Identifying service quality gaps between patients and providers in a Native American outpatient clinic

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These gaps combine to increase the breach between patient expectations and perceptions of their healthcare services. With better insight that captures what patients are looking for from a service, the potential to meet those needs increases, and patients feel that their voice is respected and valued.

We found a disconnect between what patients anticipate for care and what staff think they are anticipating. We also found a discontent between what staff believes patients need versus what the patients feel is needed.

Staff and patient interviews and surveys allowed service expectations to be assessed according to the clinic’s ability to meet those expectations. A total of 48 patients and ten staff members (83% of the staff at this clinic) participated in the study voluntarily.

Native American communities in Montana reservations have reported low-level satisfaction in health services. This research explored if the services provided at a Blackfeet Indian Reservation outpatient clinic were designed to meet patient expectations.

Background

The ability to receive critical healthcare for rural areas is crucial as people live in isolated regions [1, 2]. What can be even more challenging is when much of the population suffers from economic poverty [3]. This reduces an individual’s ability to receive the valued healthcare that they need promptly.

Native American communities found in Montana reservations with the federally funded Indian Health Service (IHS) fall within the category of rural healthcare systems [4]. In many cases, low-level satisfaction results from a disconnect in what patients look for in the service compared to what a clinic has determined to be the appropriate service.

Since 2008, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has offered a valid standard comparison tool for satisfaction criteria collection and reporting [5, 6]. Table presents a CMS report comparing patient satisfaction with their healthcare on the Blackfeet Indian Reservation with the state of Montana and nationally [7].

Table 1

Hospital at Browning- Blackfeet
(%)Montana Average
(%)National Average
(%)Patients who reported that their nurses “Always” communicated well.728181Patients who reported that their doctors “Always” communicated well.798382Patients who reported that they “Always” received help as soon as they wanted.727570Patients who reported that the staff “Always” explained about medicines before giving it to them.546966Patients who reported that their room and bathroom were “Always” clean.587376Patients who reported that the area around their room was “Always” quiet at night.756462Patients who reported that YES, they were given information about what to do during their recovery at home.708687Patients who “Strongly Agree” they understood their care when they left the hospital.425254Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).527073Patients who reported YES, they would definitely recommend the hospital.447172Open in a separate window

The report shows lower levels of satisfaction in the Blackfeet Nation than state and national averages. Communities such as the one on the Blackfeet Reservation can benefit from changes that could improve patient satisfaction and increase their health services’ quality.

Patient satisfaction or dissatisfaction is associated with the Service Quality Gap (SQG), which is the difference between what patients expect from a service and their perception of the service they receive [8, 9]. Figure depicts the patient-provider interaction that could lead to SQG. The figure is based on the Service Quality Gap model [10, 11].

The SQG model starts with a patient having a concern or a need. The patient then chooses a healthcare provider according to past experiences, word of mouth, or simply because that is the only provider available [12–15].

According to the SQG model, there are many opportunities in which gaps or divergences could occur. For instance, Gap 1 focuses on a misalignment between patients’ expectations from the service and what the provider thinks patients expect. Gap 2 identifies what healthcare providers think patients expect versus what they think patients need, which could differ in their expert opinion.

The Design Gap (Gap 3) focuses on how staffing, operations, processes, layout, and patient and information flow are designed to provide the best healthcare service possible. It also includes the physical surroundings, ambient, decorations, and cleanliness of the location. The Service Delivery Gap or Service Encounter Gap (Gap 4) is related to the human resources aspect, such as friendliness, responsiveness, empathy, inclusivity, and employee thoughtfulness.

These four gaps combine to influence patients’ service experiences and their perception of the quality of a service [16–18]. The difference between expected service and the perception of the service received creates the Service Quality Gap. Therefore, minimizing the first four gaps can increase patients’ satisfaction levels at a facility while still allowing healthcare staff to provide the needed services [17]. By doing so, there is potential for improvement of the patient’s experience in their local clinics. This, in turn, could improve the satisfaction rating of the facility, which is standardized and reported for public use, accreditation, and reimbursement purposes [19].

The literature shows evidence of healthcare providers using HCAHPS or other types of surveys to improve their customer service [20–27]. However, many of the reported cases appear to react to survey results as improvements are made only after services have been provided and measured.

In retrospect, this approach can still leave a SQG that needs to be addressed and service design can take a long time to align with patient expectations. With the ability to bring forward what each party values in their services, the ability to meet needs and expectations satisfactorily becomes more viable prior to the visit and leads to a proactive approach.

On the other hand, relying too heavily on satisfaction surveys could lead to poor healthcare practices since providers would be focusing too much on what patients want to achieve higher scores [28]. This implies that “patient wants” need to be considered but only concerning what the healthcare staff can do to treat patients effectively (patient wants vs. patient needs; Gap 2).

The balance between designing for patients’ expectations versus effective care can be difficult to assess through post-service surveys such as HCAHPS. It is important to include patient feedback when designing or re-designing a process. Baker [29] maintains that patients want to be part of the healthcare process; listening to their voice before they receive service is an important dimension of a Patient-and Family-Centered Care (PFCC) approach to healthcare design and improvement [30, 31]. In fact, it is one of the eight dimensions of PFCC [31], which is essential to any health provider, but in particular, for those in isolated regions [1] like the one on the Blackfeet Indian Reservation. From the results presented in Table , it was important to investigate why the Native American community in Browning, Montana has lower HCAHPS scores than state and nation averages.

Weidmer-Ocampo et al. [32] adapted CAHPS and surveyed a Native American population in Oklahoma. Interviews were conducted with a small group of patients to ensure the survey’s cognitive understanding was developed. Afterward, the survey was distributed via mail one week after their visit to assess their satisfaction with the healthcare facility. Their results were successful in providing meaningful direction to improve patient satisfaction with the services. While Weidmer-Ocampo et al. [32] assessed a Native American population, service expectations were not assessed prior to the visit to allow patients to have a voice in the re-design or improvement process. It was assumed that the CAHPS assessed patient expectations.

This research study explored if the services provided at a Blackfeet outpatient clinic are designed to care for the patient and meet the expectations patients anticipate. The research focused on the first two gaps of the SQG model to uncover potential misalignments between patient and healthcare provider service expectations in the Blackfeet Indian Reservation clinic. Staff and patient interviews and surveys allowed service expectations to be assessed according to the clinic’s ability to meet those expectations.