that although assessed at a level four or five, the team is still not meeting
the performance indicator goals set by the organization and is not perceived to be a truly “high
performing” team.
Related Literature
Performance Improvement Teams were created to enhance the performance of an affluent
health care organization by leveraging the power of front-line engagement. Evidence highlights
employee engagement and autonomy in defining performance measures and goals lead to higher
performance results (Alsted-Søndergaard, Burcharth, et al, 2017; Anand, G., Chhajed, et al,
2012; Barden, 2004; Peccei & Rosenthal, 2001). The current PAT appraises teams based purely
on measuring task completion, which has resulted in variability of actual team performance.
Aligning the department performance in the appraisal process of teams would more accurately
reflect the performance of the teams.
The PAT tool lists a series of checklist items a team must complete broken down by
level. Teams can reach up to a level 5 ranking. The checklist items are divided into categories of
(a) Sponsorship, (b) Leadership, (c) Training, (d) Team Process, (e) Team Member Engagement,
(f) Use of Tools, and (g) Goals and Performance. While these categories are good to evaluate,
they are primarily process-related evaluations. The goals and performance section of the
assessment provides vague directions such as: “Team is achieving targets and sustaining
performance on multiple measures.” The assessment tool does not describe what measures or
even sustaining performance means. Clark and Estes (2008) explain the importance of measuring
the impact to the bottom line, which is an analysis of the achievement of organizational goals,

5
after performance improvement has been implemented. Marsh, Pane, and Hamilton (2006) stress
the importance of measuring data during decision making in organizations.
Measuring performance must go beyond the assessment of a completed task or training as
outlined in the current PIT Performance Assessment Tool. According to Elmer (2002), effective
professional development programs outline goals that line up directly to the organization’s
mission. The organization’s mission is not to have the most task-oriented, trained professionals
in the industry. If that were the mission of this health care organization, the existing Performance
Assessment Tool may be a suitable means of assessing team success. However, the
organization’s mission is to provide affordable health care services and to improve the health of
patients and the surrounding communities. (Organization’s Website, 2017). The Performance
Assessment Tool must measure the performance goals as they line up to this mission in order to
foster professional development (Elmer, 2002).
Importance of Addressing the Problem
This problem is important to address because quality in healthcare is translated to saving
and preserving human lives. Medical errors in the United States is now the third leading cause of
death (Makary & Daniel, 2016). Healthcare costs continue to rise despite several reforms to
contain costs. Increased cost limits access to populations in the middle to lower socio-economic
demographic (Washington: U.S. Government Publishing Office, 2017). Improving performance
within the health care organization will directly impact the quality and affordability of care the
community receives including the reduction of medical errors. The purpose of this study is to
ensure enhanced performance improvement measures are in place equitably across the medical
center with a mission to improve employee and leadership engagement as well as affordability
and quality of care for patients.

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Organizational Performance Goal
The organization has established a goal for the performance of PITs at each facility. The
organization’s goal is that 85% of these teams will reach a level four or five status by December
31st, 2019. The Regional Union-Management Partnership department established this goal. The
development of this goal along with the current assessment practices outlined in the PAT creates
a “check the box” process resulting in teams achieving a level four or five without any real
improvement in their performance indicators such as attendance rates, injury rates, or customer
satisfaction scores.
A new Organizational goal will need to be defined after the implementation of the
following three recommendations: 1) Implement Clark and Estes (2008) KMO framework into
the PIT performance program and 2) Implement a department scorecard in the assessment
process for PITs. 3) Develop a new technology platform that incorporates the first two
recommendations into the program. After implementation of these practices, the number of
teams achieving a level four or five are expected to drop initially. However, the actual
performance indicators are expected to improve. The new goal should reflect the actual
performance indicators.
Description of Stakeholder Groups
The stakeholders for this goal include: Performance Improvement Teams, Performance
Improvement Team Consultants, Performance Improvement Team Sponsors, Department
Managers, Directors, Union Shop Stewards, Administrators, Union Leaders, and Patients. The
affiliated unions for this organization created a national agreement that states all members of a
participating union are members of a PIT whether their department team is active or not. In fact,
every vacant position listed on the organization’s recruitment website lists the requirement to

7
participate in this program. The reach of these teams penetrates all the way down to the patients
these departments serve, as some PITs have even included a patient advisor on their PIT.
The PIT program was designed by Administrators and Union Leaders at a corporate
level. Directors and Union Shop Stewards within the service area make up the PIT Sponsors. The
Sponsors are expected to support the PITs by removing barriers, providing resources, and
ensuring the team does not attempt to work on a project that could violate the existing bargaining
agreement. Department Managers and front-line labor employees who are selected by the labor
within the department are assigned as PIT Leads. The PIT Leads are expected to guide the team
through the PIT process towards the PAT. PIT Members are defined as every single employee
within the Union-Management Partnership agreement. Most often, all members of the PIT do not
attend the PIT meetings due to the large size of the department and the operational need to
always have someone tending to the patients. The labor within each department either elects or
volunteers certain labor employees to participate in the PIT meetings, this group is known as the
Representative Group. The Representative Group is required to collect consensus from the rest of
the department, collaborate on all initiatives, and communicate progress of goals. All employees
are expected to have an active role in the performance goals of the PIT.
Stakeholder Performance Goals
The goals for PIT stakeholders listed below reflects the current goals for the organization.
This study will examine the relationship between these goals and the department’s actual
performance in organizational initiatives.

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Table 1.
Organizational Mission, Global Goal, and Stakeholder Performance Goals
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Performance Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining PITs
will reach a level three.
PIT Member’s Goal PIT Consultant’s Goal PIT Sponsor’s Goal
By December 31st, 2019, The
PIT will complete all of their
PIT Training and have at least
three goals with at least three
tests of change aimed to
improve one of the following:
Attendance Rates, Injury
Rates, Customer Satisfaction
Scores, and/or Employee
Satisfaction Scores.
By December 31st, 2019, PIT
Consultants will complete
85% of the PIT assessments
when they are due, levels
four-five annually and levels
1-3 quarterly.
By December 31st, 2019, PIT
Sponsors will participate in at
least one meeting per quarter
for each PIT they support.

Stakeholder Group of Focus
This study will conduct a complete analysis which will involve all of the above listed
stakeholders. However, an analysis of the PIT Members will be the primary focus. This
stakeholder is selected because they are the primary drivers for the PIT’s Performance
Assessment Tool and each of the other stakeholders are also included in this group.
The goal to achieve 85% of PITs to reach level four or five was established by the
Regional Union-Management Partnership department. The goal was created after an analysis of
the average percentages of level four and five teams the year prior and what the average increase
in score has been from year to year. The purpose of this goal is that higher rated PITs should be

9
correlated to achieving higher levels of performance within the department. The PIT levels are
tracked using an internal software system called the “PIT Documentation Portal”. This tool is
where teams record their goals, progress, structure and where PIT Consultants record their
assessments.
Purpose of the Project and Questions
The purpose of this project is to study the current PIT program. The analysis will focus
on the department’s performance, the PIT member’s knowledge, skill, motivation and
organizational resources. This study will focus on the PIT Members which encompasses all of
the stakeholders. Several gaps have been identified in the PIT program’s framework therefore an
improvement model is recommended to enhance the performance of this program.
The following questions will guide an improvement study to address the gap in
performance achievement.
1. What is the stakeholder knowledge and motivation related to participation and
achievement of the levels one through five in the PIT?
2. What is the stakeholder knowledge and motivation related to working to improve their
department performance?
3. What is the interaction between organizational culture and context and the PIT member’s
knowledge and motivation?
4. What recommendations in the areas of knowledge, motivation, and organizational
resources may be appropriate for advancement of the PITs to achieve an improvement in
the performance of their department?
Methodological Framework
The Clark and Estes (2008) analytic framework provides a categorical definition of the

10
problem into either a knowledge, motivation, or organizational influence (KMO). An analysis of
the process using the KMO framework in a systematic process identifies specific stakeholder
performance gaps (Clark & Estes, 2008). To determine Stakeholder’s knowledge related to
achieving performance, the framework uses Krathwohl’s (2002) four types of knowledge or
skills: (a) factual; (b) conceptual; (c) procedural; and (d) metacognitive. Stakeholder’s evidence
of motivation to engage in performance is categorized by Reuda (2011) as: choice, persistence,
and mental effort. Rueda (2011) provides further scaffolding of motivational constructs with
principles such as self-efficacy, attributions, values or beliefs, and goal orientation. Lastly, the
Clark and Estes (2008) framework concludes with an analysis of the organizational influences
such as workplace culture, processes or bureaucracies, and resources.
The Clark and Este (2008) KMO framework will be used below to identify specific gaps
for PIT members to achieve organizational performance in at least one of the following
categories: : Department Attendance Rates, Department Injury Rates, or Customer Satisfaction
Scores. The analysis of PIT members' knowledge and motivation to participate and achieve
performance in their department PIT will be explored. Lastly, organizational influences in
stakeholder’s performance within the PIT will be considered. The KMO gap analysis influences
will then be further examined through methodology discussed in Chapter 3.
Definitions
Affiliated Unions: A group of unions and this healthcare organization who entered into a
collective agreement for the alignment of negotiations.
Performance Assessment Tool: A tool used by PIT consultants to rank the performance of PITs
on a scale of one through five.
Performance Sharing Plan: An incentive structure developed by the organization to provide

11
employees with monetary compensation above their salary for the successful
achievement of regional goals.
Union Shop Stewards: Representatives for front-line staff trained by their assigned Union in
labor relations and the facility’s local collective bargaining agreement.
Performance Improvement Team: A group of individuals represented by multiple disciplines
within a department tasked to work collaboratively across hierarchies with the mission to
enhance organizational performance.
Organization of the Study
This study is comprised of five chapters. This chapter introduces readers to the key
concepts and terminology of the PIT program. Chapter One also reviews the organization’s
mission, goals and identification of the stakeholder of focus. Finally, Chapter One will include
an introduction to the Clark and Estes (2008) framework used for the study. Chapter Two will
elaborate on the topic with a review of current literature. Topics of employee engagement,
measuring performance, and leadership collaboration will be addressed. Chapter Three will
review the assumed influences on the problem of practice and outline the methodological
approach to the study. Chapter Four will review the data and results. Chapter Five will provide
solutions based on the results reviewed in Chapter Four to close the gaps and propose solutions
for the program moving forward.

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CHAPTER TWO: REVIEW OF THE LITERATURE
Performance Improvement Teams were created to enhance the performance of an affluent
health care organization by leveraging the power of front-line engagement. However, the
program has lost its impact on the organization. Employees have lost trust in the program’s
efficacy thereby reducing their willingness to participate in a meaningful way. The program has
become a checklist where most teams seek to simply get “credit” for task completion rather than
offering a genuine engagement in seeking performance improvement. Lencioni (2002) describes
this phenomenon in his book: “The five dysfunctions of a team”. He highlights a leading cause
of dysfunctional teams to be the team’s inattention to results and satisfaction in simply reaching
a “status” rather than seeking genuine change.
The PIT Documentation Portal is built to scaffold performance improvement tools for the
PIT members to utilize as they focus performance improvement efforts within their department.
The organization refers to this model as the Rapid Improvement Model (RIM). The tool used in
the RIM is the PDSA cycle. Other performance improvement experts may call it the Plan, Do,
Check, Act (PDCA). Mount, Inozu, et al (2012) highlight the history of usage of this tool within
the healthcare industry. However, they support the claim that this tool is no longer useful for
improving performance in the United States healthcare system of today. The simple fact is, after
years of implementation of this tool, the United States healthcare system has seen little to no
improvement. Mount, Inozu, et al (2012) share the results of a study contrasting performance of
the United States healthcare system to that of six other industrialized countries. The United
States came in last or second to last in all five categories evaluated: Quality, Access, Efficiency,
Equity, and Long, Healthy, Productive Lives. Whereas in cost, the United States was the most
expensive. The PIT program uses the PDSA cycle as the foundational framework for

13
performance improvement within the department. Research supports the PDSA tool requires
additional rigor, scaffolding, or tools to increase the quality of performance improvement work
(Taylor, Mcnicholas, et al, 2014; Mount, Inozu, et al, 2012)
The structure of the PIT program offers several aspects proven to improve organizational
performance such as the collaborative approach with management (Barden, 2004), the
partnership with labor unions (Gordon & Kroppel, 2012), and the autonomy provided to
employees to participate in their own goal setting (Anand, Chhajed, & Delfin, 2012). The
implementation of Clark and Estes (2008) KMO model into the PIT’s PDSA cycle will help
employees focus on the actual problems. The implementation of a department scorecard in
alignment with organizational objectives will ensure the team is working on projects that will
provide meaningful change to the organization (Poister, Hall, & Aristigueta, 2014). The
development of a new user-friendly technology platform to implement these new concepts will
help teams stay organized and on task. This improvement strategy should help rebuild
employee’s trust and willingness to engage in the PIT program.
Measuring Performance
Performance Improvement Teams were created to enhance the performance of this
affluent health care organization by leveraging the power of front-line engagement. Evidence
highlights employee engagement and autonomy in defining performance measures and goals
leads to higher performance results (Alsted-Søndergaard, Burcharth, et al, 2017; Anand, G.,
Chhajed, et al, 2012; Barden, 2004; Peccei & Rosenthal, 2001). The current Performance
Assessment Tool appraises teams based purely on measuring task completion, which has resulted
in variability in actual team performance. Aligning the department performance in the appraisal
process of teams will more accurately reflect the performance of the teams. The current tool

14
teams use to document their work is known as “PIT Documentation Portal”. A re-design of this
platform that offers employees a view auto-populated with their current metrics, predictions, and
recommendations would provide more guidance to keep PIT members focused on the
improvement of their performance.
Role of Stakeholder Group of Focus
The healthcare industry is a fast-paced work environment where workers are often
stretched to perform their job duties (Makary & Daniel, 2016). Employees have difficulty getting
release time to work on projects outside of patient care. Employees are often mentally drained
from the stressors that occur within their daily routine. The industry is highly regulated and the
organization’s response is often more conservative than the regulations require. Offering an
opportunity to participate at the convenience of the stakeholder’s schedule will ensure a higher
response rate.
The Clark and Estes Gap Analysis Conceptual Framework
The Clark and Estes (2008) analytic framework provides a categorical definition of the
problem into either a knowledge, motivation, or organizational influence (KMO). An analysis of
the process using the KMO framework in a systematic process identifies specific stakeholder
performance gaps (Clark & Estes, 2008). To determine stakeholder’s knowledge related to
achieving performance, the framework uses Krathwohl’s (2002) four types of knowledge or
skills: (a) factual; (b) conceptual; (c) procedural; and (d) metacognitive. Stakeholder’s evidence
of motivation to engage in performance is categorized by Rueda (2011) as: choice, persistence,
and mental effort. Rueda (2011) provides further scaffolding of motivational constructs with
principles such as self-efficacy, attributions, values or beliefs, and goal orientation. Lastly, the
Clark and Estes (2008) framework concludes with an analysis of the organizational influences

15
such as workplace culture, processes or bureaucracies, and resources.
The Clark and Este (2008) KMO framework will be used below to identify specific gaps
for PIT members to achieve organizational performance in at least one of the following
categories: Department Attendance Rates, Department Injury Rates, or Customer Satisfaction
Scores. The analysis of PIT members' knowledge and motivation to participate and achieve
performance in their department PIT will be explored. Lastly, organizational influences in
stakeholder’s performance within the PIT will be considered. The comprised KMO gap analysis
will then be further examined through methodology discussed in Chapter 3.
Stakeholder Knowledge, Motivation and Organizational Influences
Knowledge and Skills
The first dimension is the knowledge influence necessary for PITs to achieve their
performance goals. According to Bloom’s revised Taxonomy, there are four dimensions of
knowledge: factual, conceptual, procedural, and metacognitive (Clark & Estes, 2008; Krathwohl,
2002; Mayer,2011; Rueda, 2011). Factual knowledge is the declarative knowledge of what
something is. Conceptual knowledge is the declarative knowledge about the relationship between
two things. Procedural knowledge is the understanding of how something works. Metacognitive
knowledge is one’s ability to self-reflect within a task. Understanding the specific knowledge
influences in these dimensions will assist the PITs in acquiring the knowledge necessary to reach
their goal. Inattention to results can lead to a superficial success by teams feeling accomplished
simply by participation alone (Lencioni, 2002).
What goals and performance metrics PITs should focus on. This factual knowledge is
a foundational concept necessary for PITs to understand what they are measuring and what their
actual goal should be. The current PAT is vague on which performance metrics PITs should

16
analyze leaving a majority of teams to come up with measures on their own. This practice results
in goal development that does not impact the organization’s objectives.
What is a gap analysis. Members on a PIT must understand what a gap analysis is in
order to focus their improvement efforts to target the problem of practice. Currently PITs follow
the Plan, Do, Study, Act (PDSA) cycle which does not incorporate any form of gap analysis to
ensure that the team is focusing on the correct source of the problem.
What are the implications of each performance metric. Each performance metric has
a direct impact on the organization and its mission. For example: injury rates lead to an increased
cost in payroll, additional costs for workers compensation claims, and associated costs with the
reduction in service levels from having less experienced employees backfill the vacancy. This
conceptual knowledge is necessary for PIT members to build value for the projects they develop.
How to locate their department performance reports. This procedural knowledge is
necessary for PITs to understand the process of evaluating their department’s current
performance in order to set goals towards improvement.
How to reflect on the effectiveness of their performance improvement initiatives.
This metacognitive knowledge is necessary for PITs to continue the cycle of performance
improvement. This self-awareness of progress will provide the knowledge PITs will need to
abandon, adapt, or adopt the tests of change implemented through their performance
improvement projects.
The table below outlines the alignment of goals from the stakeholder level to the
organizational mission. The goal breakdown is followed by an analysis of the four knowledge
types PITs will require to be successful in obtaining their goal.

17
Table 2
Knowledge Influence, Knowledge Type, and Knowledge Influence Assessment
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Global Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining
PITs will reach a level three.
Stakeholder Goal
By December 31st, 2019, The PIT will complete all of their PIT Training and have at
least three goals with at least three tests of change aimed to improve one of the following:
Attendance Rates, Injury Rates, Customer Satisfaction Scores, and/or Employee
Satisfaction Scores.
Knowledge Influence Knowledge Type Knowledge Influence
Assessment
PIT Members need
knowledge of what goals and
performance metrics they
should be focusing on in
their PIT.
Declarative
(Factual)
PIT Members are asked to
identify the organization’s
goal for each performance
metric.
PIT Members need
knowledge of what a gap
analysis is.
Declarative
(Factual)
PIT Members are asked to
identify the steps of a gap
analysis tool.
PIT Members need to know
the implications of each
performance indicator to the
organization’s goals.
Declarative
(Conceptual)
PIT Members are asked
questions pertaining to the
relationship of the different
performance indicators to
the organization’s goals.

18
PIT Members need to know
how to locate their
performance reports.
Procedural PIT Members are asked to
identify how they find the
reports for their
department’s performance
data in each performance
initiative.
PIT Members need to know
how to reflect on the
effectiveness of their
performance improvement
initiatives.
Metacognitive PIT Members are asked to
rate their perceived
effectiveness on improving
their department’s
performance.

Motivation
The second dimension of influence necessary for PITs to reach their performance goal is
Motivation. Once the PIT has obtained the knowledge necessary to achieve their goal, they will
need to obtain the motivation to move toward completion. Clark and Estes (2008) define three
dimensions of motivated performance as active choice, persistence, and mental effort.
There is substantial research on how motivation works and ways to drive motivation. For
example, Clark and Estes (2008) break down four factors that influence motivation as: “(1)
Personal and team confidence; (2) Beliefs about organizational and environmental barriers to
achieving goals; (3) The emotional climate people experience in their work environment; and (4)
The personal and team values for their performance goals.” Pintrich (2003) records five
generalizations that influence motivation: (A) Self-efficacy and competence, (B) Attributions
and beliefs, (C) Interest and Intrinsic Motivation, (D) Value, and (E) Goals. For the purposes of
this literature review, three motivational influences will be analyzed.
Utility Value. Eccles (2006) describes Utility Value (or Attainment Value) as the
correlation between a task and an individual’s self-concept. This self-image is made up of eight

19
parts: (1) personality and capabilities, (2) long-term goals or plans, (3) definition of gender roles,
(4) values, (5) motivational sets, (6) perception of what one should be like, (7) personal interests,
and (8) perception of socially appropriate behavior. The Utility Value of a task is reflected in the
applicability to these personal needs, interests, and values. Eccles (2006) highlights three basic
human needs that should influence Utility Value: autonomy, social-relatedness, and competence.
The PIT Members need to see the value in the different levels of performance
improvement training provided to enhance their team’s performance. How the PIT member
views the applicability of performance improvement in their long-term goals, social structure,
and values will leverage each member’s choice to engage, persistence to continue even when
faced with obstacles, and their mental effort to process map or brainstorm new solutions. Teams
can develop performance improvement initiatives to improve departmental performance,
ultimately ensuring the organization is providing high-quality, affordable care to the members in
the community.
Attribution. It is important that the PIT members feel they have the ability to make the
changes necessary to improve the performance in their department. If the PIT believed that the
performance of the unit was tied to a bad leader or an organizational issue, they might not choose
to participate in the initiative. Anderman & Anderman (2009) state that when individuals
attribute success or failure to effort rather than ability, motivation is enhanced. It is important for
PIT members to believe they have the potential to impact change within their PIT through their
own efforts to generate motivation to participate.
Goal Orientation. This motivational theory is defined as the beliefs individuals have
concerning their goals and why achieving these goals is important (Mccollum & Kajs, 2007).
Yough and Anderman (2006) summarize goal orientation into four categories: (1) mastery

20
approach, (2) mastery avoid, (3) performance approach, and (4) performance avoid. The main
difference between mastery and performance goal orientation is that mastery is the focus on the
subject, skill, or task. Performance goal orientation is focused on the comparison of one’s
performance to that of another. In a mastery approach, the student is genuinely interested in
mastering the task. In mastery avoid, the student is interested in avoiding misunderstandings or
misconception of the instruction. Students with a performance approach desire to appear the best
or to be a top-performer. Students with a performance avoid are seeking to avoid the appearance
of incompetence or being perceived as unintelligent. There is a great deal of research in the
different approaches to goal orientation. While there is no magic recipe, and individuals can have
multiple goal orientations for one given task, the most efficacious goal orientation is the mastery
approach.
The PIT Members should want to do more to assist their teams in reaching the highest
attainable level for their team (level 5). This is a mastery approach goal orientation. The genuine
desire to master the task without reference to the other PIT teams is what defines this goal as a
mastery approach. This goal orientation builds intrinsic motivation for each member to find
success through performance improvement initiatives, which will help the team reach
improvement in their department, ultimately ensuring the organization is providing high-quality,
affordable care to the members in the community.
Table 3 outlines the two motivational influences described above, Utility Value,
Attribution, and Goal Orientation. The PIT members will participate in a written survey to assess
their level of motivation in these three categories. For Utility Value, the assessment will read: “It
is important for me to complete PIT training”. For Goal Orientation, the assessment will read: “I
want to learn ways that I can help my department reach our goals.” These questions will be

21
scored on a four level scale from Strongly Agree to Strongly Disagree. The motivational
influences will support the stakeholder’s goals, organizational goals, and ultimately the
organizational mission.
Table 3
Assumed Motivational Influence and Motivation Influence Assessment
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Global Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining PITs
will reach a level three.
Stakeholder Goal
By December 31st, 2019, The PIT will complete all of their PIT Training and have at least
three goals with at least three tests of change aimed to improve one of the following:
Attendance Rates, Injury Rates, Customer Satisfaction Scores, and/or Employee Satisfaction
Scores.
Assumed Motivation Influences Motivational Influence Assessment

Utility Value- PIT Members need to see the
value in the different levels of performance
improvement training provided to enhance
their team’s performance.
Written survey item: “It is important for
me to complete PIT training.” (Strongly
Agree-Strongly Disagree)
Attribution- PIT Members are able to
attribute their department performance to the
efforts they have committed within their PIT.
Written survey item: “Success or failure
to reach our PSP goals is a result of my
own efforts.” (Strongly Agree-Strongly
Disagree)

22
Goal Orientation- PIT Members should want
to do more to assist their teams in reaching
the highest attainable level for their team
(level 5).
Written survey item: “I want to learn
ways that I can help my department
reach our goals.” (Strongly Agree-
Strongly Disagree)

Understanding an individual’s knowledge and motivational influences are key
components to successfully achieve performance. Knowledge is the necessary content, the
“what” or the “how” of a task or subject. Motivation is the “why”. Defining the PIT member’s
factual, procedural, and metacognitive knowledge will provide the organization with the
information necessary to fill any gaps in knowledge to ensure participant success. The analysis
of PIT member’s Utility Value, Attribution, and Goal Orientation will help the organization
recognize any motivational gaps to better scaffold instruction.
Organization
Currently PIT members are instructed to align projects with one of four values: Best
People, Best Care, Best Service, and Most affordable. This instruction is helpful in an attempt to
align projects to the organization’s values. However, there is a tremendous need for further
scaffolding. Poister, Hall, & Aristigueta (2014) state the benefits of organizations implementing
department-level scorecards for performance improvement alignment to organizational
objectives. Clark and Estes (2008) highlights the importance of stakeholder goals alignment to
organizational goals. Lencioni (2002) lists “inattention to results” as one of the five most
common dysfunctions to a team.
Cultural Model Influences. Within the organization there are cultural model influences
which represent the beliefs and values of the employees within the organization. Whereas
cultural setting influences, which will be discussed later, address tools and resources provided to

23
employees within the organization. Understanding these principles will help to eliminate any
potential barriers as well as opportunities to leverage strong values.
There needs to be a general acceptance and willingness amongst PIT Members to
implement performance improvement methodologies in their working practice. In order to
be successful in reaching their goals, the PIT members must be invested in the process by
demonstrating acceptance and exercising willful participation. Leadership modeling is important
to emphasize the importance of the PIT processes. Barden (2004) demonstrates that employees
desire leadership involvement in their work.
There needs to be a culture of trust in the organization between the PIT labor and
manager Leads in order for them to effectively engage in performance work. The concept of
partnership between labor and management is highly emphasized in PIT training. However,
some labor and managers have operated under the name of “partnership” without exhibiting any
of the qualities. They have acted in a management versus labor and visa versa relationship
instead. This has broken trust among many of the members and created hesitancy in engaging in
the PIT process. Anand, Chhajed, & Delfin (2012) share that employee trust in leadership is
essential to employee engagement.
Cultural setting influences. The cultural setting speaks to the environmental
components within the organization’s culture. These factors can be anything from tools to
processes within the organization. Evaluating the cultural setting will help to identify potential
barriers to performance achievement.
PIT Members need enough time from their regular positions in order to achieve the
goal of implementing performance improvement initiatives in their department. These
performance improvement projects require additional work outside of an employee's regular

24
scope of work. The organization must provide release time for PIT members to participate in the
necessary activities to achieve their goal.
PIT Members need a reliable and usable technology platform to complete the
performance work on their PIT. The current technology platform is outdated and not user
friendly. It does not offer any data as a resource for teams in project planning. An interactive
interface that provides the data and scaffolding for project planning will ensure PIT member’s
focus on the performance and engagement in the process.
Table 4
Assumed Organizational Influence and Organizational Influence Assessment
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Global Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining PITs
will reach a level three.
Stakeholder Goal
By December 31st, 2019, The PIT will complete all of their PIT Training and have at least
three goals with at least three tests of change aimed to improve one of the following:
Attendance Rates, Injury Rates, Customer Satisfaction Scores, and/or Employee Satisfaction
Scores.
Assumed Organizational Influences Organization Influence Assessment
Cultural Model Influence 1:There needs
to be a general acceptance and willingness
amongst PIT Members to implement
performance improvement methodologies
in their working practice.

Survey questions that tease out
willingness to change; review of PIT
documents and performance reports to see
if they have attempted to implement
performance improvement methodologies
in the past and if those attempts have been
successful.

25
Cultural Model Influence 2: There needs
to be a culture of trust in the organization
between the PIT Labor and Manager
Leads in order for them to effectively
engage in performance work.
Survey questions about trust between
labor and management.
Cultural Setting Influence 1: PIT
Members need enough time from their
regular positions in order to achieve the
goal of implementing performance
improvement initiatives in their
department.
Survey questions about how much
planning and participation time PIT
Members feel they need and whether they
currently have enough time.
Cultural Setting Influence 2: PIT
Members need a reliable and usable
technology platform to complete the
performance work on their PIT.
Survey questions about the current PIT
Documentation Portal interface.

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
The knowledge, motivation and organizational influences for PIT members to achieve
their goal can sound like three separate concepts to assess. In reality, these influencing factors
overlap and even influence each other. An illustrative map will provide clarity to these concepts
(Maxwell, 2013).

26

Figure 1. PIT Member Conceptual Framework
The conceptual framework above shows the overlapping relationship of the
Organization’s culture to the PIT Member’s knowledge and motivation. Leaders drive the culture
through the values they demonstrate to their constituents (Schein, 2017). Leader’s engagement
and general acceptance or willingness to support the PIT process sets a cultural environment for
the PIT member to adopt similar values (Barden, 2004). Another critical organizational factor to
PIT member’s success is an established trust between labor and management PIT members
(Anand, Chhajed, & Delfin, 2012). These cultural models support PIT member’s motivation to
participate and acquire the knowledge necessary to achieve their performance goals.
Cultural settings are equally important to forming a foundation for success within the
organization. Tools and processes must be adopted into the culture to support the PIT process.

27
One of the most critical (and often most challenging) aspects needed for PIT members to
participate is release time from their regular duties. In the healthcare environment, employee’s
job time is often very inflexible. Hospital operations are active around the clock and require
constant attention with little to no down time. Releasing a hospital employee to participate in any
other activities outside of their regular duties would require the participation of a relief
employee. This puts a direct impact on the department’s budget. The organization must set a
precedent by providing resources and opportunities for employees to be released for participation
in the PIT performance improvement initiatives.
One of the biggest reasons a team does not succeed is inattention to results (Lencioni,
2002). The current PIT assessment and performance improvement model does not sufficiently
align department goals with the projects the teams are working on. Development of department
performance scorecards will help the team achieve organizationally impacting results (Poister,
Hall, & Aristigueta, 2014). The knowledge necessary to implement this practice is: 1.
Declarative (Factual): Understanding what the performance indicators are; 2. Declarative
(Conceptual): Understanding the methods and implications of each indicator on the performance
scorecard; 3. Procedural: How to incorporate the feedback provided by the performance
scorecard; and 4. Metacognitive: How to reflect on the initiatives implemented in the evaluation
of the team’s performance. The PIT Consultant will need to provide training to the PIT members
for them to acquire this knowledge.
The PIT members will need motivation to engage in this training process and then again
in the implementation of the tools they are taught. Utility value will be necessary for PIT
members to value the skills and tools they are equipped with in their training for implementation.
The member’s goal orientation should be an intrinsic desire to see the performance of their

28
department improve.
The relationship of knowledge, motivation and organizational influencing factors are
interrelated and must be balanced by the leaders in the process. Understanding this conceptual
framework and how each factor is impacted by the other is critical to the leader’s ability to
juggle the organizational objectives.
Conclusion
The purpose of this study is to enhance the performance of PITs within a prominent
health care facility in an effort to improve the quality and affordability to the members the
organization serves. Chapter Two has highlighted the importance of aligning stakeholder goals
with the organization, measuring performance, identifying the source of the problem and
leadership collaboration with the front line. Chapter Three will describe the methodological
approach.

29
CHAPTER THREE: METHODS
The purpose of this project is to study the current PIT program. The analysis focused on
the department’s performance, the PIT member’s knowledge, skill, motivation, and
organizational resources. This study focused on the PIT Members. An analysis of the program
revealed that there are discrepancies in teams achieving a level five PIT rating, while not
achieving any improvements or reaching organizational benchmarks in key performance
initiatives. An improvement model is recommended to enhance the performance of this program.
The following questions guided an improvement study to address the gap in performance
achievement.
1. What is the PIT Member’s knowledge and motivation related to participation and
achievement of the levels one through five in the PIT?
2. What is the stakeholder knowledge and motivation related to working to improve their
department performance?
3. What is the interaction between organizational culture and context and the PIT member’s
knowledge and motivation?
4. What recommendations in the areas of knowledge, motivation, and organizational
resources may be appropriate for the advancement of the PITs to achieve an improvement
in the performance of their department?
Participating Stakeholders
The stakeholders for this goal included: Performance Improvement Teams, Performance
Improvement Team Consultants, Performance Improvement Team Sponsors, Department
Managers, Union Shop Stewards, Administrators, and Patients. The UMP unions created a
national agreement that states all members of a participating union are members of a PIT

30
whether their department team is active or not. The reach of these teams penetrates all the way
down to the patients these departments serve, as some PITs have even included a patient advisor
on their PIT.
An analysis of the PIT Members was the primary focus. This stakeholder was selected
because they are the primary drivers for the PIT’s Performance Assessment Tool and each of the
other stakeholders are also included in this group. The PIT members are comprised of various
roles: Labor Lead, Management Lead, Proxy, Labor Sponsor, Management Sponsor, and Safety
Lead.
Survey Sampling Criteria and Rationale
Criterion 1. All PIT members were sampled to assess knowledge in leading the PIT to
achieving goals.
Criterion 2. All PIT members were sampled to assess organizational influences to the
PIT’s performance.
Criterion 3. All PIT members were sampled to assess motivation in engagement with the
PIT.
Survey Sampling (Recruitment) Strategy and Rationale
The entire population of 2,335 enrolled PIT Members were surveyed. The population
was stratified by their roles which were comprised of approximately 76 Labor Leads, 72
Management Leads, 74 Safety Leads, 58 Proxies, 47 Management Sponsors, 20 Labor Sponsors,
and the remaining enrolled members. Some members occupy multiple roles, these responses
were stratified by their highest ranking role. This random sampling was the method
recommended (Creswell, 2014; Maxwell, 2013; Merriam & Tisdell, 2015). The survey was
available for participants to respond over a period of 12 weeks. Data collection for document

31
analysis occurred during the same time period as the surveys.
Data Collection and Instrumentation
The study was conducted using a quantitative approach utilizing a mixture of survey and
document analysis. Historical data from employee satisfaction surveys, customer service scores,
attendance rates, and injury rates were gathered and compared to PIT performance ratings over
the course of the last year.
Surveys
The survey was administered in the months of August and September. It was delivered
via email using an online survey tool. The email was sent from the UMP Management Lead for
the facility, who was also a PIT consultant in the service area. The healthcare industry is a fast-
paced work environment where workers are often stretched to perform their job duties (Makary
& Daniel, 2016). Employees have difficulty getting release time to work on projects outside of
patient care. Employees are often mentally drained from the stressors that occur within their
daily routine. Providing the survey electronically with 12 weeks time to complete provided PIT
Members a convenient approach to participate when they were able.The survey instrument
included 31 closed-ended questions.
Documents and Artifacts
Key organizational initiative reports for all 83 teams were reviewed over the course of a
one-year period. These organizational performance reports were compared to the PIT assessment
ratings for each department to reflect the overall outcome of PIT member’s participation on the
PIT and related organizational performance. This comparison of performance to assessment
ratings supported the theory that the existing process-oriented assessment practice does not
reflect an accurate representation of the PIT’s performance. The team’s PIT Documentation

32
Portal was analyzed to understand why there is such a discrepancy in the team’s actual
performance.
Injury Data. Workplace Safety is a key organizational initiative. Every PIT is asked to
have a Workplace safety goal to prevent or reduce the number of injuries in their departments.
The organization maintains a record of worker’s compensation accepted claims. The number of
injuries accepted by the worker’s compensation adjuster to be validated as a work-related injury
is calculated into a rate using the number of productive hours in a department and the number of
accepted injuries by the adjuster. This information was collected from the organization’s
database. The organization’s goal was to reduce the overall injury rate from 4.2 to 3.3.
Attendance Data. The organization has created a goal to reduce absenteeism to improve
the affordability of healthcare. Absenteeism creates overtime, the need for per diems with
differential pay, understaffing which increases patient wait times, reducing the number of
patients that can be seen in a day, decreasing customer satisfaction, increasing the risk of injury
which increases workers comp claims and more. It creates cyclical problems that result in
excessive expenses to the organization. The organization has one of the highest rates related to
absenteeism in the industry. Every PIT is asked to create a goal to reduce absenteeism. The
organization focuses on unprotected absences in the evaluation of data and goal development.
The goal was to reduce the rate of absenteeism from 9.88 average days per full-time equivalent
per year to 6.5. The data is shared transparently across the organization’s hierarchy through the
Office of Union-Management Partnership (OUMP).
Customer Service Scores. The organization has created a goal to improve customer
service. The customer service scores are evaluated through different surveys based on whether
care was delivered in the inpatient setting or outpatient setting. The out-patient service team has

33
created a goal to improve the percentage of patients who provide an “always excellent” rating for
the services received from 66% to 70%. These scores are provided by the service team for the
entire facility and capable of drilling down to each department level. The in-patient units have
different goals by department and many are driven by their regional peer-groups.
Employee Satisfaction Scores. The organization’s employee satisfaction scores were
evaluated in addition to the survey conducted in this study. The organization’s survey included
questions that covered similar topics related to this study on a larger scale.
Each of these documents corresponded to the research questions by revealing progress
made in actual performance through participation in the PIT. The documents were analyzed after
the survey. The outcome provided information to further assess PIT member’s knowledge and
motivation related to these initiatives and the PIT program overall. This information highlighted
the interaction between the organizational culture and context.
Performance Improvement Team Documentation Portal Reports. Generated reports
from PIT Documentation Portal were evaluated to review the performance ratings of teams in
their PIT, whether they are a level 1 through 5 rated PIT. The team’s goals and documentation
process was reviewed to evaluate if they were using any gap analysis or other planning tools in
the development of their goals. The goals were evaluated to determine if they were in alignment
with the organization’s mission and vision.
Data Analysis
Descriptive statistical analysis was conducted once all survey results were submitted.
Documents and artifacts were analyzed for evidence consistent with the KMO concepts of the
conceptual framework. Frequencies were calculated. The percentage of stakeholders who
strongly agreed or agreed were presented in relation to those who strongly disagreed or

34
disagreed. The survey results were triangulated with documents such as the PIT Documentation
Portal data, Performance data, and employee satisfaction survey.
Validity and Reliability
Document analysis compared the performance rating data of the PITs and the key
initiative performance data. This provided a quantitative ratio that demonstrated gaps in the PIT
program. The lack of alignment in the PIT performance assessment to actual performance
metrics has led the PIT evaluations to a system that is purely process-oriented. The PIT program
has produced teams ranking at the highest performing scale without improvement in the
organizational initiatives. The survey design for this study used the most valid scales
implementing wherever possible Ratio and Interval levels of measurement (Salkind, 2017). The
survey was evaluated alongside the employee satisfaction survey, which measured similar
concepts, in the same time frames (Salkind, 2017). This ensured reliability of the data.
After the survey was administered via email to all of the PIT Members, weekly
monitoring took place to ensure accuracy in responses and that no further alterations to the
survey process needed to take place. A reminder email was sent bi-weekly to remind participants
to complete the survey.
Ethics
Ethical concerns to consider for this study were largely due to the highly regulated and
bureaucratic environment of the healthcare industry. The prominent health care organization
used in the study is a leader in the industry and exercises extreme caution when it comes to
potential infringements on regulatory requirements. For example, the healthcare industry is
required to maintain compliance with The Health Insurance Portability and Accountability Act
also known as HIPAA (Health and Human Services, 2013). HIPAA protects patient

35
confidentiality of all health-related information.
This study is an evaluation of employees within the health care organization and their
practices working in a performance improvement program managed by the organization.
However, employees of this organization also make up the largest population of patient
demographics the organization serves. All employees are also considered patients. This study did
not pose any risk of infringement on those regulations, as the topics of the study were related to
the employee’s working practices and did not cover any personal health-related inquiries.
However, due to the prominent health care’s objective to stay extremely conservative, there was
additional scrutiny. For this reason, the study was conducted using quantitative measures to
avoid the need for in-person interviews or statements that could be identifiable to the researcher.
Each participant was provided an informed consent notifying them that the study is
voluntary, their identities and information will be kept confidential, and that they may withdraw
from participating at any time without penalty (Glesne, 2011). The study was submitted to both
the University of Southern California’s Institutional Review Board (IRB) and the organization’s
IRB.
The organization in which the study was conducted is also a unionized environment. The
union and the organization have entered into an agreement known as “The Union-Management
Partnership” or UMP. The performance improvement program being studied was developed and
managed by the UMP. The principle philosophy in the agreement between the union and the
organization is that the work is done collaboratively, in partnership, setting aside hierarchy.
Ethical considerations were taken in the study not to infringe on the contractual partnership
agreements made by the union and the organization. The survey used in this study was also
reviewed with the local union Contract Specialist for feedback and approval.

36
CHAPTER FOUR: RESULTS AND FINDINGS
In Chapter Three, assumed challenges for the PIT program were categorized using the
Clark & Estes (2008) gap analysis into knowledge, motivation, and organizational influences.
The results of this study will be organized in these same categories. The study was conducted
using quantitative analysis and document review. Surveys and multiple sources of documents
were analyzed to understand the knowledge, motivation, and organizational challenges PIT
members face as they engage in the PIT program to enhance the performance in their
department. The survey was conducted while documents were collected from the same time
period. Analysis of the documents occurred simultaneously to the analysis of survey data.
Participating Stakeholders
The stakeholders in this study included 2,335 employees from various roles within the
PIT program. The survey was delivered to all stakeholders and document analysis was collected
from all 83 of the PITs. The survey response rate was 19% with 442 responses. The table below
indicates the stakeholder breakdown by role.
Table 5
Survey Results for Role Demographics of Stakeholders.
# PIT Role Demographics (n = 352) Percentage Count
Select the role that you occupy on your PIT (If you serve multiple
roles, select all that apply):

1 Management Lead 11.08% 39
2 Labor Lead 11.65% 41
3 Safety Lead 5.40% 19
4 Management Sponsor 3.13% 11

37
5 Labor Sponsor 5.11% 18
6 Executive Sponsor 1.14% 4
7 Physician Sponsor 0.28% 1
8 Proxy 1.99% 7
9 Member 36.36% 128
10 Representative Group Member 8.52% 30
11 I do not know 15.34% 54

The average years of service to the organization for respondents was 10 years with an
average of five years’ experience working on a PIT. An interesting finding came from this
demographic question, which could have been included as a factual knowledge influence: 15%
of respondents didn’t know what their role was on the PIT. Additionally, a few employees
responded to the email prompt to participate in the survey. One employee wrote: “I don’t think I
am eligible to complete your survey because I do not participate with our [PIT] directly.” This
employee was a PIT member, but did not know.
Determination of Assets and Needs
Sources of data for this study included the 442 survey responses, document analysis of
the 83 team’s performance related to organizational initiatives for attendance, safety, and service,
document analysis of the PIT Documentation Portal tool, and document analysis of the employee
satisfaction survey. Each influence was evaluated with a question from the survey. The results
were triangulated with a corresponding document analysis that fit the influence. The survey was
open for 12 weeks with an email reminder to participate sent every 2-3 weeks until it reached a
19% response rate.

38
The organization’s goal was to have 85% of teams performing at a level four or five PIT
level. The organization met their goal with 86% of teams rated at a level four or five. Analysis of
this data set a threshold score of 85% for an influence to be determined as an asset or a need.
Since the organization has categorized level four and five PITs to be “High Performing”, the
percentage of accurate or favorable responses should correspond with the percentage of these
teams. However, as previously stated, and validated by this study, the current assessment
practice is not accurately reflective of the team’s actual performance. The current assessment
practice is purely process-based, making it possible for teams who are not performing well to
achieve a “High Performing” level four or five status. As indicated in table 6 below, only 28%-
61% of the PITs have met the organization's goal for the three key initiatives.
Table 6
Participating PITs and Corresponding Performance
PIT NAME PIT Rating Attendance Score Accepted Claim
Rate
Service
Score
Cath Lab Cardiac Svcs 5 6.08 0 75.3
Satellite A MOB PIT 5 5.69 1.12 71.3
Satellite A Psych Dept 5 0 0 71.4
HIM Operations 5 5.64 0 N/A
ROMI 4 5 0 N/A
Scan Center 4 5.75 0 N/A
Satellite B Health Education 4 2.65 3.02 N/A
Health Ed 4 2.31 0 N/A
Patient Financial Svcs 5 2.02 0 87.9
Urology 5 5.6 0 69
Rehab Innovation 5 4.49 2.07 68.8
Psych Adult/Child Recep 5 5.9 1.47 64.5
Satellite C Psychiatry 5 4.64 0 69.5
Rehab Svcs Reception 5 5.81 0 68.8
Medicine 260 5 5.77 0 66.1
Kidney Care Team 5 4.88 0 67.4
Satellite B Pedi Clinic 5 9.05 0 73.5
Cancer Treatment Center 5 7.92 2.88 71.8

39
General and Plastic Surgery 4 10.38 2.44 73.2
Cosmetics 4 12.02 0 73.2
Satellite B Materials Mgt 5 3.63 26.35 N/A
Chronic Conditions Mgt 5 7.3 3.18 N/A
Respiratory Care 4 9.18 0 N/A
HIM Coders 4 6.71 0 N/A
Specialty Call Center 4 15.85 0 N/A
Member Services 4 7.9 0 N/A
Admitting 5 5.68 5.56 91.6
Laboratory Clinical MOB 5 6.39 6.91 58.2
Nutritional Services 5 4.85 9.43 96.2
Optometrist 5 5.49 4.86 65.8
Satellite B Radiology 5 5.5 19.71 53.6
Women's Imaging 5 4.25 6.27 57.5
Ear Nose Throat 5 6.82 0 64.4
Derm 5 9.06 0 66.2
REI 5 6.74 0 69.4
Nephro-Neuro PIT 5 7.21 0 67.4
Satellite B Women's Clinic 5 9.18 0 66.2
Occ Med 5 8.73 0 67.7
Ophthalmology 5 8.99 2.57 61.2
Satellite B Medicine 5 8.17 2.54 64.2
Satellite B Psych Dept 5 7.7 0 62.6
CDRP 5 7.38 0 67.3
Pulmonary 5 10.01 0 63.6
Medicine 372 5 6.95 0 66.1
Medicine 360 5 8.64 0 66.1
Satellite C facility Ped
OB/GYN Int Med
5 7.85 4.5 71.4
Material Services 3 5.51 0 N/A
Regional Perinatal Service 3 2.51 0 N/A
Ultrasound 104 4 6.07 13.9 57.5
Ortho and Podiatry 4 10.5 0 68.9
Pediatrics 4 11.54 0 67.7
Nuclear Medicine 4 6.68 0 57.5
Skilled Nursing Facility 4 15.46 0 54.8
Medicine Reception Group 4 7.52 0 66.1
EVS 4 9.06 9.82 87.6
Cardiac Svcs Clinic 4 7.13 3.7 71.6
Oncology/Infusion Center 4 8.67 8.07 70.4
Pharmacy Services (Inpt) 4 9.77 6.36 N/A
Home Health and Hospice 4 8.58 7.14 N/A

40
Sterile Processing 4 9.81 20.07 N/A
Women's Clinic 5 10.22 5.33 67.6
Medicine 272 5 10.18 10.58 66.1
Allergy 5 15.33 18.32 68.8
Pain Management 5 12.97 11.39 62.5
ED Unit Coordinators 5 9.29 4.7 56.2
ED Registration 5 9.29 4.7 56.2
General Radiology/ CT/MRI 5 8.43 8.83 57.5
ED Techs 5 9.29 4.7 56.2
Medicine 460/472 5 7.27 6.06 66.1
GI 5 7.09 11.54 66.4
Medical Social Workers 3 12.4 0 N/A
Clinical Education 3 8.98 0 N/A
Satellite D PIT/WPS 3 8.66 1.74 67
Satellite B OPH PIT 3 8.87 0 57.8
Perinatology Clinic 3 9.78 36.02 77.2
POM Clinic and Surgery
Scheduling
1 15.19 0 69.4
Radiology Reception/Phone
Clerks
1 9.89 0 57.5
Behavior Health Center 1 12.36 5.88 84.2
Anesthesia Techs 1 11.08 5.99 75.3
Satellite B Pharmacy Services
(Outpt)
4 10.31 3.51 52.1
Pharmacy First Floor (Outpt) 4 7.53 6.74 53.9
Senior Health 4 25.61 33.37 66.1
Patient Transport 0 7.31 4.88 N/A
Percentage meeting goal 86% 31% 61% 28%

Results and Findings for Knowledge Causes
The results and findings from this study are listed using the Knowledge categories:
Factual, Conceptual, Procedural, and Metacognitive.
Factual Knowledge
Influence 1. PIT Members know what goals and performance metrics they should
be focusing on in their PIT.

41
Survey results. PIT Members were asked two multiple-choice questions to identify the
organization’s goal for attendance and workplace safety. Each question offered only one correct
answer, two false answers, and an option to state “I do not know.” As shown in Table 7, the
accuracy in identifying the organization’s goal ranged from 33% for workplace safety to 46% for
attendance. The respondents did not meet the 85% threshold. Therefore, this influence is
determined as a need from this survey.
Table 7
Survey Results for Factual Knowledge of the Organization’s Goals.
# Factual Knowledge Items (n = 260) Percentage Count
What is the accepted injury rate claims goal for the organization?
1 4.4 4.23% 11
2 3.3 33.46% 87
3 4.0 5.77% 15
4 I do not know 56.54% 147
What is the attendance rate goal for the organization?
1 6.0 16.92% 44
2 6.5 46.92% 122
3 7.0 4.62% 12
4 I do not know 31.54% 82

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. A review of the organization’s employee satisfaction survey was
conducted to triangulate survey results. The survey was conducted for all employees across the

42
organization, including unions that do not participate in the PIT program. The survey was
conducted by a third-party vendor who provides benchmarks with the top 25% leading in the
healthcare industry. Approximately 6,000 employees in the service area were provided an
opportunity to participate in the survey. The results yielded a 47% response rate. The survey
used a five-point Likert scale which was translated to a 100 point value based on average survey
ratings. The organization considers scores below 60 to be low and scores above 75 to be high.
Under a category titled “Organizational Performance”, employees were asked: “[My
organization] does a good job providing information on how well we are performing to meet our
organizational goals.” The overall score was 74, which would be an average response of
“Agree”. The healthcare benchmark was listed as a score of 72. These results would indicate that
employees feel they are provided the factual knowledge as to what the organizational goals are
and even how well they are performing.
Summary. This factual knowledge influence was determined to be a need from the
survey conducted in this study. Document analysis of the organization’s employee satisfaction
survey met the benchmark of the top 25% of organizations in the healthcare industry. Yet, it did
not meet the 85% threshold for this study.The difference in these survey items is the question
asked in this study forced participants to identify the goal. Whereas the survey item the
organization provided simply asked employees to state whether they felt the organization did a
good job providing the information or not. There was no evaluation of the employee’s actual
knowledge of the goals. This would suggest that while employees feel the organization provides
information on their goals, they do not actually demonstrate the transfer of knowledge. Therefore
this influence is determined to be a need.

43
Influence 2. PIT members know the correct definition of a gap analysis..
Survey results. PIT members were asked a multiple choice question to identify the
correct definition of a gap analysis. The question offered only one correct answer, two false
answers, and an option to state “I am not sure.” As shown in Table 8, the accuracy in identifying
the organization’s goal was 57%. The respondents did not meet the 85% threshold. Therefore,
this influence is determined as a need from this survey.
Table 8
Survey Results for Factual Knowledge of the Definition of a Gap Analysis.
# Factual Knowledge Item (n = 260) Percentage Count
In order to ensure PIT project goals are aligned with actual
problems, PITs should complete the following tasks:

1 Look at other departments to see what targets they have set for
their goals.
5.77% 15
2 Ask around to see what goals the department feels we should work
on.
26.92% 70
3 Analyze current state, desired state, and identify gaps between the
two.
57.31% 149
4 I am not sure. Goal planning isn’t really discussed in our PIT. 10.00% 26

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Document analysis of the PIT Documentation Portal reports
identified that only 32% of the 83 PIT teams are using a performance improvement tool that
includes a gap analysis. While 86% of the teams are rated at a level four or five, only 61% are
meeting the workplace safety goal, 31% are meeting the attendance goal, and only 28% are

44
meeting the service goal for the organization.
Summary. The survey conducted in this study showed that only 57% of PIT members
surveyed were able to correctly identify the definition of a gap analysis. Document analysis
revealed that only 32% of the 83 teams are even attempting to use a gap analysis tool and the
resulting performance ranges from 28% to 61%. Therefore, this influence is determined to be a
need.
Conceptual Knowledge
Influence 1. PIT Members know the implications of each performance indicator to
their department.
Survey results. PIT Members were asked four multiple-choice questions to identify the
relationship between the PIT goals and the organization’s goals. Two of the questions offered
only one correct answer, two false answers, and an option to state “I do not know.” The other
two questions offered two correct answers, one false answer, and an option to state “I do not
know what the organizational goals are.” As shown in Table 9, the accuracy in identifying the
organization’s goal ranged from 45% for workplace safety to 90% for patient satisfaction. While
two categories met the 85% threshold, the average accuracy of all four questions only reached
69%. The respondents did not meet the 85% threshold. Therefore, this influence is determined as
a need from this survey.
Table 9
Survey Results for Conceptual Knowledge Related to the Relationship Between PIT Goals and
the Organization’s Goals.

45
# Conceptual Knowledge Items (n = 231) Percentage Count
What is the relationship between employee satisfaction to our
organizational goals?

1 There is no relationship. 2.16% 5
2 Employee satisfaction is one of our Performance Sharing Plan
(PSP) goals to achieve our bonus each year.
35.06% 81
3 We are more likely to achieve our organizational goals if we are
satisfied in our jobs.
53.25% 123
4 I do not know what the organizational goals are. 9.52% 22
What is the relationship between patient satisfaction to our
organizational goals?

1 There is no relationship. 0.43% 1
2 Patient satisfaction is one of our Performance Sharing Plan (PSP)
goals to achieve our bonus each year.
47.19% 109
3 We are more likely to achieve our organizational goals if our
patients are satisfied with our service.
43.29% 100
4 I do not know what the organizational goals are. 9.09% 231
What is the relationship between workplace safety to our
organizational goals?

1 There is no relationship. 0.87% 2
2 The accepted injury claims rate is one of our Performance Sharing
Plan (PSP) goals to achieve our bonus each year.
43.72% 101
3 We are more likely to achieve our organizational goals if our
employees have a safe place to work.
45.45% 105
4 I do not know what the organizational goals are. 9.96% 23
What is the relationship between attendance to our organizational
goals?

1 There is no relationship. 0.87% 2
2 The average number of unprotected absent days per 100 employees
is one of our Performance Sharing Plan (PSP) goals to achieve our
48.48% 112

46
bonus each year.
3 We are more likely to achieve our organizational goals if our
employees have fewer days of absenteeism.
39.39% 91
4 I do not know what the organizational goals are. 11.26% 26

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Document analysis was not conducted for this influence.
Summary. The survey would indicate that PIT members have the conceptual knowledge
about the relationship between absenteeism goals and patient satisfaction goals to the
organizational goals. These two questions, however, did offer two correct responses, increasing
the odds of an accidental correct response. The other two questions only offered one correct
response and yielded much lower results. The average accuracy of all four questions was 69%.
Therefore, this influence is considered a need.
Procedural Knowledge
Influence 1. PIT Members know how to locate their performance reports.
Survey results. PIT Members were asked three multiple-choice questions to identify the
process they follow to retrieve their department’s performance in the organizational goals. The
questions offered only one correct answer, two false answers, and an option to state “I do not
know.” As shown in Table 10, the accuracy in identifying the organization’s goal ranged from
8.46% for workplace safety to 30.38% for attendance. The respondents did not meet the 85%
threshold. Therefore, this influence is determined as a need from this survey.

47
Table 10
Survey Results for Procedural Knowledge Related to the Process for Identifying Department
Performance.
# Procedural Knowledge Items (n = 260) Percentage Count
To retrieve my department’s patient satisfaction scores, I visit:
1 The local Intranet site 8.85% 23
2 Only the Manager can retrieve the report 29.62% 77
3 The regional UMP website 18.08% 47
4 I do not know 43.46% 113
To retrieve my department’s accepted injury claims rate, I visit:
1 The local intranet site 8.46% 22
2 Only the Manager can retrieve the report 27.69% 72
3 The regional UMP website 18.46% 48
4 I do not know 45.38% 118
To retrieve my department’s attendance rate, I visit:
1 The local Intranet site 7.31% 19
2 Only the Manager can retrieve the report 26.92% 70
3 The regional UMP website 30.38% 79
4 I do not know 35.38% 92

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Performance goals set by all 83 teams were analyzed in the PIT
Documentation Portal tool. There were a total of 448 goals created between all of the PITs. Out

48
of the established goals, the number of improvement initiatives that focused on the three
organizational priorities ranged from 14% for Patient Satisfaction to 16% for attendance. The
departments who included a metric in their goal ranged from 2% for workplace safety to 8% for
attendance. Each team is tasked to document whether they met the target for the goal they set
before closing out the project. The targets are set by the teams themselves, and as shown in table
11, targets can be set without a form of measurement tied to the organizational goals. When the
documents were analyzed looking at all the goals, including those without a metric to measure
performance, only 14% claimed to have met their target. The document analysis results did not
meet the 85% threshold. Therefore, this influence is determined as a need.
Table 11
Document Analysis for Procedural Knowledge Related to the Process for Identifying Department
Performance.
Total Goals 448
Goals for attendance improvement 72 16.07%
Goals for workplace safety improvement 66 14.73%
Goals for patient satisfaction improvement 65 14.51%
Total Department goals that included a metric to measure improvement 62 13.84%
Attendance goals that included a metric to measure improvement 38 8.48%
Workplace safety goals that included a metric to measure improvement 9 2.01%
Patient satisfaction goals that included a metric to measure improvement 15 3.35%
Total goals that departments met the target they set for themselves 64 14.29%
Attendance goals that departments met the target they set for themselves 17 3.79%
Workplace safety goals that departments met the target they set for themselves 25 5.58%

49
Patient satisfaction goals that departments met the target they set for
themselves
22 4.91%

Summary. The accuracy of respondents from the survey ranged from 8% to 30% with a
majority of respondents selecting the “I do not know” option. The document analysis revealed
that as little as 2% of goals are crafted using a metric tied to the organizational goal. Therefore,
this influence is considered a need.
Metacognitive Knowledge
Influence 1. PIT Members know how to reflect on the effectiveness of their
performance improvement initiatives.
Survey results. PIT Members were asked a multiple-choice question to identify their self-
reflection of the efforts they invest in improving their department’s performance. The question
was designed as a four point likert scale with an option to state “I do not know”. As shown in
Table 12, 75.75% of respondents answered favorably and 10% stated “I do not know”. Only 13%
of respondents answered “Disagree” or “Strongly Disagree”. The respondents did not meet the
85% threshold for favorable answers. Although close, this influence is determined as a need from
this survey.
Table 12
Survey Results for Metacognitive Knowledge Related to PIT Member’s Self-Reflection of Their
Effort Invested to Improve Their Department’s Performance.
# Metacognitive Knowledge Item (n = 231) Percentage Count
The efforts my team and I have invested in improving our
department performance have made a significant impact.

1 Strongly Disagree 6.93% 16

50
2 Disagree 6.49% 15
3 Agree 48.48% 112
4 Strongly Agree 27.27% 63
5 I do not know 10.82% 25

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Document analysis was not conducted for this influence.
Summary. This influence is the closest to meeting the 85% threshold for this study out of
all the knowledge influences analyzed. However, with 75.75% of respondents answering
favorably, the organization is still left with almost 25% of PIT members reflecting poorly on the
efforts they contribute to their team. Therefore, this influence is determined to be a need.
Results and Findings for Motivation Causes
The results and findings from this study are listed using the Motivation categories: Value,
Attribution, and Goal Orientation.
Value
Influence 1. PIT Members see the value in the different levels of performance
improvement training provided to enhance their team’s performance.
Survey results. PIT Members were asked three multiple-choice questions to identify their
level of value for PIT training and enhancing their department’s performance. The questions
were designed using four point likert scales. As shown in Table 13, favorable responses ranged
from 87.79% for the value of the completion of PIT training to 96.85% for the value of achieving
the organization’s attendance goal. The respondents met the 85% threshold for favorable

51
answers. Therefore, this influence is determined to be an asset from the survey results.
Table 13
Survey Results for Value Motivation Related to PIT Training.
# Value Motivation Item (n = 222) Percentage Count
It is important for me to complete PIT training.
1 Strongly Disagree 2.70% 6
2 Disagree 4.50% 10
3 Agree 64.41% 143
4 Strongly Agree 23.38% 63
It is important to me that our department achieve the
Organization’s Attendance goal.

1 Strongly Disagree 0.90% 2
2 Disagree 2.25% 5
3 Agree 60.36% 134
4 Strongly Agree 36.49% 81
It is important to me that my department achieves high customer
satisfaction scores.

1 Strongly Disagree 1.81% 4
2 Disagree 1.81% 4
3 Agree 44.80% 99
4 Strongly Agree 51.58% 114

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. A review of PIT Documentation Portal showed that 95% of teams

52
have completed the required training for their PIT. These training sessions are required for the
teams to move up to a level five. The organization offered optional training to advance member’s
skills on a PIT. Less than 20% of teams participated in the optional training.
Summary. The survey results showed that PIT members value the completion of their
PIT training and the achievement of the organization’s goals by their department. Document
analysis showed that 95% of teams have completed the required training for their team.
However, when offered training simply to enhance a skillset or equip members with tools and
resources which will help them in their PIT, without being required, less than 20% of teams
participated. The survey alone would leave the value motivation influence as an asset. When
combined with document analysis, it would appear that PIT members only value training which
is required for them to move up in their PIT level. Therefore, this influence is determined to be a
need.
Attribution
Influence 1. PIT Members are able to attribute their department performance to the
efforts they have committed within their PIT.
Survey results. PIT Members were asked two multiple-choice questions to describe how
they attribute success or failure within their team. The questions were designed using a four point
likert scale. As shown in Table 14, favorable responses ranged from 65.77% to 82.89%. These
responses did not meet the 85% threshold. Therefore, this influence is determined to be a need
from the survey results.

53
Table 14
Survey Results for Attribution of Success or Failure Within a PIT.
# Attribution Motivation Item (n = 222) Percentage Count
Success or failure to reach our PSP goals is a result of my own
efforts.

1 Strongly Disagree 7.21% 16
2 Disagree 27.03% 60
3 Agree 50.45% 112
4 Strongly Agree 15.32% 34
I have the ability to influence change in my department.
1 Strongly Disagree 5.41% 12
2 Disagree 11.71% 26
3 Agree 57.21% 127
4 Strongly Agree 25.68% 57

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Document analysis was not conducted for this influence.
Summary. The survey results showed that as much as 34.24% of PIT members do not
feel that success or failure to achieve their PSP goal is a result of their own efforts. Therefore,
this influence is determined to be a need.
Goal-Orientation
Influence 1. PIT Members should want to do more to assist their teams in reaching
the highest attainable level for their team (level 5).

54
Survey results. PIT Members were asked two multiple-choice questions to describe their
level of interest in setting personal goals to help their department achieve the organization’s
goals. The questions were designed using a four point likert scale. As shown in Table 15,
favorable responses ranged from 92.79% to 96.4%. These responses met the 85% threshold.
Therefore, this influence is determined to be an asset from the survey results.
Table 15
Survey Results for Goal Orientation of Members Within a PIT.
# Goal Orientation Motivation Item (n = 222) Percentage Count
I want to learn ways that I can help my department meet our
attendance goal.

1 Strongly Disagree 1.35% 3
2 Disagree 5.86% 13
3 Agree 64.86% 144
4 Strongly Agree 27.93% 62
I want to learn ways that I can reduce the risk of injury in my
department.

1 Strongly Disagree 1.80% 4
2 Disagree 1.80% 4
3 Agree 57.66% 128
4 Strongly Agree 38.74% 86

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. A review of projects created by PITs showed that only 14%-16% of
goals were targeting attendance, safety, or service. If every department had a goal for service,

55
safety and attendance, these percentages would range from 25%-33%. Therefore, this influence
is determined to be a need.
Summary. The survey results from this study indicated goal orientation as an asset. Up to
96% of respondents stated that they want to learn ways to improve safety and attendance in their
department. However, as little as 14% are actually creating goals to focus on these initiatives.
This would suggest that PIT members want to learn ways to improve, but they are not actually
engaging in the process of goal setting. Therefore, this influence is determined to be a need.
Results and Findings for Organization Causes
The results and findings from this study are listed using the Organization categories:
Cultural Model and Cultural Setting.
Cultural Models
Influence 1. There is a general acceptance and willingness amongst PIT Members to
implement performance improvement methodologies in their working practice.
Survey results. PIT Members were asked a multiple-choice question to determine if there
is a culture of continuous improvement within their PIT. The question was designed as a four
point likert scale. As shown in Table 16, 85.72% of respondents answered favorably. Only 14%
of respondents answered “Disagree” or “Strongly Disagree”. The respondents met the 85%
threshold for favorable answers. Therefore, this influence is determined as an asset from this
survey.

56
Table 16
Survey Results for a Cultural Model of Continuous Improvement Within a PIT.
# Cultural Model Item (n = 217) Percentage Count
There is a culture of continuous improvement in our PIT.
1 Strongly Disagree 5.99% 13
2 Disagree 8.29% 18
3 Agree 60.37% 131
4 Strongly Agree 25.35% 55

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. Document analysis of the PIT Documentation Portal reports
identified that only 32% of the 83 PIT teams were using a performance improvement tool that
includes a gap analysis and 48% were using other performance improvement tools such as a
Fishbone Diagram, Spaghetti Diagram, or other tool. This would indicate that a total of 80% of
projects included some form of performance improvement tool. Further analysis revealed that
each team’s definition and use of these tools and strategies varied based on their exposure.
Stakeholders outside of the PIT program were teaching “Performance Improvement Tools” using
different processes and vocabulary. Therefore, what some teams may be identifying as
“Performance Improvement Tools” may differ from what the program would identify. The
results do not meet the 85% threshold. Therefore, this influence is determined to be a need from
the document analysis.
Summary. The survey results from this study indicated the cultural model influence was

57
an asset. However, document analysis determined this influence was a need, although results
were close to the 85% threshold. This would suggest that PIT members feel there is a culture of
continuous improvement but that the use of performance improvement tools may not be
necessary. Therefore this influence is determined to be a need.
Influence 2. There is a culture of trust in the organization between the PIT labor
and manager Leads in order for them to effectively engage in performance work.
Survey results. PIT Members were asked a multiple-choice question to determine if there
is a culture of partnership within their PIT. The question was designed as a four point likert
scale. As shown in Table 17, 83.41% of respondents answered favorably. The respondents did
not meet the 85% threshold for favorable answers. Therefore, this influence is determined as a
need from this survey.
Table 17
Survey results for cultural model of partnership within a PIT.
# Cultural Model Item (n = 217) Percentage Count
I believe our PIT has established a culture of partnership.
1 Strongly Disagree 4.61% 10
2 Disagree 11.98% 26
3 Agree 61.29% 133
4 Strongly Agree 22.12% 48

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. A review of the employee satisfaction survey question: “In my

58
department, we communicate openly and honestly with each other, even when our opinions
differ” showed that only 67% of employees answered favorably. The top 25% of healthcare
organizations averaged 73% favorable responses. Not only did this fall short of the
organization’s benchmark, it also did not meet the 85% threshold for this study. Therefore, this
influence is determined to be a need from the document analysis.
Summary. The survey results were close to meeting the threshold for this study with 83%
favorable responses. However, document analysis showed that 33% of employees felt they
cannot communicate openly and honestly within their department. One employee responded to
the email prompt to participate in the survey. She wrote: “I left [PIT] because I felt like my voice
isn’t heard, and I feel like a lot of time was talking about attendance when people didn’t share
the same views with me. Which means how can I be a part of a team who don’t share the same
values?” This response supports the findings from the document analysis. Therefore, this
influence is determined to be a need.
Cultural Settings
Influence 1. PIT Members receive enough time from their regular positions in order
to achieve the goal of implementing performance improvement initiatives in their
department.
Survey results. PIT members were asked two multiple choice questions to determine how
much release time they recieve to work on performance improvement work in their PIT
compared to how much time they feel they need. As indicated in table 18, a majority of
respondents stated that they currently receive 0-1 hour of release time to work on performance
improvement efforts within their PIT. A majority of respondents indicated that they need 2-4
hours of release time to work on performance improvement efforts within their PIT. This

59
influence is determined to be a need based off of the survey results.
Table 18
Survey Results for Cultural Setting of Time Resources Within a PIT.
# Cultural Setting Item (n = 217) Percentage Count
How much time do you currently receive outside of your regular
tasks to participate in the PIT?

1 0-1 hours per month 28.57% 62
2 2-4 hours per month 45.16% 98
3 1-2 hours per week 21.20% 46
4 More than 8 hours per month 5.07% 11
How much time do you currently receive outside of your regular
tasks to participate in the PIT?

1 0-1 hours per month 65.90% 143
2 2-4 hours per month 25.35% 55
3 1-2 hours per week 6.45% 14
4 More than 8 hours per month 2.30% 5

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.
Document analysis. The PIT program requires the PIT Documentation Portal tool to be
updated every 90 days at a minimum. A review of PIT Documentation Portal indicated that only
59% of teams updated the PIT Documentation Portal within 90 days. This could indicate that
teams are not meeting due to lack of release time. Therefore, this influence is determined to be a
need based on the findings from document analysis.

60
Summary. The survey results from this study indicated that a majority of respondents do
not feel they have enough release time to focus on performance improvement efforts within their
PIT. Document analysis indicated that 41% of teams have not updated their PIT Documentation
Portal tool within the required 90 day period. Therefore, this influence is determined to be a need
based on these findings.
Influence 2. PIT Members have a reliable and usable technology platform to
complete the performance work on their PIT.
Survey results. PIT Members were asked a multiple-choice question to determine if the
existing PIT Documentation Portal tool is meeting the needs of the PIT members to achieve their
goals. The question was designed as a four point likert scale. As shown in Table 19, 82.95% of
respondents answered favorably. The respondents did not meet the 85% threshold for favorable
answers. Therefore, this influence is determined as a need from this survey.
Table 19
Survey Results for Cultural Setting of Available Tools.
# Cultural Setting Item (n = 217) Percentage Count
The PIT Documentation Portal provides the resources my PIT
needs to achieve our goals.

1 Strongly Disagree 2.30% 5
2 Disagree 14.75% 32
3 Agree 68.20% 148
4 Strongly Agree 14.75% 32

Interview findings. Interviews were not conducted for this influence.
Observation. Observations were not conducted for this influence.

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Document analysis. A review of PIT Documentation Portal showed inconsistent
accuracy in completion of each section. For example, many would write a problem statement in
the section where they were supposed to write a S.M.A.R.T. goal. Only 2%-8% of teams
included a metric accurately. As reviewed in the last influence, only 59% of teams have updated
their PIT Documentation Portal tool within the required 90 day period. Some teams wrote a
results summary indicating their project was closed, but the project was not properly marked as
closed in the PIT Documentation Portal tool. Other teams confused the “Test of Change” section
by entering a S.M.A.R.T. goal there, some didn’t even include any “Tests of Change”. The PIT
Documentation Portal tool itself utilizes outdated technology. One would have to click on text to
expand certain sections, which may be overlooked. Therefore, this influence is determined to be
a need.
Summary. The survey results from this study indicated that 82% of PIT members feel
that the PIT Documentation Portal tool provides the resources necessary to meet their department
goals. Though this is a relatively high percentage, it did not meet the 85% threshold. A review of
reports from PIT Documentation Portal and the tool itself, showed several gaps in the efficacy of
the tool demonstrated by nearly 98% of members not accurately completing the documentation
and nearly 60% not meeting the required documentation deadlines. Therefore, this influence is
determined to be a need.
Summary of Validated Influences
Table 20, 21, and 22 show the knowledge, motivation and organization influences for this
study and their determination as an asset or a need.

62
Knowledge
Table 20
Knowledge Assets or Needs as Determined by the Data
Assumed Knowledge Influence Asset or Need?
PIT Members need knowledge of what goals and performance
metrics they should be focusing on in their PIT.

Declarative (Factual)
Need
PIT Members need knowledge of what a gap analysis is.

Declarative (Factual)
Need
PIT Members need to know the implications of each performance
indicator to the organization.

Declarative (Conceptual)
Need
PIT Members need to know how to locate their performance
reports.

Procedural
Need
PIT Members need to know how to reflect on the effectiveness of
their performance improvement initiatives.

Metacognitive
Need

63
Motivation
Table 21
Motivation Assets or Needs as Determined by the Data
Assumed Motivation Influences Asset or Need?
Utility Value- PIT Members need to see the value in the different
levels of performance improvement training provided to enhance
their team’s performance.
Need
Attribution- PIT Members are able to attribute their department
performance to the efforts they have committed within their PIT.
Need
Goal Orientation- PIT Members should want to do more to assist
their teams in reaching the highest attainable level for their team
(level 5).
Need

Organization
Table 22
Organization Assets or Needs as Determined by the Data
Assumed Organizational Influences Asset or Need?
Cultural Model Influence 1:There needs to be a general
acceptance and willingness amongst PIT Members to implement
performance improvement methodologies in their working
practice.
Need
Cultural Model Influence 2: There needs to be a culture of trust
in the organization between the PIT labor and manager Leads in
order for them to effectively engage in performance work.
Need
Cultural Setting Influence 1: PIT Members need enough time
from their regular positions in order to achieve the goal of
implementing performance improvement initiatives in their
department.
Need

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Cultural Setting Influence 2: PIT Members need a reliable and
usable technology platform to complete the performance work on
their PIT.
Need

Chapter five will review the needs identified in this study with recommendations based
on empirical evidence.

65
CHAPTER FIVE: RECOMMENDATIONS, IMPLEMENTATION, AND EVALUATION
Assumed influences identified at the beginning of this study were validated in Chapter
Four and categorized using Clark and Estes (2008) knowledge, motivation, and organizational
(KMO) framework. Similarly, chapter five will present recommendations categorized using the
KMO framework and scaffold recommendations with research-based theories using the New
World Kirkpatrick (Kirkpatrick & Kirkpatrick, 2016 ) approach.
A summary of the organization’s background and overview of this study is restated
below from previous chapters for easy reference while reviewing the recommendations from this
study.
Organizational Context and Mission
The medical centers in this study are made up of three separate entities: a not-for-profit
branch (in-patient services), a health insurance branch (also not-for-profit), and a for-profit
branch (outpatient services). The organization is managed into eight different regions across the
United States with 39 hospitals and 680 medical offices. The regions include Northern
California, Southern California, Colorado, Georgia, Hawaii, Mid-Atlantic States, Northwest, and
Washington.
This organization prides itself on being one of the most culturally sensitive companies to
work for in the United States with hundreds of awards including ranking in DiversityInc’s Top
50 companies for Diversity 10 years in a row. They offer several business resource groups
providing a culture of inclusion for a variety of groups including race, religion, gender identity,
and more (Organization’s Website, 2018).
The organization’s mission is to provide affordable health care services and to improve
the health of patients and the surrounding communities. The organization maintains a patient-

66
centered focus where they move beyond treating illness to prevention and wellness
(Organization’s Website, 2017).
Organizational Performance Goal
The organization has established a goal for the performance of PITs at each facility. The
organization’s goal is that 85% of these teams will reach a level four or five status by December
31st, 2019. The Regional Union-Management Partnership department established this goal. The
development of this goal along with the current assessment practices outlined in the PAT creates
a “check the box” process resulting in teams achieving a level four or five without any real
improvement in their performance indicators such as attendance rates, injury rates, or customer
satisfaction scores.
A new Organizational goal will need to be defined after the implementation of the
following three recommendations: 1) Implement Clark and Estes (2008) KMO framework into
the PIT performance program and 2) Implement a department scorecard in the assessment
process for PITs. 3) Develop a new technology platform that incorporates the first two
recommendations for the program. After the implementation of these practices, the number of
teams achieving a level four or five are expected to drop initially. However, the actual
performance indicators are expected to improve. The new goal should reflect the actual
performance indicators.
Description of Stakeholder Groups
The stakeholders for this goal include Performance Improvement Teams, Performance
Improvement Team Consultants, Performance Improvement Team Sponsors, Department
Managers, Directors, Union Shop Stewards, Administrators, Union Leaders, and Patients. The
Affiliated Unions for this organization created a national agreement that states all members of a

67
participating union are members of a PIT whether their department team is active or not. In fact,
every vacant position listed on the organization’s recruitment website lists the requirement to
participate in this program. The reach of these teams penetrates all the way down to the patients
these departments serve, as some PITs have even included a patient advisor on their PIT.
The PIT program was designed by Administrators and Union Leaders at a corporate
level. Directors and Union Shop Stewards within the service area make up the PIT Sponsors. The
Sponsors are expected to support the PIT by removing barriers, providing resources, and
ensuring the team does not attempt to work on a project that could violate the existing bargaining
agreement. Department Managers and front-line labor employees who are selected by the labor
within the department are assigned as PIT Leads. The PIT Leads are expected to guide the team
through the PIT process towards the PAT. PIT Members are defined as every single employee
within the Union-Management Partnership agreement. Most often, all members of the PIT do not
attend the PIT meetings due to the large size of the department and the operational need to
always have someone tending to the patients. The labor within each department either elects or
volunteers certain labor employees to participate in the PIT meetings, this group is known as the
Representative Group. The Representative Group is required to collect consensus from the rest of
the department, collaborate on all initiatives, and communicate the progress of goals. All
employees are expected to have an active role in the performance goals of the PIT.
The Goal of the Stakeholder Group for the Study
The goals for PIT stakeholders listed below reflect the current goals for the organization.
This study will examine the relationship between these goals and the department’s actual
performance in organizational initiatives.

68
Table 23.
Organizational Mission, Global Goal, and Stakeholder Performance Goals
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Performance Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining PITs
will reach a level three.
PIT Member’s Goal PIT Consultant’s Goal PIT Sponsor’s Goal
By December 31st, 2019, The
PIT will complete all of their
PIT Training and have at least
three goals with at least three
tests of change aimed to
improve one of the following:
Attendance Rates, Injury
Rates, Customer Satisfaction
Scores, and/or Employee
Satisfaction Scores.
By December 31st, 2019, PIT
Consultants will complete
85% of the PIT assessments
when they are due, levels
four-five annually and levels
1-3 quarterly.
By December 31st, 2019, PIT
Sponsors will participate in at
least one meeting per quarter
for each PIT they support.

Purpose of the Project and Questions
The purpose of this project is to study the current PIT program. The analysis focuses on
the department’s performance, the PIT member’s knowledge, skill, motivation and
organizational resources. This study focuses on the PIT Members. After analysis of the program,
there are several gaps identified in the framework therefore an improvement model is
recommended to enhance the performance of this program.
The following questions will guide an improvement study to address the gap in

69
performance achievement.
1. What is the stakeholder knowledge and motivation related to participation and
achievement of the levels one through five in the PIT?
2. What is the stakeholder knowledge and motivation related to working to improve
their department performance?
3. What is the interaction between organizational culture and context and the PIT
member’s knowledge and motivation?
4. What recommendations in the areas of knowledge, motivation, and organizational
resources may be appropriate for advancement of the PITs to achieve an
improvement in the performance of their department?
Introduction and Overview
After analysis of the survey and review of documents a summary of recommendations
have been made to reinforce existing assets in the program and close gaps identified in
knowledge, motivation, and organizational influences. The first recommendation is a redesign of
the PIT Documentation Portal to incorporate live feedback, visual prompts, and modeling. This
technology advancement will also scaffold a redesign of the performance improvement
methodology to include an efficacious gap analysis. Kick-off training will be provided and then
reinforced with quarterly peer group meetings and monthly assessments.
Recommendations for Practice to Address KMO Influences
Data analysis identified gaps in PIT Member’s knowledge influences. Specifically,
factual, procedural, conceptual and metacognitive knowledge gaps. Motivational influences were
identified as gaps in value, attribution, and goal orientation. Organizational influences were
identified as gaps in cultural model and setting.

70
Knowledge Recommendations
Recommendations grounded in research were identified to close the identified knowledge
gaps.
Introduction. Table 24 outlines the needs and assets identified from the findings of this
study.
Table 24
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence
Asset or
Need
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
PIT Members do not
know what goals and
performance metrics
they should be focusing
on in their PIT. (D)
Need Y Self-regulatory
strategies,
including goal
setting, enhance
learning and
performance
(APA, 2015:
Dembo & Eaton,
2000; Denler, et
al., 2009).

Providing
scaffolding and
assisted
performance in a
person’s Zone of
Proximal
Development
(ZPD) promotes
developmentally
appropriate
instruction (Scott
& Palincsar,
2006).
Provide opportunities
for PIT Members to
check their progress
and adjust their
learning strategies as
needed by
incorporating their
department
performance live
within the PIT
Documentation
Portal tool

Provide sufficient
scaffolding by listing
the department’s live
performance within
the PIT
Documentation
Portal with guidance
in the form of hoover
prompts for goal
planning to facilitate
learning and
performance.

71
PIT Members do not
know what a gap
analysis is. (D)
Need Y Social
interaction,
cooperative
learning, and
cognitive
apprenticeships
(such as
reciprocal
teaching)
facilitate
construction of
new knowledge
(Scott &
Palincsar, 2006).

Providing
scaffolding and
assisted
performance in a
person’s Zone of
Proximal
Development
(ZPD) promotes
developmentally
appropriate
instruction (Scott
& Palincsar,
2006).

Managing
intrinsic load by
segmenting
complex material
into simpler
parts and pre-
training, among
other strategies,
enables learning
to be enhanced
(Kirshner,
Kirshner, &
Paas, 2006).
Provide pre-training
on the overall use of
the new PIT
Documentation
Portal tool in a peer
group setting.

Present information
within the PIT
Documentation
Portal in manageable
parts to scaffold the
steps for a gap
analysis.

Provide spoken
words during
multimedia
presentations, rather
than printed.

PIT Members do not Need Y Information Information will be

72
know the implications of
each performance
indicator to their
department.(D)
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).

How individuals
organize
knowledge
influences how
they learn and
apply what they
know (Schraw &
McCrudden,
2006).
constructed during
training to connect
the implications of
each performance
indicator to relevant
prior knowledge.

.

PIT Members do not
know how to locate their
performance reports. (P)
Need Y Modeling to-be-
learned strategies
or behaviors
improves
learning, and
performance
(Denler, Wolters,
& Benzon,
2009).

Effective
observational
learning is
achieved by first
organizing and
rehearsing the
modeled
behaviors, then
Provide online
demonstrations of
how to locate
performance reports.

Include live updates
on the department’s
performance reports
within PIT
Documentation
Portal to provide
performance
feedback..

Place printed words
near the performance
reports with an
explanation to

73
enacting them
overtly (Mayer,
2011).

Feedback that is
private, specific,
and timely
enhances
performance
(Shute, 2008).
interpret results to
reduce the need for
visual scanning.

PIT Members do not
know how to reflect on
the effectiveness of their
performance
improvement initiatives.
(M)
Need Y The use of
metacognitive
strategies
facilitates
learning
(Baker, 2006).
Provide opportunities
for PIT members to
engage in guided
self-monitoring and
self-assessment.

Increasing PIT Member’s knowledge about what goals and performance metrics
they should be focusing on in their PIT. The results and findings of this study indicated that
over 60% of PIT Members surveyed do not know what the organization’s goals are that they
should be focusing on in their PIT. A recommendation from Sociocultural theory has been
selected to close this declarative knowledge gap. Scott & Palincsar, 2006 discussed that
providing scaffolding and assisted performance in a person’s Zone of Proximal Development
(ZPD) promotes developmentally appropriate instruction. The ZPD is the space between the
learner’s ability to perform the functions of a task independently and their ability to perform
functions with assistance (Scott & Palincsar, 2006). This suggests that providing PIT Members
with scaffolding would assist their learning. In addition to scaffolding, Dembo & Eaton (2000)
state that self-regulatory strategies such as goal setting enhance learning and performance. The
recommendation is to scaffold the organization’s goals with live updates on the department’s
actual performance in the PIT Documentation Portal and hoover prompts to provide direction on

74
goal setting.
Hartjes (2010) provides supporting evidence that scaffolding goals in real time not only
improves organizational performance, but also patient outcomes. This Intensive Surgical Care
Unit implemented a daily score sheet attributing their enhanced performance to this improved
communication tool. Communicating real time progress, goals, and offering an open dialogue for
discussion on the work has proven to improve healthcare performance in patient care. This
supports the idea of expanding this practice to other organizational objectives that are more
administrative in nature, such as employee attendance rates or workplace safety. This research
supports the recommendation to scaffold the organization’s goals with live performance
feedback to the Performance Improvement Teams.
Increasing PIT Member’s knowledge about what a gap analysis is. The results and
findings of this study indicated that only 57% of PIT Members were able to accurately identify
what a gap analysis is. Furthermore, only 32% of PITs are using a gap analysis in their project. A
recommendation from Sociocultural theory has been selected to close this declarative knowledge
gap. Scott & Palincsar (2006) state that social interaction, cooperative learning, and reciprocal
teaching facilitate the construction of new knowledge. The recommendation to provide training
for the newly designed PIT Documentation Portal tool with the scaffolded gap-analysis tool in a
peer-group setting with activities of self-guided learning and cognitive apprenticeship
opportunities would help to close this knowledge gap.
A study at the University of California, San Diego (UCSD) Skaggs School of Pharmacy
and Pharmaceutical Sciences (SSPPS) comprised of 57 Pharmaceutical students evaluated the
attitude and knowledge impacts of self-guided active learning in peer groups. Students attended a
50-minute lecture then were asked questions regarding their attitude and knowledge of the

75
content. Three weeks later, the same students were smaller peer-groups where they were tasked
with activities to engage in self-guided learning and an assignment to create a presentation to the
whole class regarding the content they learned. The results of the study showed an improvement
in knowledge from 24% overall correct answers to 74% (Atayee, Singh, 2012). This study
supports the recommendation from social cognitive theory to provide training for the revised gap
analysis tools using self-guided learning strategies in a peer group setting.
Increasing PIT Members knowledge about the implications of each performance
indicator to their department. The results and findings of this study indicated an overall
accuracy of 69% of PIT Members knowledge related to the implications of their department’s
performance to the organization’s goals. A recommendation grounded in Information Processing
System Theory has been selected for this conceptual knowledge gap. Schraw & McCrudden,
(2006) state that information tied to prior knowledge is retained more quickly and accurately.
The recommendation to provide information tied to PIT Member’s prior knowledge will
help to close this knowledge gap. An example may be: when providing training to explain the
implications to the organization for workplace safety, asking members to share experiences of
working under-staffed in their department, then tying the connection between employees who
have to go on a leave of absence due to a work-related injury. Explaining the constraints of
healthcare budgets for mostly fixed staffing models and the increased risk of others becoming
injured due to working under-staffed.
A study conducted with 72 computer-science undergraduate students evaluated the
efficacy of knowledge transfer using learner’s conversation to build on prior knowledge. The
study evaluated two groups, one where conversational prompts were presented to engage in
dialogue with the students, and one where the lecture was controlled by the facilitator. The

76
results of the study showed that students who were provided opportunities to engage in
conversation regarding the content to build upon prior knowledge demonstrated higher rates of
knowledge retention (Tegos & Demetriadis, 2017). This supports the recommendation to engage
PIT Members in dialogue to build upon prior knowledge while learning the implications of
performance indicators to the organization.
Increasing PIT Members knowledge about how to locate their performance reports.
The results and findings of this study indicated that less than 30% of PIT members were able to
locate their performance reports . As little as 2% of teams are including the appropriate
performance metric in their goals. A recommendation from social cognitive theory has been
selected to close this procedural knowledge gap. Research states that observational learning
through modeling improves learning and outcomes (Denler, Wolters, & Benzon, 2009; Mayer,
2011). Shute (2008) indicates that timely, specific, and private feedback enhances performance.
This would suggest that providing live feedback as to department performance and modeling for
how PIT members should set goals would improve the department’s performance. The
recommendation is to include a live feed for each of the organization’s initiatives in the PIT
Documentation Portal with virtual hoover prompts to guide the department in how to set specific,
measurable, attainable, realistic and time-bound goals in alignment with the organization’s
objectives.
A study conducted evaluating the impact of compensation controls versus feedback
controls identified the best practice of providing compensation incentives for a single task, and
feedback controls for the other dimensions of the task. Ultimately, compensation in the form of
incentive pay by itself is not enough to enhance employee’s performance. The combination of
compensation incentives with timely feedback has proven to provide the best practice for

77
improving employee performance (Christ, Emett, Tayler & Wood, 2016). The organization
already has compensation incentives in place for these key initiatives. The recommendation to
provide live feedback for PIT performance is supported by research and would close this
knowledge gap.
Increasing PIT Members' knowledge about how to reflect on the performance of
their performance improvement initiatives. The results and findings from this study indicated
that 23% of PIT Members were not able to reflect on the efforts of their team and the impact to
their performance. A recommendation grounded in Information Processing System Theory has
been selected for this metacognitive knowledge gap. Baker (2006) states that the use of
metacognitive strategies improves performance. Providing PIT Members opportunities to engage
in guided self-monitoring and self assessment will enhance their performance. This can be
achieved by providing PIT Members opportunities to complete a structured self-assessment in
alignment with the live performance scorecard within the PIT Documentation Portal tool.
Using data sets from four different studies, D’eon & Trinder (2014) evaluated the validity of
performance outcomes from individual and group self-assessments. The findings from the study
showed that individuals were more likely to rate themselves below actual performance. Whereas,
group assessments were more accurately aligned with actual performance. Providing the PIT
Members with an opportunity to engage in a group self-assessment practice aligned with the
performance scorecard within their PIT Documentation Portal, will help to close this
metacognitive knowledge gap.
Motivation Recommendations
The results of this study validated motivational gaps in value, attribution, and goal
orientation. The recommendations below are written to support the presented needs of PIT

78
member’s motivation. Table 25 shows the gaps identified from the findings of this study.
Table 25
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence

Asset or
Need
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-
Specific
Recommendati
on
Utility Value- PIT
Members need to see the
value in the different levels
of performance
improvement training
provided to enhance their
team’s performance.
Need Y Activating and
building upon
personal interest
can increase
learning and
motivation
(Schraw &
Lehman, 2009).

Rationales that
include a
discussion of the
importance and
utility value of
the work or
learning can help
learners develop
positive values
(Eccles, 2006).
During training,
describe the
personal
benefits from
the use of
performance
improvement
tools such as
increased
productivity
which could
result in higher
bonuses.
Attribution- PIT Members
are able to attribute their
department performance to
the efforts they have
committed within their PIT.
Need Y Learning and
motivation are
enhanced when
individuals
attribute success
or failure to
effort rather than
ability.
(Anderman &
Anderman,
2009).
Provide timely
feedback during
the assessment
process of teams
to express the
success
achieved tied to
effort.(The
assessment will
recognize the
efforts each
individual
contributes to
the project.)

79
Goal Orientation- PIT
Members should want to do
more to assist their teams in
reaching the highest
attainable level for their
team (level 5).
Need Y Focusing on
mastery,
individual
improvement,
learning, and
progress
promotes
positive
motivation
(Yough &
Anderman,
2006).
Provide
opportunities for
PIT members to
achieve various
levels of success
such as a
“Senior Lead”
for increased
time of
individual effort
or for individual
achievement of
goals.Provide
drop down
badge
identification to
identify these
specialized
roles.

Increase utility value of Performance Improvement Team Members. Although nearly
90% of the respondents stated that they valued performance improvement training and 95% of
the teams have completed the required PIT training, less than 20% of teams participated in the
optional training that provided resources and tools to enhance performance. A recommendation
rooted in theories of building interest by Schraw & Lehman (2009) has been selected to close
this motivational gap. Building upon personal interests will enhance motivation and learning.
The recommendation is to include supporting evidence that performance improvement tools have
proven to enhance results, thus providing employees with a higher likelihood of achieving their
goals and receiving a higher bonus incentive.
Thibault Landry, Gagné, et al (2017) discuss the implications of financial incentives,
motivation, and performance. The findings from their study showed that employees who were
given autonomy in their work and incentivised for their performance yielded higher levels of

80
motivation and engagement. Employees who were merely incentivised financially as a means to
meet an organizational objective were less motivated to engage and yielded lower performance
results. The performance improvement training for PIT members is designed to provide that level
of autonomy for employees to develop their own goals. These goals are then tied to their annual
bonus incentives. The recommendation to include supporting evidence that performance
improvement tools enhance results through employee driven planning and the financial incentive
as a reward for this accomplishment will increase motivation for employees to engage in the
training.
Increase PIT Member’s attribution of performance to effort. The results and findings
in this study indicated that as little as 45% of PIT Members attributed their performance to the
efforts they had contributed to improving performance within their PIT. A recommendation
grounded in Expectancy Value Theory (Eccles, 2006) has been selected. Anderman & Anderman
(2009) state that motivation is enhanced with individuals attribute success or failure to effort
rather than ability. Providing the PIT members with timely feedback through quarterly
assessments for level four and five teams and monthly assessments for level one through three
teams highlighting individual efforts within the PIT will help to close this motivational gap.
A literature review of 59 empirical articles identified the enhanced performance of
individuals when provided with a combination of performance (metric) feedback in conjunction
with process feedback (Gabelica, Bossche, et al, 2012). This would suggest that maintaining
some of the existing process-based assessments for PIT Members as individuals and PITs as
groups would increase performance. These process-based elements should tie to some of the
performance elements to tie attribution of success or failure to effort rather than ability.
Increased goal orientation for PIT members in reaching the highest attainable level

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for their team (level 5). Although over 92% of PIT members stated they want to learn ways to
help their department reach the organizational goals, a review of document analysis identified
approximately 15% of teams are actually setting goals in alignment to the organization's
initiatives. A recommendation grounded in goal orientation theory by Yough & Anderman
(2006) has been selected. Providing levels of mastery through promotional opportunities to roles
such as “Senior PIT member” for benchmark achievements will enhance motivation of PIT
members to set goals for increased participation.
Pink (2009) describes mastery as one of the three critical elements to employee
motivation. The other two elements Pink describes are autonomy and purpose. The PIT program
is structured in a way to provide autonomy in goal development. The recommendation to provide
promotional opportunities within the PIT program will provide mastery reinforcing goal-
orientation. Previous recommendations made in this study to improve the utility value of
performance improvement practices would promote the “purpose” element of Pink’s (2009)
motivation trifecta.
Organization Recommendations
The results of this study identified two key organizational setting gaps in the PIT
program. The first was the resource of time and the second was the resource of tools such as
technology. Table 26 outlines the gaps and assets identified from the findings of this study.
Table 26
Summary of Organization Influences and Recommendations
Assumed Organization
Influence

Asset or
Need
Priorit
y
Yes,
No
(Y, N)
Principle and
Citation

Context-Specific
Recommendatio
n

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Cultural Model Influence
1:There needs to be a general
acceptance and willingness
amongst PIT Members to
implement performance
improvement methodologies
in their working practice.
Need Y Effective change
efforts insure
that all key
stakeholders’
perspectives
inform the
design
and decision-
making process
leading to the
change (Clark &
Estes, 2008).

Collaborate with
stakeholders
utilizing
performance
improvement
methodology in
the organization
and align the
strategies, tools,
and vocabulary to
make ease of use
more natural for
PIT Members.
Cultural Model Influence 2:
There needs to be a culture of
trust in the organization
between the PIT labor and
manager Leads in order for
them to effectively engage in
performance work.
Need Y “Organizations
with high levels
of cultural trust
tend to produce
high quality
products and
services at less
cost because
they can recruit
and retain highly
motivated
employees.
These
employees are
more likely to
enjoy their
work, take the
time to do their
jobs correctly;
make their own
decisions; take
risks; innovate;
embrace the
organization’s
vision, mission,
and values; and
display
organizational
citizenship
behavior (e.g.,
helping a
coworker in
The organization
should establish
the expectation
that managers
provide
opportunities for
the front line to
establish their
own goals
through
consensus
decision making
and interest based
problem solving,
the adherence to
this process will
be included in the
team’s
assessment.

83
need)”
(Colquitt, Scott
& LePine, 2007
as cited in
Starnes, Truhon
& McCarthy,
2010, p. 6).
Cultural Setting Influence 1:
PIT Members need enough
time from their regular
positions in order to achieve
the goal of implementing
performance improvement
initiatives in their department.
Need 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
resources are
aligned with
organizational
priorities (Clark
and Estes,
2008).
Reasonable
considerations
for the amount of
work should be
determined at an
organizational
level and a set
standard of
release time
should be built
into every
employee’s work
schedule to
participate in
their performance
improvement
work.
Cultural Setting Influence 2:
PIT Members need a reliable
and usable technology
platform to complete the
performance work on their
PIT.
Need 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
resources are
aligned with
organizational
priorities (Clark
and Estes,
2008).
Launch a revised
PIT
Documentation
Portal tool based
on the
recommendations
identified from
the KMO gap
influences.

84
There needs to be a general acceptance and willingness amongst PIT Members to
implement performance improvement methodologies in their working practice. While 85%
of surveyed PIT Members stated they felt there was a culture of continuous improvement in their
department, only 32% of the 83 PIT teams were using a performance improvement tool that
includes a gap analysis and 48% were using other performance improvement tools such as a
Fishbone Diagram, Spaghetti Diagram, or other tool. The results of the study were close to
meeting the 85% threshold for this study. However, further analysis revealed that each team’s
definition and use of these tools and strategies varied based on their exposure. Stakeholders
outside of the PIT program were teaching performance improvement methodology using
different processes and vocabulary. Clark & Estes (2008) indicate that effective change is
possible when collaboration with all stakeholders is made possible. This would support the
recommendation to bring together stakeholders in the organization that may be outside of the PIT
program, but who are teaching and promoting the use of performance improvement tools.
A study evaluating the performance of a Seattle Emergency Department showed that the
use of lean methodology, including the implementation of standardized work, greatly improved
performance outcomes (Rutman, Stone, et al, 2015). This study provides an explanation of the
foundational framework behind lean processes. One of the foundational principles listed was
standard work. For the organization in this study, the stakeholders teaching and promoting lean
methodology (including standard work) are not in alignment with the tools, practices, and
vocabulary. This has created confusion to the PIT Members who are tasked with utilizing
performance improvement tools in their projects. The recommendation for the organization to
bring all the stakeholders together who teach and promote performance improvement methods to
collaborate and design a standard practice for performance improvement methodology will close

85
this organizational gap.
There needs to be a culture of trust in the organization between the PIT labor and
manager Leads in order for them to effectively engage in performance work. The survey
from this study identified 17% of respondents did not feel there was a culture of partnership in
their department. Document analysis using the organization’s employee satisfaction survey
identified 33% of respondents did not feel that they could communicate openly and honestly in
their department. Furthermore, one employee responded to the email prompt to participate in
the study stating that she decided not to participate in the PIT because she felt her voice was not
heard. Colquitt, Scott & LePine (2007) state that organizations with high levels of trust in the
culture perform better at less cost. The PIT program already requires completion of training for
Consensus Decision Making (CDM) and Interest Based Problem Solving (IBPS). However,
scaffolding of these concepts into the actual design of the program is lacking. Reinforcing these
concepts in the PIT Documentation Portal and an evaluation of adherence in the assessment
process would help to close this organizational gap.
A case study in Washington state across several government and community agencies
evaluated the success of IBPS and CDM for public decision making (Anderman & Anderman,
2009). The implementation of these practices went beyond an initial training. The public
meetings, agendas, and methods of evaluating needs scaffolded concepts from IBPS and CDM
at each level. The results were improved efficiency and lower costs. This study supports the
recommendation to scaffold IBPS and CDM throughout the PIT program including the
Documentation Portal tool and the assessment process.

86
PIT Members need enough time from their regular positions in order to achieve the
goal of implementing performance improvement initiatives in their department. A majority
of PIT Members stated that they do not receive enough release time to work on their PITs.
Document analysis identified that only 41% of teams are updating their PIT Documentation
Portal tool, which could be an indication they do not have the time to participate. Clark & Estes
(2008) indicate that effective organizational change is supported when employees are provided
the time and resources necessary to complete their job. This supports the recommendation for the
organization to set a standard release time for employees to participate in their PITs.
Waters, Marzano & McNulty (2003) state that ensuring staff’s resource needs are met
increases organizational outcomes. Johnson (2006) indicates that effective leaders consider
equity and access when allocating resources for the organization. The provision of standard
release time for all employees to participate in their PIT projects would pose a financial impact
to the organization but should be considered in order to create an inclusive environment.
Furthermore, Clark & Estes (2008) support the theory that positive emotional environments
enhance employee’s motivation to participate in organizational change. Providing a standard
release time would reduce frustration, provide equitable access, and reinforce the opportunity to
provide input in the PIT initiatives thereby cultivating an increased positive emotional
environment.
PIT Members need a reliable and usable technology platform to complete the
performance work on their PIT. The survey results showed that 82% of employees surveyed
felt that the PIT Documentation Portal provided the resources they needed to complete
performance improvement work on their PIT. However, document analysis showed that 41% of
teams are not updating the PIT Documentation Portal and as little as 2% are accurately

87
completing the PIT Documentation Portal. The same Clark & Estes (2008) theory used to
support standard release time for employees also applies to this recommendation to provide a
more meaningful and useful technology platform for PIT members to conduct their
performance improvement efforts.
In a longitudinal study covering 3615 United States hospitals from 2007 through 2012,
Sharma, Chandrasekaran, et al (2016) demonstrated the correlation between health care
technology advancements and organizational performance. At first, the study showed an
improvement in performance but a decrease in return on investment. However, after further
evaluation, the researchers determined that the cost of the technology when weighed against the
benefits still resulted in a return on investment to the organization. This study supports the
recommendation to provide an enhanced technology platform for PIT members to conduct their
performance improvement efforts.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The implementation and evaluation plan for the recommendations were developed using
the new world Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2016). The new world Kirkpatrick
model uses the same principles outlined in the original “Kirkpatrick Model” Reactions, Learning,
Behavior and Results (Kirkpatrick & Kirkpatrick, 2006). The new model simply reverses the
order of design ensuring the program is rooted in the outcomes (or results) the organization aims
to achieve.
Organizational Purpose, Need, and Expectations
The organization’s mission is to provide affordable health care services and to improve
the health of patients and the surrounding communities. In an effort to reach this mission, the

88
organization has set a goal for 85% of PITs to reach a level four or five and all remaining PITs to
reach a level three status during their 2019 assessment. This goal should drive the local medical
centers towards achievement of the organization’s mission through the performance
improvement structure of the PIT program. The problem is that a majority of level four and five
PITs are not meeting the organization’s key initiatives such as patient satisfaction, workplace
safety, or the reduction in absenteeism.
The stakeholder goal is for the PITs to complete all of their training and have at least
three goals with at least three tests of change aimed to improve one of the key initiatives of the
organization demonstrating at least a one percent improvement over the previous year. This goal
would drive the organization’s mission with a focus on the PITs performance rather than the
process of participation.
The recommendations made from this study will help to drive this enhanced
performance. The study has identified some assets the PIT program already offers as well as gaps
in the program. The reinforcement of the program strengths and implementation of
recommendations to close the program gaps will result in an increased performance in each of
these key initiatives driving progress towards the organization’s mission and vision.
Level 4: Results and Leading Indicators
Using the new world Kirkpatrick (2016) model, the table below outlines the results and
outcomes expected to emerge after recommendations are implemented. See table 27.

89
Table 27
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased patient
satisfaction survey
responses collected by
regulatory agencies.
The CMS patient satisfaction
scores
Solicit data from the CMS
Improved quality
outcomes for patient care
The number of adverse patient
events
Solicit data from CMS, CDPH
and the CDC
Decreased healthcare
costs for members
The average cost per member Department of Healthcare
Services
Internal Outcomes
Increased patient
satisfaction with the
survey provided by the
organization.
The internal patient satisfaction
survey
Aggregate data from Member
Patient Satisfaction Survey
(MPS)
Improved employee
morale
The rates or employee
satisfaction surveys
Aggregate data from People
Pulse Surveys
Decrease in work related
injuries
The number of accepted workers
compensation claims
Aggregate data from WIIS
Decreased absenteeism The number of absent days per
FTE
Aggregate data from the CLTM
database
Decreased employee
turnover
The number of
terminations/transfers
Aggregate data from HR Trax

Level 3: Behavior
Critical behaviors. Using the new world Kirkpatrick (2016) model, the table below
outlines the behaviors expected to emerge after recommendations are implemented. See table 28.
Table 28
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s) Method(s) Timing
PIT Members will
correctly identify
current
The average number
of absent days per
FTE
The team shall locate
the data within the
revised PIT
Quarterly

90
departmental
performance
Documentation Portal
tool to compare progress
The total number of
accepted claims and
submitted
Supervisor’s First
Reports of an incident
The team shall locate
the data within the
revised PIT
Documentation Portal
tool.
Quarterly
The patient
satisfaction
percentage of
excellent only ratings
The team shall locate
the data within the
revised PIT
Documentation Portal
tool.
Quarterly
PIT Members will
set goals in
alignment with the
organization’s
objectives.
The average number
of absent days per
FTE
The team shall locate
the organization’s goal
within the revised PIT
Documentation Portal
tool
Quarterly
The total number of
accepted claims and
submitted
Supervisor’s First
Reports of an incident
The team shall locate
the organization’s goal
within the revised PIT
Documentation Portal
tool
Quarterly
The patient
satisfaction
percentage of
excellent only ratings
The team shall locate
the organization’s goal
within the revised PIT
Documentation Portal
tool
Quarterly
PIT Members will
perform a gap
analysis to
effectively set
goals for
improvement.
The number of
completed gap
analyses
The team shall
implement the
appropriate steps to
complete a gap analysis
for every project they
complete.
Ongoing
Employees will
come to work when
scheduled on a
consistent basis
The average number
of absent days per
FTE
The employees will
appropriately use their
sick time when they are
sick rather than calling
out sick for vacations or
personal days.
Ongoing

Required drivers. Table 29 outlines the required drivers to ensure successful adoption of
the program after recommendations are implemented. See the table below.

91
Table 29
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Provide live integration in
PIT Documentation Portal
with the reports for
department specific
performance in attendance,
injuries, and service.
Ongoing 1,2,3
Provide hoover prompts that
respond with user interface
within the PIT
Documentation Portal to
scaffold instruction and
practice including the
organization’s goals per
metric.
Ongoing 2,3
Scaffold the goal planning
prompts within PIT
Documentation Portal to
guide PIT members through
an effective gap analysis
process.
Ongoing 3
Provide links to video
tutorials within the
Documentation Portal
explaining the gap analysis
methodology.
Ongoing 1,2,3
Encouraging
Provide an overall progress
bar to show individual and
department performance
against organizational goals
Ongoing 2,3
Provide a progress bar to
show improvements within
each goal towards achieving
organizational performance
Ongoing 2,3
Rewarding
Provide milestone
achievement recognitions for
individuals who participate
Ongoing 1,2,3

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in the PIT.
Provide promotional
opportunities for roles
within the PIT such as
“Senior”.
Ongoing 1,2,3
Monitoring
Provide a standard practice
for release time within
departments so that
members have the
opportunity to participate in
their PIT.
Ongoing 1,2,3
Generate reports from the
recommended revised PIT
Documentation Portal to
inform the organization of
progress made and future
opportunities for
development
Quarterly 1,2,3

Monitoring. These strategies can be reinforced through accountability. The PIT consultants will
provide monthly assessments for all teams to ensure frequent check-ins. Quarterly peer group
meetings will provide a setting for teams to share out on their successes and collaboration
opportunities for struggles. The monthly leadership report will inform sponsors of the team’s
progress and specific details as to how the department could be further supported.
Organizational support. The organization will support these recommendations by
providing PIT members with the time and tools they need to be successful in the program.
Level 2: Learning
Learning goals. Following completion of the recommended solutions, the PIT members
will be able to:
1. Summarize the organization’s performance goals for attendance, workplace
safety, and patient satisfaction. (D)

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2. Define what a gap analysis is. (D)
3. Differentiate the implications of each performance goal to the organization. (C)
4. Recall the location of their department’s performance related to attendance,
workplace safety, and patient satisfaction. (P)
5. Reflect on the effectiveness of their performance improvement initiatives within
their PIT. (M)
6. Value the different levels of performance improvement training provided. (Value)
7. Attribute department performance to the efforts committed to their PIT.
(Attribution)
8. Create individual goals to assist their PIT in reaching the highest assessment
level. (Goal Orientation)
Program. Redesigning the PIT Documentation Portal to incorporate the
recommendations will be the foundation for improvements to the program. After the technology
advancements and program elements are incorporated in the platform, training will commence.
From re-design to launch, the program should require approximately six months. After
implementation and training the further program revisions to include quarterly peer group
meetings and monthly assessments will take place. From start to finish, the entire program
recommendations should take 12-18 months.
Evaluation of the components of learning. To ensure the success of the program,
evaluation tools have been developed and provided, see table 30.

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Table 30
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks polling random department
staff members
Quarterly
Data review demonstrating accurate alignment of
actual performance with organizational
objectives
Quarterly
Procedural Skills “I can do it right now.”
Demonstrated use of the new tools during PIT
meetings
Weekly, Bi-weekly, or Monthly
depending on the department’s structure
Positive feedback at all staff meetings reflecting
articulate understanding of the methodologies
Monthly
Attitude “I believe this is worthwhile.”
Inclusive use of the PIT Documentation Portal
for all projects the department works on such as
annual departmental goals.
Ongoing
Observations by the consultants of departments
spreading the use of these tools as best practice.
Ongoing
Confidence “I think I can do it on the job.”
Interviews by Consultants on random staff
members on their confidence using the new
tools.
Quarterly
Commitment “I will do it on the job.”
Data review showing usage rates of the new
tools.
Quarterly
Consultant observation of the tools being used in
meetings without prompting
Weekly, Bi-weekly, or Monthly
depending on the department’s structure

Level 1: Reaction
To finish the new world Kirkpatrick (2016) model, an outline of PIT member’s reactions
are listed in table 31..

95
Table 31
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observation of team members utilizing the
tools in their PIT meetings.
Ongoing
Observation of department staff checking
the status of projects outside of PIT
meetings.
Ongoing
Data review of the number of projects each
department is working on.
Ongoing
Data review of the individual participation
rates in the program
Ongoing
Relevance
Verbal feedback during training of the
revised PIT tools and program
Initially, and annual as needed
At the end of each project closed, a survey
prompt will inquire as to the relevance of
the new tools.
Ongoing
Customer Satisfaction
At the end of each project closed, a survey
prompt will inquire feedback on employee
satisfaction with the program and
recommendations for further development
Ongoing

Evaluation Tools
Immediately following the program implementation. The PIT Consultants will
observe the team’s use of the new PIT Documentation Portal. Monthly activity reports will
provide the completion rates of the teams engaging in the use of the new tools. At the end of
each project, a survey prompt will pop up for participants to provide feedback as to the relevance
and success of the new tools. PIT Consultants will ask participants to share feedback as to ways
they will use the new tools in their department. At the end of the training, the participants will
engage in an interactive game to measure their level 2 learning. All of this feedback will be
compiled into a leadership report along with the PIT’s performance progress in the three key

96
initiatives since the roll out of the program. Recommendations for additional organizational
support will be provided at the conclusion of this quarterly report.
A quarterly peer group session will provide a setting for PIT consultants and sponsors to
monitor the progress of the program changes, receive feedback from the departments, and
scaffold additional support as needed. This setting will also offer an opportunity for high-
performing teams to model best practices for other teams still adapting to the changes.
Evaluations will be provided for teams to provide their feedback anonymously so that further
development of the program can occur.
Instead of providing the annual assessments for level four and five teams and quarterly
assessments for levels one through three, PIT Consultants will provide monthly assessments for
all teams. This frequency of evaluation and feedback will provide more opportunities for the
team to receive assistance when needed. See appendix A for a sample assessment.
Delayed for a period after the program implementation. After the first quarter of
implementation, leadership will attend some of the PIT meetings in the role of a sponsor and ask
participants to share their overall satisfaction and perspective of relevance for the new program
structure (Level 1). The sponsor will also ask team members to share their confidence and value
for the new program (Level 2). The sponsor will observe the team’s use of the new tools in their
team meeting to measure the team’s application of the training and will ask for feedback on the
support they received from PIT Consultants during the implementation process (Level 3).
Finally, the sponsor will review data from the new PIT reports detailing the department’s
progress in their goals and towards the organization’s objectives (Level 4). See appendix B for a
sample.

97
Data Analysis and Reporting
The monthly assessments conducted by PIT consultants will be rolled up with the
performance data of the department and provided to each individual team as well as the team
sponsors, and executive leaders. This will provide an evaluation of the program’s level 4 goals.
Similar reports will be assimilated and provided to detail levels one, two, and three.
Summary
The recommendations grounded in the Clark & Estes (2008) framework provide
evidence-based solutions to the identified gaps and assets in PIT member’s knowledge,
motivation, and organizational influences. Using the new world Kirkpatrick (2016) model by
starting the implementation design from the outcomes or results ensures alignment with the
organization’s mission and vision.
Strengths and Weaknesses of the Approach
The Clark & Estes (2008) methodology used in this study was effective for identifying
underlying causes to the problem of practice. The validity of results and completeness of
evaluation using the KMO framework was accurate and thorough. The use of this tool was time
consuming and required significant education to implement. For this study, the framework was
efficacious because the problem of practice was large and complex. However, for smaller or
simpler problems of practice, the time and skill needed to conduct a KMO analysis may
outweigh the benefits.
Limitations and Delimitations
Some limitations were unavoidable in this study and could have an impact on the final
outcome. The response rate for the study was 19%. While a lower response rate is to be expected
when surveying over 1000 people, there were some organizational factors that influenced this

98
rate. The study was conducted during a bargaining year for the union. During times of
bargaining, perspectives of respondents may be influenced by regional negotiations and local
union activity. Respondents may have exaggerated negative experiences assuming that the
survey may have bargaining power during negotiations. Despite the lower response rate, the
population mix of respondents was well balanced in the number of managers versus the number
of front-line employees.
This study focused on the PITs in one service area in the Northern California region of a
prominent health care organization. The union partnership structure is different in Northern
California from the other regions in the organization and excludes a number of healthcare
disciplines such as registered nurses. The delimitation in selection of this target population for
the study will impact the ability to generalize findings to the entire healthcare industry.
Future Research
Future research is recommended to evaluate employee engagement and leadership
collaboration for PITs within this organization in other regions which do not have the same
constraints of participating unions and non-participating unions. An analysis of how other
organizations employ engagement and collaboration strategies in non-union environments would
also be beneficial. Further qualitative analysis within the medical center evaluated in this study
would also help triangulate the quantitative data this study analyzed.
This study was completed at the beginning of the Coronavirus pandemic. Though not
included in this study, the PIT dynamics were challenged given the social distancing
requirements. Many PITs cancelled their meetings altogether. The PIT could be the perfect
setting for the teams to plan their new Coronavirus workflows and adaptation to the changes
made by the new environment. Some teams decided to meet virtually. Should this become a

99
successful practice, there may be room to include a virtual meeting space within the newly
revised PIT Documentation Portal tool recommended in this study.
Conclusion
This study evaluated the performance inequities in a performance improvement program
implemented in a prominent healthcare organization. Using the Clark & Estes (2008) KMO
framework, underlying gaps in the program were identified in the categories of knowledge,
motivation, and organizational influences. Using cutting edge research, recommendations were
presented to close the gap in each of these categories. The findings from this study could not
only improve the program within the organization of focus, but other healthcare organizations
could use the information to develop effective performance improvement programs within their
facilities to leverage the power of employee engagement and leadership collaboration. The
United States Healthcare industry is in desperate need of continual performance improvement.
The implementation and monitoring of initiatives such as the PIT program could literally save
our nation millions of dollars and even save thousands of lives by the reduction of medical errors
and the improvement of healthcare programs.

100
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107
APPENDIX A
Survey Items
Demographic
1. Select the role that you occupy on your PIT (if you serve multiple roles, select all that
apply):
A) Management Lead
B) Labor Lead
C) Safety Lead
D) Management Sponsor
E) Labor Sponsor
F) Executive Sponsor
G) Physician Sponsor
H) Proxy
I) Member
J) Representative Group Member
K) I do not know
2. I have been an employee at this organization for ______ years.
A) 0-5 years
B) 6-10 years
C) 11-15 years
D) 16+ Years
3. I have ______ years of experience working on a PIT.
A) 0-5 years

108
B) 6-10 years
C) 11-15 years
D) 16+ Years
4. Select the description that most closely matches your work location:
A) Off-site clinic
B) Medical Center
5. How many PITs are you a part of? _____
A) 1
B) 2
C) 3+
6. What level is your PIT rated? (if part of multiple teams, select the rating of your highest
team)
A) 1
B) 2
C) 3
D) 4
E) 5
F) I do not know.
7. If part of multiple teams, select the rating of your lowest team.
A) 1
B) 2
C) 3
D) 4

109
E) 5
F) N/A, I only have one PIT I participate on.
Knowledge
8. In order to ensure project goals are aligned with actual problems, PITs should complete the
following tasks:
A) Look at other departments to see what targets they have set for their goals.
B) Ask around to see what goals the department feels we should work on.
C) Analyze current state, desired state, and identify gaps between the two.*
D) I am not sure. Goal planning isn’t really discussed in our PIT.
9. What is the accepted injury claims rate goal for the organization?
A) 4.4
B) 3.3*
C) 4.0
D) I do not know
10. What is the attendance rate goal for the organization?
A) 6.0
B) 6.5*
C) 7.0
D) I do not know
11. To retrieve my department’s patient satisfaction scores, I visit:
A) The local Intranet site*
B) Only the Manager can retrieve the report
C) The regional UMP website

110
D) I do not know
12. To retrieve my department’s accepted injury claims rate, I visit:
A) The local Intranet site*
B) Only the Manager can retrieve the report
C) The regional UMP website
D) I don’t know
13. To retrieve my department’s attendance rate, I visit:
A) The local Intranet site
B) Only the Manager can retrieve the report
C) The regional UMP website*
D) I do not know
14. What is the relationship between employee satisfaction to our organizational goals?
A) There is No Relationship
B) Employee satisfaction is one of our Performance Sharing Plan (PSP) goals to achieve
our bonus each year.
C) We are more likely to achieve our organizational goals if we are satisfied in our
jobs.*
D) I do not know what the organizational goals are.
15. What is the relationship between patient satisfaction to our organizational goals?
A) There is No Relationship
B) Patient satisfaction is one of our Performance Sharing Plan (PSP) goals to achieve our
bonus each year.*
C) We are more likely to achieve our organizational goals if our patients are satisfied

111
with our service.*
D) I do not know what the organizational goals are.
16. What is the relationship between workplace safety to our organizational goals?
A) There is No Relationship
B) The accepted injury claims rate is one of our Performance Sharing Plan (PSP) goals
to achieve our bonus each year.
C) We are more likely to achieve our organizational goals if our employees have a safe
place to work.*
D) I do not know what the organizational goals are.
17. What is the relationship between attendance to our organizational goals?
A) There is No Relationship
B) The average number of unprotected absent days per 100 employees is one of our
Performance Sharing Plan (PSP) goals to achieve our bonus each year.*
C) We are more likely to achieve our organizational goals if employees have fewer days
of absenteeism.*
D) I do not know what the organizational goals are.
18. The efforts my team and I have invested in improving our department performance have
made a significant impact.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
E) I do not know

112
Motivation
19. It is important for me to complete PIT training.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
20. Success or failure to reach our PSP goals is a result of my own efforts.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
21. I want to learn ways that I can help my department meet our attendance goal.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
22. It is important to me that our department achieve the Organization’s Attendance goal.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
23. I want to learn ways that I can reduce the risk of injury in my department.
A) Strongly Disagree

113
B) Disagree
C) Agree
D) Strongly Agree
24. I have the ability to influence change in my department.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
25. It is important to me that my department achieves high customer satisfaction scores.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
Organization
26. There is a culture of continuous improvement in our PIT.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree
27. I believe our PIT has established a culture of partnership.
A) Strongly Disagree
B) Disagree
C) Agree

114
D) Strongly Agree
28. How much time do you feel you need outside of your regular tasks to participate in the
PIT?
A) 0-1 hours per month
B) 2-4 hours per month
C) 1-2 hours per week
D) More than 8 hours per month
29. How much time do you currently receive outside of your regular tasks to participate in
the PIT?
A) 0-1 hours per month
B) 2-4 hours per month
C) 1-2 hours per week
D) More than 8 hours per month
30. The PIT Documentation Portal provides the resources my PIT needs to achieve our goals.
A) Strongly Disagree
B) Disagree
C) Agree
D) Strongly Agree

115
APPENDIX B
Document Analysis
Organizational Mission
To provide affordable health care services and to improve the health of patients and the
surrounding communities.
Organizational Global Goal
By December 31st, 2019, 85% of PITs will reach a level four or five and all remaining PITs
will reach a level three.
Stakeholder Goal
By December 31st, 2019, The PIT will complete all of their PIT Training and have at least
three goals with at least three tests of change aimed to improve one of the following:
Attendance Rates, Injury Rates, Customer Satisfaction Scores, and/or Employee Satisfaction
Scores.

Knowledge Influence Document
Examined
Present
Y or N
Notes
PIT Members need
knowledge of what goals
and performance metrics
they should be focusing
on in their PIT.

Declarative (Factual)
Employee
Satisfaction
Scores
Y The employee
satisfaction survey
included a question
regarding employee’s
knowledge of the
organization’s goals.
PIT Members need
knowledge of what a gap
analysis is.

Declarative (Factual)
Attendance Data
Injury Data
Service Scores
PIT
Documentation
Portal
Y Comparing the team’s
performance with the
team’s goals
documented in
Documentation Portal
provided information as
to the planning process
teams were or were not
using in their goal
development.

116
PIT Members need to
know the implications of
each performance
indicator to the
organization.

Declarative (Conceptual)
N/A N/A N/A
PIT Members need to
know how to locate their
performance reports.

Procedural
Attendance Data
Injury Data
Service Scores
PIT
Documentation
Portal
Y Comparing the data
documented in
Documentation Portal to
the departments actual
performance showed
whether they were able
to locate the data.
PIT Members need to
know how to reflect on
the effectiveness of their
performance
improvement initiatives.

Metacognitive
N/A N/A N/A

Assumed Motivation
Influences
Document
Examined
Present
Y or N
Notes
Utility Value- PIT
Members need to see the
value in the different
levels of performance
improvement training
provided to enhance their
team’s performance.
PIT
Documentation
Portal
Y Completion of the
training as documented
in PIT Documentation
Portal provided
information as to if PIT
member’s were
motivated to complete
the training.

117
Attribution- PIT
Members are able to
attribute their department
performance to the efforts
they have committed
within their PIT.
N/A N/A N/A
Goal Orientation- PIT
Members should want to
do more to assist their
teams in reaching the
highest attainable level
for their team (level 5).
PIT
Documentation
Portal
Y Evaluating the team’s
progress or lack of
progress in the PIT
Documentation Portal
provided information as
to the team’s goal
orientation.

Assumed
Organizational
Influences
Document
Examined
Present
Y or N
Notes
Cultural Model Influence
1:There needs to be a
general acceptance and
willingness amongst PIT
Members to implement
performance
improvement
methodologies in their
working practice.

PIT
Documentation
Portal
Y The use of performance
improvement tools were
documented in PIT
Documentation Portal.
Cultural Model Influence
2: There needs to be a
culture of trust in the
organization between the
PIT labor and manager
Leads in order for them
to effectively engage in
performance work.

Employee
Satisfaction
Scores
Y The employee
satisfaction survey
included questions about
employee’s perception
of their relationship with
their manager.

118
Cultural Setting
Influence 1: PIT
Members need enough
time from their regular
positions in order to
achieve the goal of
implementing
performance
improvement initiatives
in their department.

PIT
Documentation
Portal
Y Gaps in documentation
in PIT Documentation
Portal can be an
indication that the team
is not meeting, which
could be an indication
they struggled with
release time.
Cultural Setting
Influence 2: PIT
Members need a reliable
and usable technology
platform to complete the
performance work on
their PIT.

PIT
Documentation
Portal
Y Evaluating the accurate
completion of PIT
Documentation Portal
can be an indicator if the
teams understand how to
use the tool.

Abstract (if available)

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Asset Metadata

Creator Kelly, Ashley Rae (author)

Core Title Employee engagement and leadership collaboration: a gap analysis of performance improvement teams in healthcare

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 06/15/2020

Defense Date 03/30/2020

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

Tag employee engagement,healthcare,leadership collaboration,OAI-PMH Harvest,performance improvement

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth (committee chair), Foulk, Susanne (committee member), Hinga, Briana (committee member)

Creator Email ashleyraekelly@gmail.com,kellya@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-318539

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Legacy Identifier etd-KellyAshle-8590.pdf

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Document Type Dissertation

Rights Kelly, Ashley Rae

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...

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